Health inspection·October 20, 2023

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. 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 facilitate the resident's right to organize resident group (council) meetings. The group council meetings stopped during the COVID-19 (a respiratory virus that is easily spread causing mild, moderate, or serious illness) lockdown and were never resumed. There was no designated staff person approved by the residents to be responsible for assisting and responding to the resident's concerns or requests that result from group meetings. Residents Affected - Many This failure had the potential to cause residents emotional distress and a decline in their quality of life. Findings: During an interview on 10/16/23 at 9:44 a.m., Resident 3 stated the resident council meeting was not held for a long time since the COVID-19 lockdown in 2020 because there was no staff to assist with meeting arrangements. Resident 3 further stated he would like the residents 'council meetings restarted to discuss activities and concerns. Review of the Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 4/21/23, indicated Resident 3's Basic Interview of Mental status (BIMS, a scoring system to determine cognitive status) score was 14 (meaning cognitively intact and able to understand others and be understood. During an interview on 10/17/23 at 9:48 a.m., with the Registered Nurse/Administrator (RN/Admin), RN Admin stated the facility had no active resident council meetings since COVID-19 lockdown in 2020 because staff were busy providing bedside care. During an interview on 10/19/23 at 12:15 p.m., RN/Admin stated activity staff were responsible to aid with resident council meetings and had no activity staff since COVID-19 lock down in 2020. RN/Admin further stated the Director of Nursing (DON) was responsible to hire activity staff. DON was not available for an interview. Review of the resident council meeting attendance binder indicated the last meeting was held on 3/9/2020. Review of Resident 163's clinical record indicated she was admitted on [DATE]. During an interview on 10/19/23, at 2:06 p.m., with Resident 163, Resident 163 stated the residents used to have Resident council meetings once a month for years, until COVID-19 in 2020 and the Page 1 of 28 555466 555466 10/20/2023 Ashby Care Center 2270 Ashby Avenue Berkeley, CA 94705

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many resident council meetings stopped. Resident 163 further stated attending the resident council meetings was good because the residents could talk about anything and could express their emotions. We had activities like church on Sundays, bible study on Monday, and a catholic woman came on Wednesday to give communion. I miss that. Review of Resident 167 clinical record indicated she was admitted on [DATE]. A review of Resident 167's MDS, dated [DATE] indicated the resident's cognition was mildly impaired. During an interview on 10/19/23, at 2:10 p.m., with Resident 167, Resident 167 stated she wanted to attend resident council meetings. During a review of the facility's policy and procedure (P&P) titled, (Quality of Life), the P&P indicated, . A resident has the right to organize and participate in resident groups in the facility; . the facility must provide a designated staff person responsible for providing assistance and responding to written requests that result from group meetings . 555466 Page 2 of 28 555466 10/20/2023 Ashby Care Center 2270 Ashby Avenue Berkeley, CA 94705

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct comprehensive Minimum Data Set assessments (MDS, an assessment tool used to direct resident care) for six of thirteen sampled residents (Resident 5, 58, 60, 61, 62 and 63) as required by the regulation. These failures had the potential to result in not planning and meeting the residents' needs, strengths, and goals of care. Findings: Review of Resident 5's MDS assessment indicated the last comprehensive assessment was completed on 1/21/2019. Review of Resident 58's MDS assessment indicated Resident 58 was admitted on [DATE]. Resident 58's admission comprehensive assessment with ARD (Assessment Reference Date,is the last day of the observation period the assessment covers for the resident) of 7/13/2023 was not completed. Review of Resident 60's MDS assessment indicated the last comprehensive assessment was completed 10/01/2019. Review of Resident 61's MDS assessment indicated the last comprehensive assessment was completed 11/6/2021. Review of Resident 62's MDS assessment indicated the last comprehensive assessment was completed 10/6/2021. Review of Resident 63's MDS assessment indicated the last comprehensive assessment was completed 8/2/2019. During an interview on 10/19/23 at 12:15 p.m., Registered Nurse/Admininistrator (RN/Admin) stated she was aware that the residents' MDS were late. and was responsible for the completion and transmission of the residents MDSs. RN/Admin also stated she worked to pass medications, provide bedside nursing care, do administrative work, and was responsible for staff development and training, and did not have enough time to complete the residents' MDS. RN/Admin further stated It was hard to hire nurses because nurses want more money than what the facility can afford. 555466 Page 3 of 28 555466 10/20/2023 Ashby Care Center 2270 Ashby Avenue Berkeley, CA 94705

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, for six (Resident 4, 5, 60, 61, 63 and 159) of thirteen sampled residents, the facility failed to complete the quarterly Minimum Data Set assessments (MDS - Resident Assessment and care guide tool) according to the regulation. Residents Affected - Some This failure had the potential to result in the delayed assessment of residents' needs, goals of care and inability to monitor each residents' progress over time. Findings: The following MDS record reviews were not completed every three months as follows: Review of Resident 4' MDS assessment indicated the last quarterly MDS assessment was completed 12/22/22. Review of Resident 5's MDS assessment indicated the last quarterly assessment was completed on 4/24/23. Review of Resident 60's MDS assessment indicated the last quarterly assessment was completed on 1/1/2023. Review of Resident 61's MDS assessment indicated the last quarterly assessment was completed on 2/6/2023. Review of Resident 63's MDS assessment indicated the last quarterly assessment was completed on 5/2/2022. Review of Resident 159's MDS assessment indicated the last quarterly assessment was completed on 4/27/2023. During an interview on 10/19/23 at 12:15 p.m., the registered nurse administrator (RN/Admin) stated she was aware that residents' MDSs were late, and was responsible for the completion and transmission of all the residents' MDS assessments but had other responsibilities to provide resident bedside care, staff development and training, and administrative work. RN/Admin stated the facility was a small building and cannot afford the high salary pay for staff. Review of the Long -Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, dated October 2019, indicated the quarterly assessment should be completed not later than 14 days after ARD (Assessment Reference Date). The Quarterly assessment is used to track a resident's status to ensure critical indicators of gradual change in a resident's status are monitored. The quarterly assessment is an OBRA (Omnibus Budget Reconciliation Act) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. {Reference: https://downloads.cms.gov/files} 555466 Page 4 of 28 555466 10/20/2023 Ashby Care Center 2270 Ashby Avenue Berkeley, CA 94705

