Health inspection·July 12, 2021

F 0557 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Based on observation, interview and record review, the facility failed to maintain residents' privacy, dignity and respect for three of 24 sampled residents (Residents 48, 47 and 99) when: Residents Affected - Few 1. The activity aid (ACA) was standing in front of Resident 48 while assisting the resident in the hallway with the lunch meal. 2. Resident 47 was using the bathroom and the door was left opened. 3. During GT administration observation Resident 99's room door was open, and her abdomen was exposed to public view in the hallway. These failures had the potential to affect Resident 48 47 and 99's self-esteem and self-worth. Findings: 1. During multiple observations on 7/6/21 at 12:15 p.m., 12:30 p.m., 12:40p.m., and 12:51 p.m., the ACA was standing in front of Resident 48 while assisting the resident with her lunch meal. During a concurrent observation and interview on 7/6/21 at 12:51 p.m., with ACA, he confirmed the above observations and stated that he should have been sitting while assisting Resident 48 with her meal. 2. During an observation on 7/6/21 at 10:27 a.m., certified nursing assistant N (CNA N) assisted Resident 47 to use the bathroom. The bathroom door was left open. During an interview with CNA N on 7/6/21 at 10:29 a.m., CNA N confirmed the above observation and stated she should have closed the bathroom door. 3. During observation and concurrent interview with licensed vocational nurse J (LVN J), on 7/7/21 at 4:02 p.m., LVN J administered medications in Resident 99's gastrostomy tube (g-tube, surgically placed tube into the stomach that brings nutrition and medications directly to the stomach) with Resident 99's abdomen exposed as the room curtain and bedroom door were open to public view in the hallway. LVN J confirmed this observation and stated he should have closed the curtain and door for Resident 99's privacy. During interview with the Assistant Director of Nursing (ADON), on 7/9/21 at 4:00 p.m., the ADON confirmed nurses should provide privacy to residents when administering medications in the resident's Page 1 of 24 555487 555487 07/12/2021 Mission DE LA Casa 2501 Alvin Avenue San Jose, CA 95121

F 0557 g-tube. Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy Dignity, revised 11/1/2017, indicated residents should be treated with dignity and respect at all times. Residents Affected - Few 555487 Page 2 of 24 555487 07/12/2021 Mission DE LA Casa 2501 Alvin Avenue San Jose, CA 95121

F 0558 Reasonably accommodate the needs and preferences of each resident. 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 needs were accommodated for five of 24 sampled residents (Residents 99, 52, 119, 114, 122) when call light devices were not within reach of the residents. Residents Affected - Few This failure had the potential for a delayed response and not meeting the resident's needs. Findings: 1. Review of Resident 99's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including hemiplegia (loss of muscle function of one side of the body) hemiparesis (partial weakness of one side of the body) affecting the right dominant side During an observation of Resident 99's room on 7/6/21 at 9:50 a.m., Resident 99 was in bed and her call light was on the floor. Resident 99 was moving her hand but was not able to reach the call light. During a concurrent observation and interview with licensed vocational nurse F (LVN F) on 7/6/21 at 9:52 a.m., she confirmed the above observation and stated Resident 99 could not reach the call light that was on the floor. 4. Review of Resident 114's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including quadriplegia (paralysis of all 4 limbs), multiple sclerosis (progressive disease involving damage to nerve cells in the brain and spinal cord), and contractures (shortening and hardening of muscles, tendons, and other tissues leading to deformity and rigidity of joints). Review of Resident 114's minimum data set (MDS, an assessment tool) dated 5/4/21, indicated he had total dependence on staff for bed mobility, dressing, eating, toileting, bathing, and personal hygiene. During an observation in Resident 114's room on 7/7/21 at 1:10 p.m., Resident 114 was in bed and his call light was on the floor under his bed, out of reach of Resident 114. During a concurrent observation and interview with certified nursing assistant H (CNA H) on 7/7/21 at 1:14 p.m., he confirmed the above observation and stated Resident 114 could not reach the call light that was on the floor. CNA H further stated residents should always have their call lights within their reach. During interview with UM A on 7/9/21 at 11:50 a.m., she stated Resident 114 had upper body limitations and required a call light which had a pad instead of a button to push. UM A stated Resident 114 could use his elbows to press the pad to activate the call light. She further stated that all residents should have access to a call light. 5. Review of Resident 122's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including congestive heart failure (heart cannot pump enough blood to meet the body's needs), pleural effusion (build up of fluid around the lungs), muscle weakness, abnormalities of gait 555487 Page 3 of 24 555487 07/12/2021 Mission DE LA Casa 2501 Alvin Avenue San Jose, CA 95121