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for four (Resident 3, 59, 61, and 164) of 13 sampled residents , the facility failed to electronically transmit accurate and complete Minimum Data Set (MDS - an assessment screening tool used to guide care), data to the CMS system within 14 days after the facility completes a resident's assessment. Residents Affected - Some Medicare and Medicaid-a government national health insurance program that provided health insurance for adults and children with limited income and resources. These failures had the potential to result in the delay of assessment of residents' needs, goals of care and inability to monitor each residents progress over time. Findings: Review of the MDS 3.0 Final Validation report dated 10/16/23 indicated Resident 3's quarterly assessments were completed on 7/22/2022 and the comprehensive assessment on 4/21/23 and was transmitted on 10/16/2023. Further review indicated Resident 3's comprehensive assessment was completed on 4/22/22, 4/21/2023, and the quarterly assessment completeted 7/22/23 were transmitted on 10/19/23. Review of MDS 3.0 Final Validation report dated 10/16/23 indicated Resident 59's annual comprehensive assessments completed 3/10/23, quarterly assessment completed 6/10/23 and 9/10/23 was transmitted on 10/16/2023. Review of MDS 3.0 Final Validation report dated 10/19/23 indicated Resident 61's comprehensive assessment was completed on 11/6/2021 and transmitted on 10/19/2023. Review of the MDS 3.0 Final Validation report dated 10/16/23 indicated Resident 164's comprehensive assessment dated [DATE], and quarterly assessments dated 10/1/2023, were transmitted on 10/16/2023. During an interview on 10/18/23 at 1:28 p.m., the registered nurse administrator (RN/Admin) stated the facility was aware of delayed MDS completions and late transmissions and had tried to hire someone for the MDS position, but had difficulty finding staff. RN/Admin stated the delayed MDSs were not discussed at the Quality Assurance meetings and there was no QAPI (quality assurance and performance improvement) plan. Review of the Long -Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17., dated October 2019, indicated the Assessment transmission: comprehensive assessments must be https://downloads.cms.gov/files} 555466 Page 5 of 28 555466 10/20/2023 Ashby Care Center 2270 Ashby Avenue Berkeley, CA 94705

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an ongoing activity program to support residents in their choice of activities. The facility did not have an active activity program or staff responsible for providing assistance with the activities program. Residents Affected - Many This failure had the potential to cause residents emotional distress and decline in their quality of life. Findings: 1. Review of Annual Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 4/21/23, indicated: Resident 3's Basic Interview of Mental status (BIMS- score was 14 meaning cognitively intact). Resident 3's activity preferences included listening to music, doing things with groups of people and participate in religious services or practices that were very important. Resident 3's diagnoses included schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly). Review of the activity care plan initiated on 7/1/21 indicated for staff to invite Resident 3 to participate in activities. During an interview on 10/16/23 at 9:44 a.m., Resident 3 stated there was no group activities since COVID-19 lockdown in 2020. Resident 3 stated he watched television to pass time and stayed in his room. During an observation and concurrent interview on 10/16/23 at 10:14 a.m., Resident 3 was sitting up in bed in his room looking out the door. Resident 3 said there was nothing to do. 2. Review of the MDS dated [DATE], indicated: Resident 5's BIMS score was 10 meaning mild, cognitive impairment. Resident 5 had clear speech, makes self understood, and understands others. Resident 5's activity preferences indicated having books, newspapers and magazines to read, listen to music, keep up with news, doing things with groups of people and participate in religious services or practices were very important. Review of the activity care plan initiated 10/8/2019 indicated Resident 5 has activity needs related to anoxic (lack of oxygen) brain damage and interventions included to invite resident to participate in activities. During an observation and concurrent interview on 10/17/23 at 8:27 a.m., Resident 5 was in a wheelchair watching television in her room. Resident 5 stated she got up daily to watch television and likes reading books, music , singing, story telling, and exercises. Resident 5 further stated before the COVID-19 lockdown in 2020, they used to have books and did not know where the books were kept. 3. Review of the MDS, dated [DATE], indicated Resident 61's BIMS score was 15, meaning cognitively intact. Resident 61's activity preferences indicated having books, newspapers and magazines to read, listening to music, be around animals such as pets, and go outside to get fresh air when the weather is good, and participate in religious services or practices were very important. 555466 Page 6 of 28 555466 10/20/2023 Ashby Care Center 2270 Ashby Avenue Berkeley, CA 94705

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of the activity care plan initiated 7/1/21 indicated Resident 61's activity interventions included to invite resident to participate in activities. During an observation and concurrent interview on 10/16/23 at 9:23 a.m., Resident 61 was up in a wheelchair watching television in her room. Resident 61 stated she watched television every day, walked up and down the hallways, and walk to her bathroom and back for exercise. Resident 61 stated there had been no activity program since COVID-19 lockdown in 2020, and it would be fun to have activities and engage with other residents sometimes. Resident 61 further stated she likes music, singing, exercise and story telling. Resident 61 stated the facility used to have books in the dining area and did not know where the books were kept. 4. Review of the MDS dated [DATE] indicated Resident 62's BIMS score was 15, meaning cognitively intact. Resident 62's activity preferences were having books, newspapers and magazines to read, and keeping up with the news. During and observation and concurrent interview on 10/17/23 at 8:32 a.m., Resident 62 was in bed in her room, awake and verbally responsive. Resident 62 stated the activities program was stopped during COVID-19 lockdown. Resident 62 further stated she watched television every day but would like to sing with others and do some exercises. During an interview on 10/17/23 08:48 a.m., the Registered Nurse/Administrator (RN/Admin) stated the activity staff last worked at the facility in March 2020. RN/Admin stated the books in the dining room area were thrown away because the books were old. RN/Admin stated Resident 62 had no activity care plan. During an interview on 10/19/23 at 11:11 a.m., RN/Admin stated the facility had no activity staff and no activity program since COVID-19 lock down in 2020, because staff had been busy providing bedside care and had no time to set up activities. Review of the Residents Rights, undated document indicated the facility must care for its residents in a manner and in an environment that promotes maintenance or enhancement of each residents's quality of life. The resident has the right to choice activities, schedules, and healthcare consistent with his or her interests, assessments and plan of care. 5. A review of Resident 163's clinical record indicated she was admitted on [DATE]. During an interview on 10/19/23, at 2:06 p.m., Resident 163 stated the facility used to have a lot of group activities for the residents before the strict COVID-19 outbreak isolation rules in 2020, and the group activities had to stop. Stated she wanted to attend facility group activities again, like church and bible studies. 6. A review of Resident 167's clinical record indicated she was admitted on [DATE]. A review of Resident 167's MDS, dated [DATE] indicated the resident's cognition was mildly impaired. During an interview on 10/19/23, at 2:10 p.m., with Resident 167, Resident 167 stated she wanted to attend facility group activities again. During a review of the facility's policy and procedure (P&P) titled, (Quality of Life), the P&P indicated, . A resident has the right to participate in social, religious, and community activities that do not interfere with the rights of other residents in the facility .The facility must provide for 555466 Page 7 of 28 555466 10/20/2023 Ashby Care Center 2270 Ashby Avenue Berkeley, CA 94705

F 0679 an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interest and the physical, mental and psychosocial well-being of each resident . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 555466 Page 8 of 28 555466 10/20/2023 Ashby Care Center 2270 Ashby Avenue Berkeley, CA 94705

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutrition status for one ( (Resident 159) of three residents when Resident 159 lost 24% of her body weight in the last nine months. Resident 159 was not seen by a Registered Dietitian (RD) for a dietary evaluation since June 2023. Residents Affected - Few This failure had the potential to cause additional weight loss and increase Resident 159's risk of morbidity (the condition of suffering from a disease or medical condition) and mortality (death). Findings: 1. During an observation on 10/16/23 at 12:20 PM, Resident 159 was in bed. She was not able to respond to questions with yes or no. Her food tray was on the side table and appeared untouched. The tray ticket (identifies patient name, their diet, and food likes and dislikes) indicated, Resident 159 was on a regular diet, mechanical soft texture, thin liquid diet. The tray had two items 1) a small bowl of porridge and 2) a 12 oz (ounce) can of soda. The resident was having trouble feeding herself and was spilling food on herself. A review of Resident 159's face sheet (a summary of patient's demographic information), indicated Resident 159 was admitted to the facility, on 10/20/21, with diagnoses that included moderate protein calorie malnutrition (PCM), which refers to a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), adult failure to thrive (FTT) happens when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal), cachexia (ill health, malnutrition and wasting), anorexia (an eating disorder characterized by an abnormally low body weight), and dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). During a review of Resident 159's Weights (undated) indicated the following: March 2, 2023 - 98 lbs. (pound) April 1, 2023 - 77 lbs. May 1, 2023 - 77 lbs. June 1, 2023 - 74 lbs. July 1, 2023 - 76 lbs. August 1, 2023 - 74 lbs. September 1, 2023 - 73 lbs. October 1, 2023 - 74.6 lbs. During a review of Resident 159's Nutritional Progress Notes, dated June 23, 2023, documented by Registered Dietician (RD) indicated, PO (by mouth) intake remains fair/poor. 555466 Page 9 of 28 555466 10/20/2023 Ashby Care Center 2270 Ashby Avenue Berkeley, CA 94705

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Residents 159's Nutritional Progress Notes, dated June 2, 2023, by RD 1 indicated, Resident with significant weight loss x 3 and 6 months. Continue weekly Weights x 4 weeks and Physician to adjust Remeron/appetite stimulant per physician discretion. During a review of Resident 159's Nutritional Progress Notes, dated May 5, 2023 indicated, CBW (current body weight) 74 lbs., -17.89% (16 lbs.) weight loss x 3 months, significant and Started fortified diet 5/1/23, Remeron medication started 4/28/23 - 7.5 mg (milligram). Receiving med pass (Health Shake) 90 ml (milliliter) BID (two times a day) between meals. During a review of Residents 159's Nutritional Progress Notes, dated April 28,/2023, indicated, Resident reweighed - CBW & lbs (pounds). -21% x 1 month, significant and recommend fortified diet. During a review of Residents 159's Nutritional Progress Notes, dated June April 14, 2023 indicated, Weight loss x 1 month, significant .BMI (body mass index, a measure of body fat based on height and weight) underweight and recommend fortified diet. During an interview on 10/17/23 at 10:30 AM, with the Dietary [NAME] (Cook), [NAME] stated Resident 159's family brings in food every morning and is kept in the kitchen fridge. [NAME] stated he does not fortify the soup nor provide med pass, and only heats the soup in the microwave. [NAME] stated the facility did not have a dietician for the past three months and was not aware of any weight loss issues with Resident 159. During a telephone interview with the Registered Dietician Consultant (RDC), RDC stated the facility did not have a contract in place with [company name] for the past three months, and No dietician has been at this facility since July 2023. RDC stated the kitchen should not handle food the family brings in for Resident 159, and the facility could ask the family to fortify prior to bringing food in. RDC further stated nursing staff would have told the dietician if weekly weights were not carried out. During a review of the facility's policy and procedure (P&P) titled, High Nutrition Risk Residents dated 2023, the P&P indicated, Facilities may call the Registered Dietician Nutritionist for follow up on established high risk residents. During a review of the P&P titled, Significant Weight Changes dated 2023 indicated, Residents experiencing significant weight changes will be identified and asked in a timely manner in order to minimize further unplanned significant weight changes by identifying the underlying causes and contribution factors and intervening as appropriate to resolve the problem During a review of the article, Evaluating and Treating Unintentional Weight loss in the Elderly American Family Physician, Volume 64, Number 2, dated February 15, 2002, which indicated, nursing home patients had a significantly higher mortality rate in the six months after losing 10 percent of their body weight, irrespective of diagnoses or cause of death. In another study, institutionalized elderly patients who lost 5 percent of their body weight in one month were found to be four times more likely to die within one year. 555466 Page 10 of 28 555466 10/20/2023 Ashby Care Center 2270 Ashby Avenue Berkeley, CA 94705

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical review, the facility failed to provide pharmaceutical services to meet the needs of four of 14 sampled residents (Residents 63, 162, 163, and 170) when the facility failed to perform daily glucometer (small machine that measures blood glucose or sugar level) quality control checks to ensure accurate readings. This failure had the potential risk of adverse consequences associated with the glucometer used for Residents 163 and 170 whose insulin dosage (medication that lowers the blood glucose) were dependent on the accuracy of the glucometer readings. For Residents 63 and 162, this had the risk of incorrect blood glucose readings and inappropriate medical interventions for Residents 63 and 162. Findings: 1. During a concurrent interview and record review on [DATE], at 11:50 a.m., with Administrator (Adm), the glucometer quality control log was reviewed. There was no record of the glucometer quality control checks being done since [DATE]. Adm confirmed the findings and stated the facility was only using one FreeStyle Freedom Lite glucometer for Residents 63,162,163, and 170. Adm stated the risk of using an uncalibrated (not adjusted)glucometer were inaccurate blood glucose results for Residents 63,162,163, and 170. Review of Resident 163 's medical record showed Resident 163 was admitted to the facility on [DATE], with diagnoses including diabetes (blood sugar disorder). Review of the monthly physician orders dated 10/2023, showed an order dated [DATE], for blood sugar readings to be checked before breakfast and at bedtime daily, and to call the physician if blood sugar was less than 80 or greater than 400. Another order dated [DATE], indicated Novolin N insulin (works in the body for 24 hours), 15 units subcutaneously (inject under the skin), every morning and to hold if blood sugar was less than 100. Also, an order dated [DATE], indicated Lantus insulin (works in the body for 24-hours), five units subcutaneously at bedtime and hold if blood sugar was less than 100. 2. Review of Resident 170's medical record showed Resident 170 was admitted to the facility on [DATE], with diagnoses including diabetes. Review of the monthly physician orders dated [DATE], showed an order dated [DATE], for blood sugar readings to be checked daily at bedtime. An order dated [DATE], indicated glucose gel (treats low blood sugar) 5 mg (milligram) by mouth if blood sugar was less than 60 PRN (as needed). Another order dated [DATE], indicated Levemir insulin (works in the body for 24 hours) 14 units subcutaneously at bedtime, hold if blood sugar was less than 100. 3. Review of Resident 162's medical record showed Resident 162 was admitted to the facility on [DATE], with diagnoses including diabetes. Review of the monthly physician orders dated [DATE], indicated an order dated [DATE], for blood sugar readings to be checked two times a week, Mondays and Thursdays in the morning. 4. Review of Resident 63's medical record showed Resident 63 was admitted to the facility on [DATE], with diagnoses including diabetes. Review of the monthly physician orders dated [DATE], indicated an order dated [DATE], for blood sugar readings to be checked once a week on Mondays. During an interview on [DATE], at 11:06 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 555466 Page 11 of 28 555466 10/20/2023 Ashby Care Center 2270 Ashby Avenue Berkeley, CA 94705