F 0558 and mobility, and need for assistance with personal care. Level of Harm - Minimal harm or potential for actual harm Review of Resident 122's MDS dated [DATE], indicated he required staff assistance for bed mobility, transfer, dressing, toileting, bathing, and personal hygiene. Residents Affected - Few During an observation in Resident 122's room on 7/7/21 at 9:45 a.m., Resident 122 was sitting in his wheelchair next to his bed. Resident 122 stated he was tired and wanted to lie down on his bed but could not find his call light. The call light was observed under the pillow at the head of Resident 122's bed, out of reach of the resident. During a concurrent observation and interview with certified nursing assistant I (CNA I), on 7/7/21 at 9:50 a.m., she confirmed Resident 122's call light was under the pillow on his bed and out of his reach. She further stated residents should always have their call lights within their reach. Review of the facility's 11/2019 policy, Call Light, indicated when the resident was sitting in her chair or confined to her bed, to make sure to provide resident with call light access. 2. During an observation on 7/6/21 at 11:10 a.m., Resident 52 was lying in bed and the call light device was not within reach During an observation on 7/9/21 at 8:42 a.m., Resident 52 was lying in bed and the call light device was hanging on the wall. During an observation and interview with unit manager A (UM A) on 7/9/21 at 8:45 a.m., she confirmed Resident 52's call light device was hanging on the wall and the call light device was not within reach. 3. Review of Resident 119's clinical record indicated she was admitted on [DATE] with diagnoses of diabetes (increased blood sugar), muscle spasm, and need for assistance with personal care. During an observation and interview with UM A on 7/9/21 at 8:46 a.m., Resident 119 was observed lying in her bed and the call light device was at the back of the bed. UM A stated Resident 119 call light device was not within reach. During an observation and interview with the assistant director of nursing (ADON) on 7/12/21 at 11:04 a.m., she stated Resident 119's call light device was hanging at the back of her bed and the resident could not reach her call light device. 555487 Page 4 of 24 555487 07/12/2021 Mission DE LA Casa 2501 Alvin Avenue San Jose, CA 95121