F 0755 Level of Harm - Minimal harm or potential for actual harm verified, Residents 163 and 170 had insulin administered based on blood sugar results obtained using the FreeStyle Freedom Lite glucometer. LVN also stated, the facility started using the glucometer for maybe less than a year and was aware the glucometer quality control checks were supposed to be done daily. LVN further stated, the risk of not performing the control checks could be life threatening to residents who were receiving insulin because the wrong dose of insulin could be given due to inaccurate blood sugar results. Residents Affected - Many During an interview on [DATE], at 11:06 a.m., with the Pharmacist Consultant (PC), PC stated, she did not know the facility was not performing the glucometer quality control checks. PC stated the calibration of the glucometer must be done daily to ensure accuracy of the blood glucose readings. PC further stated the risk of not doing daily glucometer control checks would be giving wrong doses of insulin to the residents due to wrong blood glucose results. Review of the FreeStyle Freedom Lite glucometer manual, pages 21 and 22 indicated, The purpose of doing a control solution test is: . To confirm that the meter and test strips work together properly . Causes of out-of-range results include . Expired or bad test strip . Meter malfunction, Test strip deterioration . During a review of the facility's policy and procedure (P&P) titled, (Glucometer Maintenance), the P&P indicated, . the purpose of this policy is to set forth the requirements to ensure the proper functioning of the glucometer through daily quality control tests .The glucometer will be tested daily . with test results documented on the Glucometer Quality Control Record. In addition, glucometer should be tested: 1. Before using the system for the first time, 2. When opening a new vial of strips, 3. If test results seem unusually high or low based on the patient's condition, 4. If strip vial has been left open or exposed to extreme heat, cold or humidity, 5. Whenever a check on the performance of the system is needed, or 6. If meter damage is suspected (meter dropped, crashed, wet, etc.) 555466 Page 12 of 28 555466 10/20/2023 Ashby Care Center 2270 Ashby Avenue Berkeley, CA 94705

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure two (Resident 59 and 2 ) of five sampled residents were free from unnecessary drug when; 1. Resident 59 was administered Zyprexa (antipsychotic) drug without adequate clinical indication for its use. Antipsychotic medications are used to treat mental health conditions, capable of affecting the mind, emotions, and behavior. 2. Resident 2's PRN (as needed) order for Haldol (antipsychotic) drug had no informed consent and stop date. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Zyprexa can increase the risk of death in elderly people who have memory loss and is not approved for use in psychotic conditions related to dementia. [Reference: www.[NAME].comp]. These failures had the potential for residents to receive unnecessary drugs and suffer adverse medication side effects. Findings: Review of Minimum Data Set (MDS, a resident assessment and care guide tool), dated 9/10/23, indicated Resident 59's Basic Interview of Mental status (BIMS) score was 07 (meaning poor cognition). Resident 59 had clear speech, makes self understood and understand others. Resident 59 had no evidence of an acute change in mental status from baseline. Resident 59 had verbal/vocal symptoms, like screaming and disruptive sounds. Resident 59's diagnoses included Non-Alzheimer's Dementia (a group of diseases characterized by progressive deficits in behavior, executive function or language) and depression. MDS section I Active diagnoses did not indicate Resident 59 had a diagnosis of schizophrenia. Review of Resident 59's physician order dated 9/26/23 indicated Zyprexa 2.5 mg (milligram) one tablet by mouth every morning and 5 mg by mouth every hour of sleep for schizophrenia. Review of the Medication Administration Record (MAR), dated September 2023 and October 1st to 18th 2023 indicated Resident 59 was administered Zyprexia 2.5 mg by mouth every morning and 5 mg by mouth every hour of sleep for schizophrenia manifested by hallucination, cursing with profound language. During an interview and concurrent review of Resident 59's MDS, admission records, hospital notes, physician progress notes on 10/16/23 at 1:33 p.m., with Registered Nurse/Administrator (RN/Admin), the records did not indicate Resident 59 had a diagnosis of schizophrenia. RN/Admin stated Resident 59 was administered Zyprexa for cursing out loud at night and for disturbing his roommates. During an interview on 10/17/23 at 9:26 a.m., Certified Nursing Assistant (CNA 1) stated Resident 59 had episodes of screaming at times when he pee on himself. CNA 1 stated Resident 59 screamed curse words, was not combative, and cooperate with care. During an interview on 10/17/23 at 11:38 a.m., Licensed Vocational Nurse (LVN 1) stated Resident 59 555466 Page 13 of 28 555466 10/20/2023 Ashby Care Center 2270 Ashby Avenue Berkeley, CA 94705

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few received Zyprexa for yelling. LVN 1 stated Resident 59 yells when he pee on himself and needed to be changed. During an interview on 10/18/23 at 11:45 a.m., RN/Admin stated she did not know why schizophrenia was added as a diagnosis. RN/Admin further stated the Director of Nursing (DON) transcribed the order to include schizophrenia. RN/Admin stated DON was on vacation (unavailable for interview). Review of the Consultant Pharmacist (CP) recommendation to the interdisciplinary team (IDT, members of different departments, like social services, rehabilitation therapists, nurses), dated 1/31/23, indicated Resident has an order for Zyprexa 5 mg daily for schizophrenia since 11/1/18. Resident 59 had no noted sadness, insomnia, or yelling. He also had zero episodes of sadness, social isolation, withdrawn or sad affect. It would be appropriate to review (Zyprexa). During an interview on 10/18/23 at 2:17 p.m., Medical Director (MD) stated he had to review Resident 59 records regarding the schizophrenia diagnosis. MD further stated cursing with profound language was not an appropriate indication for use of antipsychotic drugs. 2. A review of Resident 2's admission record indicated the resident was admitted on 3/11 /23 with diagnoses that included senile degeneration of the brain (mental decline) and dementia (loss of memory, language, problem-solving and other thinking abilities). A review of Resident 2's MDS dated [DATE] indicated the resident had severe cognitive impairment. A review of the physician's orders dated October 2023, indicated Haloperidol (Haldol, a strong antipsychotic) 1 mg every 4 hours prn for anxiety or agitation. The prn Haldol order had no stop date after the physician ordered the medication on 3/11/23. Review of facility's policy and procedure titled, Psychotropic Medication,(undated) indicated the purpose of the Psychotropic Drugs policy is to develop a facility system to ensure a resident is not given psychotropic medications unless a comprehensive assessment identifies clear indications and parameters for their use based upon regulatory compliance and best practices. PRN orders for psychotropic drugs are limited to 14 days or prescribing practitioner believes that it is appropriate for PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical records. 555466 Page 14 of 28 555466 10/20/2023 Ashby Care Center 2270 Ashby Avenue Berkeley, CA 94705

F 0761 Level of Harm - Minimal harm or potential for actual harm 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 dispose of expired medications. Residents Affected - Few These failures had the potential to result in the administration of expired medications to the residents and possible adverse (unwanted, undesirable) side effects or receiving medications that have become less effective for treatment. Findings: During a concurrent observation and interview on 10/17/23, at 10:51 a.m., with the Administrator (Adm), about the Medication Cart 1 ten tablets of expired famotidine (medication for excess stomach acid) 10 mg (milligram) were found inside Medication Cart 1's top drawer. Adm stated, the expired medications should not be in the cart and should have been disposed. During an interview on 10/19/23, at 11:06 a.m., with the Pharmacist Consultant (PC), PC stated, she was responsible for the disposal of expired medications from the medication cart. PC stated, expired medications should not be in the medication cart because of the possibility of giving the residents the expired medications. PC further stated, the residents could suffer the adverse side effects (unwanted and unexpected drug reactions) of the expired medicine if given to the residents. During a review of the facility's policy and procedure (P&P) titled, Medication Storage, dated 2023, the P&P indicated, . outdated, contaminated, discontinued or deteriorated medications . are immediately removed from stock, disposed of according to procedures for medication disposal . and reordered from the pharmacy . 555466 Page 15 of 28 555466 10/20/2023 Ashby Care Center 2270 Ashby Avenue Berkeley, CA 94705

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation, interview, and record review, the facility failed to have Registered Dietitian (RD) oversight of the kitchen and clinical nutrition care (ensuring residents are consuming an adequate amount of nutrients for good health) since 7/28/23. There was no full-time Dietary Manager (DM) to manage kitchen operations when the menu was not being followed (cross-reference 803), unsanitary conditions in the kitchen (cross-reference 812), no pest control program (cross-reference 925), and the nutrition status of one (Resident 159) was not being maintained (cross-reference 692). These failures placed 26 of 26 residents who received food from the kitchen at risk for compromised nutritional status and had the potential for transmission of food borne illness. Findings: During an interview on 10/16/23 at 09:30 a.m., with the Dietary [NAME] (Cook), [NAME] stated the facility did not have a Dietary Manager (DM) for the past three years and the RD had not come into the facility for the past three months. [NAME] stated he was solely responsible for the cooking, cleaning, and ordering the food for the entire facility. During a telephone interview on 10/18/23 at 12:06 p.m., with the Registered Dietitian (RD) who was the COO (Chief Operating Officer) of the [Company Name], RD stated they haven't been at the facility for the last three months, because the facility had not signed an updated contract or were current with their payments. RD stated the facility had been informed on a recurrent basis of the state requirement for having a DM on staff. RD further stated the facility just re-signed a contract on 10/16/23. The Registered Dietitian 1 (RD 1) first day in the building was on 10/18/23. During an interview on 10/18/23 at 2:44 p.m. with Administrator (Admin), Admin stated the facility has not had an RD because the contract company said they did not sign the contract. Admin stated they had trouble filling the DM position because the facility cannot offer a full-time positon. During a review of the facility's position description for Dietary Services Manager (DM), undated, the DM position indicated, the DM ensured the delivery of meals, hydration, and nourishment in accordance with assessed needs and nutritional plans while under the direction of a Registered Dietitian. 555466 Page 16 of 28 555466 10/20/2023 Ashby Care Center 2270 Ashby Avenue Berkeley, CA 94705

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, staff interview, and facility document review, the facility failed to ensure the planned menu was followed when the Cold [NAME] Bean Salad was substituted for Creamy Cucumber Celery Salad on Monday 10/16/23. The lunch menu for 10/16/23 had already included a hot green bean side dish. This failure had the potential to result in not meeting the nutritional needs of the residents and compromising the nutritional status of the residents. Findings: During a review of the Fall Menu Week 3 Monday: 9/18/23, 10/16/23, 11/13/23: Therapeutic Spreadsheets and the Weekly Menu: October 16 - 22, 2023, undated showed Creamy Cucumber & Celery Salad was listed on the lunch menu for all diets. During a concurrent observation and interview on 10/16/23 at 10:42 a.m., with Dietary [NAME] (Cook) of the Trayline food service in the kitchen, Cold [NAME] Bean Salad was substituted for Creamy Cucumber & Celery Salad on the lunch trays. [NAME] stated the Creamy Cucumber & Celery Salad was on the weekly menu and on the therapeutic spreadsheet and was not provided to the residents. During a telephone interview on 10/18/23 at 12:06 p.m., with Registered Dietician (RD), stated Any and all substitutions should have been noted on the log. If it's logged, then the RD can see what was substituted and discuss with the cook. During a concurrent interview and record review on 10/18/23 at 12:15 p.m., with [NAME] 2, [NAME] 2 stated Creamy Cucumber & Celery Salad was not available. The Menu Substitution Record was reviewed. [NAME] 2 stated [NAME] 1 did not make the notation on the menu Substitution Record but should have. [NAME] 1 also stated no one, including the RD, reviewed or approved menu substitutions. During an interview on 10/18/23 at 11:53 a.m., with Administrator (Admin), Admin stated menu substitutions were incomplete and could not be reviewed by an RD to ensure nutrient/caloric needs of all residents were being met. During a review of the policy and procedure (P&P) titled, Menus dated 2003, showed Menu substitution must be made for specific reasons, i.e., food not available, out of season, or resident's preference .should be approved and signed off by the Registered Dietician .1. Facilities must keep a menu Substitution Record which includes the date, food item to be changed, food item substituted and the reason. The menu Substitution record should be kept on file for 30 days. 555466 Page 17 of 28 555466 10/20/2023 Ashby Care Center 2270 Ashby Avenue Berkeley, CA 94705

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, staff interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety when: Residents Affected - Many 1. A refrigerator in the kitchen was dirty, food was not labeled and dated, the door was dirty with smudges. The top freezer of the refrigerator had crusted food and food crumbs, and food was not labeled and dated. A reach-in freezer had food crumbs and the door had dark, brown build-up. This had the potential to contaminate the food or the hands of food workers, that could lead to food borne illness. 2. Dry food storage bins had yellow and brown stains and were not safe for storing food. This had the potential to contaminate the food stored inside. 3. Island shelves storing clean dishware and trays were sticky with grime and food crumbs in the corners. The utensil storage container, storing clean utensils had food crumbs. This had the potential to contaminate food and clean dishware. 4. All the upper cabinetry and lower cabinets in the kitchen were made of wood that was deteriorating. Chunks of the wood were missing and there were wood shavings on the inside shelves. The face of the cabinets and the shelves were sticky and had yellow stains. This had the potential to contaminate the clean dishes stored inside. 5. Under the 3-compartment sink, the tiles were uneven and there was a build-up of food crumbs between the tiles. This had the potential for microorganism growth and attraction of pests. 6. The oven had a rusty color inside, and was crusted with black grime and had the potential to contaminate food being cooked. These failures put the facility at increased risk for food contamination and food borne illness for 26 residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview during the initial kitchen tour, on 10/16/23 at 09:45 a.m., with Dietary [NAME] (Cook), there was a pan with cooked and partially used, unlabeled and undated, noodle with green leafy vegetable and small pieces of white meat. In addition, there was dried brown residue inside on the bottom surface of the refrigerator. Dark pink residue was adhered to the right side of the refrigerator and on the bottom wire shelf. Also, dried tan particles were on the surface of the shelving in the door of the refrigerator. [NAME] stated the noodle dish was made a few days ago and had forgotten to label and date the saucepan. During an observation and concurrent interview during the initial kitchen tour, on 10/16/23 at 10:00 a.m.,with Cook, the top freezer of the [NAME] refrigerator contained food in individual clear transparent plastic boxes that were unlabeled and undated. There were food crumbs and yellow residue on the freezer bottom shelf. [NAME] stated the food items were cheesecakes that had been there for a while. [NAME] stated the fridge and freezers had not been cleaned for a few years. Further observation and interview during the initial kitchen tour, on 10/16/23 at 10:20 a.m., with Cook, the reach-in freezer has crusted food and trash on the bottom shelf. The freezer door frame 555466 Page 18 of 28 555466 10/20/2023 Ashby Care Center 2270 Ashby Avenue Berkeley, CA 94705