F 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an observation, interview and record review, the facility failed to complete a significant change in status assessment (SCSA) in minimum data set (MDS, an assessment tool) for one of 24 sampled residents (Resident 61). The resident had declined in activities of daily living (ADL, daily self-care tasks, e.g., bathing, toileting, and transferring), balance during transition and walking, and declined in bowel and bladder continence. Residents Affected - Few These failures had the potential to result in Resident 61 being unable to achieve or maintain optimal status of health, function and quality of life. Findings: Review of Resident 61's face sheet (summary page of a patient's important information) indicated he was admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing), major depressive disorder (mood disorder that interferes with daily life), dementia with behavioral disturbance (decline in mental capacity affecting daily function) and Alzheimer's disease (progressive disease that destroys memory and mental functions). Review of Resident 61's MDS dated [DATE], indicated her cognition (mental, thought processes) and was severely impaired. She required extensive assistance with one person assist in activities of daily living (ADL), needed supervision with set up help with transfer, walk in room/corridor and locomotion on unit/off unit. Her bowel continence was frequently incontinent, two or more episodes of bowel incontinence but at least one continent bowel movement and urinary continence was frequently incontinent. Seven or more episodes of urinary incontinence, but at least one episode of continent voiding. Her balance during transitions and walking was not steady, but was able to stabilize without staff assistance (moving from seated to standing position). Review of Resident 61's MDS dated [DATE], revealed she required extensive assistance with more than two people physical assistance with bed mobility, dressing and toilet use. She required limited assistance with more than two people physical assist with transfer, supervision with one-person physical help with locomotion on unit, locomotion off unit and walk in room/corridor. Her bowel continence was always incontinent. No episode of continent bowel movement and urinary continence was always incontinent. No episodes of continent voiding. Her balance during transitions and walking was not steady, only able to stabilize with staff assistance (moving from seated to standing position). During an interview and concurrent record review on 7/12/21 at 10:54 a.m., with minimum data set coordinator assistant (MDSCA), he reviewed the MDS dated [DATE] and 5/20/21. He stated that Resident 61 had two or more ADLs which declined, and declined in her urinary/bowel continence and balance. He further stated that there was no evidence an SCSA comprehensive assessment was done and no interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) discussion about criteria of SCSA. During an interview and concurrent record review on 7/12/21 at 2:57 p.m., with the regional consultant (RC), she reviewed the MDS dated [DATE] and 5/20/21. She stated that Resident 61 had two or more ADLs to decline, and declined in her urinary/bowel continence and balance. She further stated that a comprehensive assessment should have been done within 14 days from the determination of the significant change status. 555487 Page 5 of 24 555487 07/12/2021 Mission DE LA Casa 2501 Alvin Avenue San Jose, CA 95121

F 0637 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Resident Assessment Instrument Manual 3.0 Version 1.16.1, dated 10/2019, indicated, .a significant change in status assessment must be completed on the fourteenth calendar day after determination that a significant change in the resident's status occurred. The manual further indicated an SCSA MDS is appropriate when a resident declined in two or more areas or the resident's incontinence pattern changes. Any decline in ADL'S physical functioning area (at least 1) since last assessment and does not reflect normal fluctuations in the individual's functioning. 555487 Page 6 of 24 555487 07/12/2021 Mission DE LA Casa 2501 Alvin Avenue San Jose, CA 95121

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of Resident 47's clinical record indicated she was admitted on [DATE] with diagnosis including schizoaffective disorder (mental disorder including schizophrenia [serious mental disorder in which people cannot distinguish reality] and mood disorder), dementia (memory loss). Further review of Resident 47's clinical record, there was no PASARR documentation found. During an interview with the regional consultant (RC) on 7/8/21 at 10:07 a.m., the RC stated the facility could not find the PASARR. During an interview with the assistant director of nursing (ADON) on 7/8/21 at 11:29 a.m., the ADON stated she could not find Resident 47's completed PASARR. During an interview with the medical records director (MRD) on 7/8/21 at 2:14 p.m., the MRD stated he could not find Resident 47's PASARR. During an interview with the ADON on 7/9/21 at 11:18 a.m., the ADON could not provide a completed PASARR and stated Resident 47's PASSAR should have been done. Review of the facility's undated policy, PASRR indicated the facility ensures individuals with a mental disorder or intellectual disabilities continue to receive care and services they need in the most appropriate setting. Based on interview and record review, the facility failed to develop and accurately assess the preadmission screening and resident review report (PASRR, an evaluation data requirement to determine whether a resident with mental illness (MI) requires specialized services such as referral to a mental health authority) for two of 24 sampled residents (Residents 66 and 47). This failure had the potential to put the residents at risk for not receiving appropriate care and services. Findings: Review of Resident 66's clinical record indicated he was admitted on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body), dementia (memory problem), hypertension (increased blood pressure), and a history of falling. Review of Resident 66's PASRR dated 8/27/19, indicated Resident 66's PASRR did not categorize the diagnosis for dementia and cerebrovascular accident (CVA, loss of blood flow to part of the brain). Review of Resident 66's Discharge summary dated [DATE], indicated Resident 66 was admitted [DATE] with diagnosis of CVA and dementia. During an interview with unit manager B (UM B) on 7/9/21 at 02:04 p.m., she stated Resident 66 had a diagnosis of CVA and dementia. UM B stated the PASRR was not accurately assessed and coded for CVA and dementia. 555487 Page 7 of 24 555487 07/12/2021 Mission DE LA Casa 2501 Alvin Avenue San Jose, CA 95121

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. During observation and concurrent interview with RN G, on 7/6/21 at 8:15 a.m., RN G was observed preparing medications for Resident 84. As RN G withdrew Dutasteride (medication for urine retention), the capsule still containing medication fell to the floor. RN G administered to Resident 84 what she withdrew from the capsule. Further examination of the capsule that fell on the floor indicated medication was left in the capsule. RN G confirmed this observation and confirmed the Resident 84 received a partial dose. Residents Affected - Few Review of Resident 84's physician orders, dated 6/18/19, indicated the order was for Dutasteride capsule 0.5 mg by mouth once daily. During an interview with the director of nursing (DON), on 7/7/21 at 10:25 a.m., the DON stated RN G should not have given a partial dose to Resident 84. The DON stated RN G should have discarded the medication she withdrew and given Resident 84 the full dose the physician ordered. Review of the facility's policy, Medication Administration, revised 6/1/2020, indicated .medications must be administered in accordance with the orders. Based on observation, interview, and record review, the facility failed to ensure services were provided to meet the professional standard of practice for five of 24 residents when: 1. Resident 65's dermatology appointment was not followed-up; 2. Resident 75's oxygen order was not clarified; 3. Resident 121's weight was not monitored daily; 4. Resident 4's pacemaker was not monitored; 5. Registered nurse G (RN G) did not follow Resident 84's physician order. These failures had the potential to jeopardize the residents' health. Findings: 1. Review of Resident 65's acute care clinical record dated 3/5/20 indicated she had pruritis (itchy skin) rash. Review of Resident 65's progress notes dated 3/26/21 indicated, she went to a dermatology appointment but was not seen due to insurance issues. Further review of Resident 65's clinical record did not indicate a documented follow-up attempt regarding her dermatology appointment. During a concurrent interview and record review with unit manager B (UM B) on 7/12/21 at 11:01 a.m., UM B reviewed Resident 65's clinical record and stated there was no documentation regarding the attempt to reschedule Resident 65's dermatology appointment. 555487 Page 8 of 24 555487 07/12/2021 Mission DE LA Casa 2501 Alvin Avenue San Jose, CA 95121

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Further review of Resident 65's clinical record indicated she had a dermatology appointment on 6/14/21 but was not seen due to an insurance issue. 2. Review of Resident 75's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a group of lung diseases that can cause difficulty of breathing) and dementia (memory loss). Review of Resident 75's physician order dated 9/7/20 indicated oxygen two liters per minute (lpm) via nasal cannula (tubing connected to an oxygen concentrator [oxygen source]) to keep oxygen saturation (oxygen level in the blood) above 90% every shift. During an interview with registered nurse K (RN K) on 7/8/21 at 3:40 a.m., RN K reviewed Resident 75's physician order and stated the order should have been clarified. During an interview with the assistant director of nursing (ADON) on 7/9/21 at 11:24 a.m., the ADON confirmed Resident 75's order should have been clarified. Review of the facility's undated policy Oxygen Administration, indicated an oxygen order should include . usage of therapy continuous or as needed (prn). 3. Review of Resident 121's clinical record indicated she was admitted to the facility on [DATE] with primary diagnosis of chronic diastolic [congestive] heart failure (CHF, the heart cannot pump or fill blood adequately). Review of Resident 121's physician order dated 6/16/21 indicated weigh resident weekly. Further review of Resident 121's clinical record indicated she had right upper and lower extremity edema (swelling) and left upper and lower extremity edema. During an interview with UM B on 7/8/21 at 8:12 a.m., UM B confirmed Resident 121 had the diagnosis of CHF and should be on daily weights. During an interview with the ADON on 7/8/21 at 8:13 a.m., the ADON stated CHF management protocol was to weigh the resident daily. Review of the American Heart Association website, https://www.heart.org/-/media/files/health-topics/heart-failure/hf-symptom-tracker.pdf, Self-Check Plan for HF Management, indicated to monitor weight change of 2-3 pounds in a 24 hour period. Review of the facility's undated policy Heart Failure Protocol, indicated licensed staff to provide the necessary care and services for the care of patients diagnosed with heart failure. 4. Review of Resident 4's clinical record indicated he was admitted on [DATE] with diagnoses including atrial fibrillation (irregular heart rate), hypertension (increase in blood pressure), hyperlipidemia (an abnormally high concentration of fats in the blood), and presence of automatic (implantable) cardiac defibrillator. (ICD, like a pacemaker, a small battery-powered device placed in the chest to monitor the heart rhythm and detect irregular heartbeats. An ICD can deliver electric shocks via one or more wires connected to the heart to fix an abnormal heart rhythm.) 555487 Page 9 of 24 555487 07/12/2021 Mission DE LA Casa 2501 Alvin Avenue San Jose, CA 95121