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many was broken, and the insulation was loose. Food crumbs were on the bottom shelf. [NAME] stated he is the individual responsible for cooking, cleaning, and ordering food and had not cleaned the kitchen since the pandemic. During an interview on 10/18/23 at 11:09 a.m. with Cook, [NAME] stated there was no schedule for cleaning of the refrigerators and freezers in the kitchen. During an interview on 10/18/23 at 12:06 p.m., with the Registered Dietician (RD), RD stated the interior and exterior of the refrigerators and freezers should be cleaned and sanitized on a regular basis. According to the 2022 FDA Federal Food Code, 4-601.11 indicates, (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. During a review of the facility's policy and procedure (P&P) titled, Cleaning and Defrosting Freezers dated 2023, indicated Reach-in freezers will be cleaned and sanitized once a week .2. Wash all shelves by cleaning with a wet cloth or removing them and washing in a sink of hot, soapy water. 3. Rinse, sanitize and air dry the shelves. During a review of the facility's policy and procedure (P&P) titled, Refrigerated Storage dated 2023, indicated .7. All cooked food must be labeled and dated .9. Leftover food .should be covered, labeled, and dated . 2. During a concurrent observation and interview, during the initial kitchen tour on 10/16/23 at 10:20 a.m., with Cook, the dry storage bins used to store onions, thickeners, and rice had yellow and brown stains and were not safe for storing food. [NAME] stated he purchased the storage bins and would wash them in the dishwasher and did not know if the storage bins met food grade requirements. During an interview on 10/18/23 at 11:09 a.m. with Cook, [NAME] stated there was no schedule for cleaning the bins in the storage room. During an interview on 10/18/23 at 12:06 p.m., RD stated all the food should be in food safe containers. According to the 2022 FDA Federal Food Code, 4-101.11 indicates, Materials that are used in the construction of utensils and food-contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be: (A) Safe; (B) Durable, corrosion-resistant, and nonabsorbent; (C) Sufficient in weight and thickness to withstand repeated warewashing; (D) Finished to have a smooth, easily cleanable surface; and (E) Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. During a review of the facility's policy and procedure (P&P) titled Canned and Dry Good Storage dated 2023, indicated All the food and non-food items purchased by the department of food and nutrition services will be stored properly .9. Metal, plastic containers (with tight fitting lids and NSF approved), .will be used for staples and opened packages of items such as pastas, rice, dry cereals, etc. 555466 Page 19 of 28 555466 10/20/2023 Ashby Care Center 2270 Ashby Avenue Berkeley, CA 94705

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 3. During a concurrent observation and interview during the initial kitchen tour, on 10/16/23 at 10:30 a.m., with Cook, seven of seven randomly selected pans and eight of eight randomly selected trays from those stacked and stored on the Island shelves had residue on the inside surface. The island shelves were sticky and had sticky grime and food crumbs in the corners. The center island had yellow grime in the crevices of the shelves. The clean utensil storage had food crumbs in the trays of the utensils. [NAME] agreed the shelves were sticky and verified the presence of food crumbs in the utensil drawers. During an interview on 10/18/23 at 12:06 p.m., RD stated surfaces should not be sticky and there should not be any crumbs on the shelves and drawers or any build-up. According to the 2022 FDA Federal Food Code, 4-601.11 indicates, (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. During a review of the facility's policy and procedure (P&P) titled Sanitizing Equipment, food and Utility Carts dated 2023, indicated .4. All kitchen equipment and surfaces which come in contact with food will be cleaned and sanitized after each use. 5. Food and utility carts will be cleaned and sanitized after each meal or use. 4. During a concurrent observation and interview during the initial kitchen tour, on 10/16/23 at 10:35 a.m., with Cook, a set of cabinets attached to the wall in the kitchen that held single use food service items and dishware had doors with dark residue surrounding the cabinet handles. There was peeling paint and chipped wood on the cabinet doors. Another cabinet attached to the wall in the dry storage room, held staff personal items, and had doors with black residue on the outside surface, especially around the handles. At the base of the outside surface of the cabinet was dark brown residue, as well as residue build-up on the floor next to the cabinet base, Additionally, the cabinet drawers were lined with foil and/or shelf liner, and underneath the foil and shelf liner were food crumbs. The exterior wood cabinets was sticky with crusted yellow grime. The cabinets were chipped and rotting at the corners and edges. The stand-alone shelves in the dry storage room had food crumbs. [NAME] stated a deep cleaning was not scheduled yet. [NAME] stated staff mopped the floor every day but did not pull the racks out and the floorboards needed to be cleaned. [NAME] stated the cabinets attached to the wall were in disrepair and confirmed there was peeling paint and chipped wood. [NAME] confirmed the staff storage cabinet was dirty and had to be cleaned. During an interview on 10/18/23 at 11:09 a.m. with Cook, [NAME] stated there was no schedule for replacing the cabinets in the kitchen. During an interview on 10/18/23 at 12:06 p.m., RD stated the facility should get rid of the wood cabinet, and shelves in the kitchen and dry storage areas and put in better materials, that are easily cleaned. According to the 2022 FDA Federal Food Code, 4-101.19 indicated, Nonfood-Contact Surfaces of equipment that are exposed to splash, spillage, or other food soiling or that require frequent cleaning shall be constructed of a corrosion-resistant, nonabsorbent, and smooth material. In addition, Nonfood-contact surfaces of equipment routinely exposed to splash or food debris are required to be constructed of nonabsorbent materials to facilitate cleaning. Equipment that is easily cleaned minimizes the presence of pathogenic organisms, moisture, and debris and deters the attraction of rodents and insects. 555466 Page 20 of 28 555466 10/20/2023 Ashby Care Center 2270 Ashby Avenue Berkeley, CA 94705