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 4's clinical record indicated the physician visited on 3/20/14 and assessed the resident. The physician referred Resident 4 to a cardiologist (a doctor who specializes in heart disease and abnormalities) for pacemaker follow-up. During an interview with the unit manager A (UM A) on 7/9/21 at 10:30 a.m., she stated residents with pacemakers should have physician orders for care of the pacemaker and cardiologist visits as prescribed by the physician. The UM A further stated the licensed nurses should monitor heart rate, pacemaker site for redness, and for signs and symptoms of altered cardiac output or pacemaker malfunction. During a concurrent review of Resident 4's clinical record with the unit manager A (UM A) on 7/9/21 at 10:30 a.m., she confirmed there was no monitoring of Resident 4's ICD. She further stated there was no evidence that Resident 4 had seen a cardiologist to check the ICD since his admission to the facility on 3/19/14. A review of the facility's policy Pacemaker Care, dated 10/1/2020, indicated to ensure the health and safety of a resident using a pacemaker the facility provides the necessary care including assessing the functioning of the pacemaker. Unless otherwise ordered by a physician, pacemaker checks occur by obtaining an annual rhythm strip. website, www.nhlbi.nih.gov, indicated a pacemaker can stop working properly over time because the wires get dislodged or broken, the battery gets weak or fails, the heart disease progresses, and other devices have disrupted its electrical signaling. Your doctor can tell you whether your pacemaker or its wires need to be replaced when you see him or her for follow-up visits. Your doctor also may ask you to have an EKG (electrocardiogram) to check for changes in your heart's electrical activity. 555487 Page 10 of 24 555487 07/12/2021 Mission DE LA Casa 2501 Alvin Avenue San Jose, CA 95121

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 showers for one of 24 sampled residents (Resident 88) when the resident was unable to carry out showers independently. This failure had the potential to negatively affect the resident's physical and psychosocial well-being. Residents Affected - Few Findings: Review of Resident 88's clinical record indicated she was admitted [DATE] with diagnoses including urinary tract infection (infection in any part of urinary system), diabetes (increased blood sugar), and peripheral vascular disease (PVD, circulatory problem in which narrowed blood vessels and reduce blood flow). Review of Resident 88's minimum data set (MDS, an assessment tool) dated 6/11/21, indicated Resident 88 was moderately impaired in cognition, required staff assistance for bed mobility, transfer, toileting, and personal hygiene. The MDS also indicated bathing did not occur the entire 7 day look back period. During an observation and interview with Resident 88 on 7/6/21 at 9:50 a.m., Resident 88 was lying in bed and she stated she did not have a shower for about a month. She also stated she had one pound of dirt on her body and she felt itchy. During a concurrent observation and interview with certified nursing assistant D (CNA D), she confirmed Resident 88's hair was oily and sticky. During the interview and record review with unit manager B (UM B) on 7/8/21 at 12:14 a.m., she stated Resident 88 was scheduled for Tuesday and Friday showers but she did not get showered on 6/8/21, 6/11/21, 6/18/21, and 6/22/21. UM B stated the CNA should have provided showers to Resident 88. Review of the facility's 7/2015 policy, Showering a Resident, indicated a shower bath was given to the residents to provide cleanliness, comfort, and to prevent body odor. 555487 Page 11 of 24 555487 07/12/2021 Mission DE LA Casa 2501 Alvin Avenue San Jose, CA 95121

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to initiate new intervention on a fall care plan for a resident with multiple falls, revise, update an individualized and comprehensive person-centered fall care plan and person-centered interventions for three of 24 sampled residents (Residents 32, 61 and 16.) This failure had the potential to put the resident at risk of sustaining injuries and had the potential to result in not meeting the resident's needs. Findings: 1. During a record review of Resident 32's care plans for her five falls, one of the care plans did not have a new intervention to decrease her chance of falling. The care plan initiated on 12/12/2020 indicated an intervention to reinforce staff to frequently check the resident for safety. The care plan initiated on 12/14/2020 indicated an intervention to reinforce staff to monitor the resident closely for safety. During an interview with licensed vocational nurse F (LVN F) on 7/12/21 at 1:33 p.m., LVN F stated the interventions on 12/12/2020 and 12/14/2020 were the same. 2. Review of Resident 61's clinical record indicated Resident 61 was admitted to the facility on [DATE] with diagnosis including repeated falls, dementia with behavioral disturbance (decline in mental capacity affecting daily function) and Alzheimer's disease (progressive disease that destroys memory and mental functions). Review of Resident 61's Fall Risk Assessment (assessment tool used to determine the likelihood of a person falling), dated 2/16/21 indicated a score of 15 (high risk) and 5/17/21 indicated a score of 17 (high risk). Review of Resident 61's Minimum Data Set (MDS, an assessment tool) dated 11/23/2020, 2/19/21 and 5/20/21 indicated her cognition (ability to remember, judge and use reason) was severely impaired. During an interview and record review with unit manager P (UM P) on 7/12/21 at 8:22 a.m., she reviewed Resident 61's clinical record and stated that Resident 61 had multiple falls on1/11/21, 2/23/21, 4/12/21, and 5/2/21. During an interview and record review with UM P on 7/12/21 at 8:28 a.m., she reviewed Resident 61's fall care plan and confirmed that the initial fall care plan was not updated since it was initiated on 4/11/17, and revised on 6/15/21. She stated that the initial fall care plan intervention was not person-centered because care plan indicated staff will orient and re-direct Resident 61. She further stated that the care plan should have been updated when Resident 61 fell. 3. Review of Resident 16's clinical record indicated Resident 61 was admitted to the facility on [DATE] with diagnosis including history of falling, dementia with behavioral disturbance and epilepsy (an abnormal activity in the brain causing uncontrollable jerking movements of the arms and legs, and loss of consciousness). 555487 Page 12 of 24 555487 07/12/2021 Mission DE LA Casa 2501 Alvin Avenue San Jose, CA 95121

F 0689 Review of Resident 16's Fall Risk Assessment dated 9/2/20 indicated a score of 17 (high risk). Level of Harm - Minimal harm or potential for actual harm Review of Resident 16's MDS, dated [DATE], 10/13/20, 1/11/21 and 4/8/21 indicated his cognition was severely impaired. Residents Affected - Few During an interview and record review with UM P on 7/7/21 at 10:00 a.m., she reviewed Resident 16's fall care plan and confirmed that the initial fall care plan was not updated since it was initiated on 9/2/20, and revised on 6/4/21. She stated that the initial fall care plan intervention was not person-centered because care plan indicated staff educate the resident about safety reminders and what to do if a fall occurs. During an interview and record review with the minimum data set coordinator assistant on 7/7/21 at 3:30 p.m., he reviewed Resident 16's fall care plan and confirmed that the initial fall care plan was not updated since it was initiated on 9/2/20, and revised on 6/4/21. He stated the interdisciplinary team (IDT, facility staff members from different departments who coordinate care provided to residents) did not revise, update a comprehensive person-centered care plan with measurable objectives, goals and person-centered interventions for Resident 16. He further stated that IDT must review and update the care plan at least quarterly, in conjunction with the required quarterly MDS assessment. Review of the facility's revised November 1, 2019 policy, Develop- Implement Comprehensive Care Plan, indicated the facility develops a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, address the resident's medical, physical, mental and psychosocial needs. Care plans must be person centered and reflect the resident's goals for admission and desired outcomes. 555487 Page 13 of 24 555487 07/12/2021 Mission DE LA Casa 2501 Alvin Avenue San Jose, CA 95121