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a review of the facility's policy and procedure (P&P) titled, Canned and Dry Good Storage dated 2023, indicated All the food and non-food items purchased by the department of food and nutrition services will be stored properly .3. The storage area (cupboards, shelves, drawers, storeroom) will be clean and dry .6. It is not recommended that shelves and cupboards be lined with shelf paper or other liner. If they are lined the lining should be changed frequently .9. Metal, plastic containers (with tight fitting lids and NSF approved), .will be used for staples and opened packages of items such as pastas, rice, dry cereals, etc.17. Storage area will be cleaned and maintained . During a review of the facility's policy and procedure (P&P) titled, Sanitizing Equipment, food and Utility Carts dated 2023, indicated .4. All kitchen equipment and surfaces which come in contact with food will be cleaned and sanitized after each use. 5. Food and utility carts will be cleaned and sanitized after each meal or use. 5. During a concurrent observation and interview during the initial kitchen tour on 10/16/23 at 10:40 a.m., with Cook, the area under the food preparation sink had a build-up of food crumbs and black grime on the floor between the uneven tiles. There were three opened #10 cans on the floor under the counter containing trash and food inside. [NAME] stated there was no schedule for cleaning the kitchen floor. During an interview on 10/18/23 at 12:06 p.m., RD stated the kitchen floor should be sealed and there should not be any crumbs or gaps in tiles. During a review of the FDA Federal Food Code, dated 2022, 4-101.19 indicated, Nonfood-Contact Surfaces of equipment that are exposed to splash, spillage, or other food soiling or that require frequent cleaning shall be constructed of a corrosion-resistant, nonabsorbent, and smooth material. In addition, Nonfood-contact surfaces of equipment routinely exposed to splash or food debris are required to be constructed of nonabsorbent materials to facilitate cleaning. Equipment that is easily cleaned minimizes the presence of pathogenic organisms, moisture, and debris and deters the attraction of rodents and insects. 6. During a concurrent observation and interview during the initial kitchen tour on 10/16/23 at 10:47 a.m., with Cook, the oven had rust with crusted black grime inside. The handles had yellow grime build up. [NAME] verified the oven was rusted inside. During a telephone interview on 10/18/2023 at 12:06 PM, with the Registered Dietitian Consultant (RDC), RDC stated the oven should be cleaned daily and deep-cleaned to ensure no residue build-up. During a review of the FDA Federal Food Code, dated 2022, 4-602.13 indicated, Non-food contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. During a telephone interview on 10/18/23 at 12:06 p.m., with RDC, RDC stated the facility did not have a contracted dietician since 7/27/23, and just signed a contract on 10/16/23. RDC acknowledged the facility did not have a dietary manager (DM) and had informed the facility they needed to have a full time DM and/or RD employed full time for a minimum of 35 hours/week. RDC was concerned that the dry storage space was used as an office, and personal food and items were kept there. 555466 Page 21 of 28 555466 10/20/2023 Ashby Care Center 2270 Ashby Avenue Berkeley, CA 94705

F 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record review, the facility failed to develop an effective Quality Assurance and Performance Improvement plan (QAPI) that identified and addressed the following: Residents Affected - Many - Lack of activity program for residents, - No designated staff person responsible for providing assistance with resident group meetings and activities program, - No resident group meetings since 2020, - Late completion and transmission of Minimum Data Set (MDS- Resident Assessment tool used to guide care). These failures had the potential to cause the residents emotional distress, and decline in residents quality of life and quality of care. Findings: During an interview on 10/19/23 at 12:15 p.m., Registered Nurse/Administrator (RN/Admin) stated the facility did not identify or address with QAPI, about the residents lack of an activity program, open position for activity staff, and no designated staff person responsible for providing assistance with resident council meetings. There were no resident group meetings since COVID-19 lockdown in 2020 and were never resumed, and had late completion and transmission of residents' MDS. RN/Admin stated these concerns were not discussed during the monthly and quarterly QA committee meetings. During an interview on 10/19/23 at 12:37 p.m., the Medical Director (MD) stated he was not aware that activities were not provided for residents. MD stated when he visited he saw residents engaging and socializing doing some activities. MD stated he was not aware that resident assessments -MDSs were not completed timely and transmitted. MD further said he was not aware the facility had no activity staff, no dietary supervisor. MD stated he attended QA meetings at the facility on a regular basis. During review of the QAPI plan and concurrent interview on 10/20/23 at 11:13 a.m., RN/ Admin stated the facility's QA plan did not identify and address lack of activity program for residents, open position for activity staff, no resident group/ council meetings since 2020 and late completion and transmission of residents' MDSs with action plan. Review of facility's QAPI Plan, dated 2023, indicated; The purpose of QAPI in our organization is to take a proactive approach to continually improve the way we care for and engage with our residents, caregivers and other partners so that we may realize our vision to provide quality care through respect and dignity. QAPI focuses on systems and processes rather than individuals. The emphasis is on identifying system gaps rather than on blaming individuals. The outcome of QAPI in our organization is to improve the quality of care and quality of life of our residents. 555466 Page 22 of 28 555466 10/20/2023 Ashby Care Center 2270 Ashby Avenue Berkeley, CA 94705

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 interview and record review the facility failed to develop a policy and procedure for an active water management program to address prevention of Legionnaires (LD) and other opportunistic pathogens (disease causing) in water. The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Residents Affected - Many This failure had the potential to cause spread of water borne pathogen growth in the facility. Findings: During an interview on 10/18/23 at 1:20 p.m., with Registered Nurse/Administrator (RN/Admin)accompanied by Assistant Director of Nursing (ADON), RN/Admin stated, facility had no water treatment program at this time. RN/ Admin could not provide documentation for facility's water treatment program to prevent Legionnaire and spread of water pathogen. RN/Admin stated facility was not aware of water management measures for water borne pathogens and had no water management policy. .Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as showerheads, cooling towers, hot tubs, and decorative fountains. Facilities must have water management plans and documentation that, at a minimum, ensure each facility conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens . [Reference: Center for Clinical Standards and Quality/Quality, Safety and Oversight Group Ref: QSO-17-30-REVISED 07.06.2018} 555466 Page 23 of 28 555466 10/20/2023 Ashby Care Center 2270 Ashby Avenue Berkeley, CA 94705

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the following equipment was maintained in good repair as follows: Residents Affected - Many 1. [NAME] refrigerator with top freezer: the bottom right side of the rubber gasket on the freezer door was torn and peeled away from the door. 2. Reach-in stainless steel freezer: the door frame was broken off the hinges, the rubber gasket was torn across the top of the lid and there was ice buildup on the inside walls. The Freezer had a crack with the insulation covered with masking tape. This failure had the potential for the refrigerator and freezers to not maintain appropriate temperatures and put the facility at risk for diminished quality of food stored in the freezer and/or affecting the safe storage of food leading to foodborne illness for 26 residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview on 10/16/23 at 10:47 a.m., during the initial kitchen tour, the rubber gaskets around the interior perimeter of the two reach-in refrigerators, and one reach-in freezer doors were torn. Dietary [NAME] (Cook) stated the gaskets should not be torn and need replacement. During a concurrent observation and interview on 10/16/23 at 11:10 a.m., with [NAME] in the kitchen, [NAME] stated the reach-in refrigerator thermometer was 43 degrees. [NAME] stated the refrigerator temperature should be 41 degrees or below. The rubber gasket was loose from the door, the exterior of the refrigerator was dirty on the surface, and on the door handle. The interior of the refrigerator was dirty with food crumbs throughout. [NAME] stated he was assigned to clean the kitchen and had not cleaned the kitchen in a few months. 1. During a concurrent observation and interview on 10/16/23 at 11:00 a.m., with Cook, during the initial kitchen tour, the rubber gasket on the [NAME] refrigerator was torn and peeled away from the bottom right side. During a telephone interview on 10/18/23 at 12:10 p.m. with Registered Dietician Consultant (RDC), RDC stated equipment should be maintained in good repair and fixed if broken. 2. During a concurrent observation and interview on 10/16/23 at 11:17 a.m., with the Cook, during the initial kitchen tour, the reach-in stainless steel freezer door frame was detached from the hinges. The white rubber gasket was stained a tan color, torn, with an insulation crack, and was covered with masking tape. [NAME] stated the freezer needed to be fixed. During a telephone interview on 10/18/23 at 12:10 p.m. with RDC, RDC stated equipment should be maintained in good repair and fixed if broken. During an interview on 10/18/23 at 2:31 p.m. with Administrator (Admin), Admin stated the facility hasn't done preventative maintenance on equipment and only called outside vendors for assistance when something broke. 555466 Page 24 of 28 555466 10/20/2023 Ashby Care Center 2270 Ashby Avenue Berkeley, CA 94705

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many According to the 2022 FDA Federal Food Code, 4-501.11 indicates, (A) equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. In addition, Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk. For example, refrigeration units in disrepair may no longer be capable of properly cooling or holding time/temperature control for safety foods at safe temperatures. 555466 Page 25 of 28 555466 10/20/2023 Ashby Care Center 2270 Ashby Avenue Berkeley, CA 94705

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 and interview, the facility had six residents (Rt) rooms (room [ROOM NUMBER], 3, 5, 7, 8 and 9) with multiple beds that provided less than 80 square foot (sq. ft) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents in each room or for storage of residents' belongings. Findings: During an observation on 10/17/23 and 8:00 a.m., in the presence of Registered Nurse/Administrator (RN/Admin), the following rooms and corresponding sq. ft per bed were identified: Room Activity/Room Size Floor Area 1 Rt room /299.63 sq. ft 74.9 sq. ft 3 Rt room / 293.25 sq. ft 73.32 sq. ft 5 Rt room / 299 sq. ft 74.75 sq. ft 7 Rt room / 299 sq. ft 74.75 sq. ft 8 Rt room / 299 sq. ft 74.75 sq. ft 9 Rt. room / 299 sq. ft 74.75 sq. ft During an interview on 10/17/23 at 8:22 a.m., Certified Nursing Assistant (CNA 2) stated there was enough space to provide care for residents. CNA 2 stated she had no problems going in and out with necessary care equipment. During an interview on 10/18/23 at 10:57 a.m., CNA 1 stated it was easy to provide care for residents in these rooms with ease. During an interview on 10/18/23 at 10:49 a.m., Resident 3 stated he had enough room space for his belongings and had no concerns and space. During an interview on 10/18/23 at 11:06 a.m., Resident 62 stated she had enough room space for her belongings and care. During an observation and concurrent interview on 10/18/23 at 11:02 a.m., there was sufficient space for provision of care for the residents in all rooms. CNA 1 stated there was no heavy equipment kept in the rooms that might interfere with residents care and each resident had adequate personal space and privacy. There was no complaints from residents regarding insufficient space for their belongings. There was no negative consequences attributed to the decreased space/ or safety concerns in the six rooms. Granting of the room size waiver is recommended. 555466 Page 26 of 28 555466 10/20/2023 Ashby Care Center 2270 Ashby Avenue Berkeley, CA 94705

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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 a functioning call light (communication system) for four of 26 sampled residents (Residents 8, 158, 159, and 160). The facility had no documented call light system tests since 6/9/22. Residents Affected - Many This deficient practice resulted in Residents 8, 158, 159, and 160 not being able to summon staff for care and assistance in an emergency. For all residents, this had the potential for being unable to call for help if the call lights fail to work. Findings: During a concurrent observation and interview on 10/16/23, at 10:54 a.m., with Licensed Vocational Nurse (LVN)1, in room [ROOM NUMBER], Residents 159 and 160's call light strings were not within the resident's reach and were not alarming and lighting outside the resident's door when the strings were pulled. LVN 1 confirmed the call lights were not within residents' reach and were not working. LVN 1 further stated, the facility should have provided Residents 159 and 160 with call bells at the bedside to communicate their needs to the staff. LVN 1 confirmed there were no call bells and was a safety risk because the residents could fall and not be able to ask for help. During a concurrent observation and interview on 10/18/23, at 8:40 a.m., with Maintenance Supervisor (MS), in room [ROOM NUMBER], Residents 8,158,159, and 160's call lights were not working. MS stated, two weeks ago, he started cleaning the call light wirings in room [ROOM NUMBER]. MS admitted he made a mistake of not telling the staff that all the call lights in room [ROOM NUMBER] were not working. During a concurrent interview and record review on 10/18/23 at 9 a.m., with MS, the call lights maintenance logs were reviewed. The maintenance logs indicated the last documented date the call lights were checked was on 6/9/22. MS further stated all call lights were supposed to be checked weekly for maintenance. During an interview on 10/19/23, at 10:53 a.m., with Administrator (Adm), Adm stated she did not know the call lights in room [ROOM NUMBER] were not working. Adm also stated, the risks for the residents who did not have call lights were not having their basic needs met and not getting help on time if they fell. During a review of the facility's policy and procedure (P&P) titled, Interior General Maintenance, the P&P indicated, Nurses Call System . Check daily a proportionate number of nurses call system buttons, buzzers, cords, and lights so that each part of the system is checked at least once each week. Press button. Check to see that sign lights up over the patient's door, . replace immediately all defective light bulbs or buzzers . 555466 Page 27 of 28 555466 10/20/2023 Ashby Care Center 2270 Ashby Avenue Berkeley, CA 94705

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. 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 pest free environment when pest droppings and cobwebs were seen in the kitchen and inside the dry food storage. This failure had the potential to contaminate food and cause foodborne illness to 27 of 27 medically compromised residents who received food from the kitchen. Residents Affected - Many Findings: During a concurrent observation and interview on 10/16/23 at 12:55 p.m., with Dietary [NAME] (Cook), there were droppings on the light switch by the handwashing station. There was also a hole extending behind the backsplash on the counter and potential entry point. room [ROOM NUMBER] dry storage area had cobwebs under the shelves and under the stainless-steel sink. [NAME] stated he was not aware of any Pest Control services performed in a few months. [NAME] further stated he was solely responsible for cleaning the kitchen and had not performed a cleaning in over a year. During an interview on 10/18/23 at 11:49 a.m., with Administrator (Admin), Admin stated the facility had only one pest control service performed in August 2023 for fly activity. Admin stated the facility did not have a monthly service agreement for pest control services. During an interview on 10/18/23 at 12:06 p.m., with Registered Dietitian Consultant (RDC), RDC stated the kitchen should not have any pests or cobwebs and there should be monthly pest control services performed. During a review of the facility's document titled, (company name) Commercial Special Service Agreement, dated 8/27/2023, the (company name) Commercial Work Order indicated evidence of fly activity were found in the lobby walls, shower, laundry room, soiled linen room and kitchen. During an observation on 10/18/23, at 12:45 p.m., in Storage room [ROOM NUMBER], droppings and cobwebs were found on multiple wooden shelves and in the corners of the room. During a review of the facility's policy and procedure (P&P) titled, Pest Control, dated December 2023, the P&P indicated, The facility will ensure a pest control prevention program provides monthly inspection, treatment, and prevention of vermin and insect infestation .1. The kitchen will be kept clean, free from litter rubbish, protect from rodent, roaches, flies, and other insects . The P&P also indicated, 11. It is recommended that a pest control company be retained on a monthly basis, or more often if necessary. Our facility shall maintain an effective pest control program. 555466 Page 28 of 28