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement the policy and procedure for continence management for one of 24 sampled residents (Resident 88) when the resident was not properly assessed for bowel and bladder (B&B) training. This deficient practice had the potential to cause a decline in B&B control. Findings: Review of Resident 88's clinical record indicated she was admitted [DATE] with diagnoses including urinary tract infection (infection in any part of urinary system), diabetes (increased blood sugar), and peripheral vascular disease (PVD, circulatory problem in which narrowed blood vessels and reduce blood flow) Review of Resident 88's minimum data set (MDS, an assessment tool) dated 6/11/21, indicated Resident 88 was moderately impaired in cognition, required staff assistance for bed mobility, transfer, toileting, and personal hygiene. Review of Resident 88's nursing bowel and bladder assessment dated [DATE], indicated Resident 88 was continent and the recommendation was to assist the resident every two hours to improve incontinence. There was no documented evidence Resident 88 was offered assistance every two hours During an interview and record review with unit manager B (UM B) on 7/9/21 at 9:40 a.m., she stated the licensed nurses should have properly assessed Resident 88 for B&B program. UM B also stated Resident 88 was incontinent and B&B program should have been offered every two hours. Review of the facility's 7/2015 policy, Continence Management Guideline, indicated the purpose continence management guideline was to facilitate improvement in bladder and bowel function and prevent deterioration of bladder/bowel function. 555487 Page 14 of 24 555487 07/12/2021 Mission DE LA Casa 2501 Alvin Avenue San Jose, CA 95121

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 dialysis services consistently with professional standards and to ensure staff had coordinated residents' care with the dialysis center for one of five sampled residents (Resident 53) receiving hemodialysis (medical procedure to remove fluid and waste products from the blood and to correct electrolyte, i.e., salts and mineral imbalances by using a machine and an artificial kidney) when: Residents Affected - Few 1. Communication with the dialysis center was not properly coordinated when dialysis communication records (DCR) were not completed; 2. Inaccurate access site information and communication with the facility to dialysis center; 3. There was no emergency dialysis kit available in the unit; and 4. The dialysis care plan was not resident- person centered. These failures may affect the quality of dialysis care being provided to the residents. Findings: 1. Review of Resident 53's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including end stage renal disease (a condition in which the kidney no longer functions normally to filter waste and excess water from the blood as urine) and dependence on renal dialysis (a process of removing waste and excess water from the blood in those kidneys that have lost normal function). She was scheduled for dialysis every Tuesday, Thursday and Saturday. During review of Resident 53's clinical record revealed dialysis communication records (DCRs) dated 5/14, 5/15, 5/27, 6/3, 6/10, 6/12, 6/15, 6/17, 6/22, and 6/24/21, DCR's predialysis assessment was not completed by a dialysis center. DCRs dated 5/18, 5/25, 6/17, 6/26 and 6/29/21 pre and post dialysis assessments were not completed by a dialysis center. During a concurrent interview and record with unit manager P (UM P) on 7/7/21 at 10:19 a.m., she confirmed DCRs were incomplete on the above dates and stated licensed nurses should have followed-up with the dialysis center and completed the DCRs pre and post dialysis assessment for Resident 53's continuity of dialysis care. She further stated that there were no documentations in the nurse's notes indicating that licensed nurse called the dialysis clinic to inquire about Resident 53's pre and post assessment or special instructions and condition while at the dialysis center. 2. During a concurrent interview and record review with UM P on 7/7/21 at 10: 27 a.m., she reviewed Resident 53's DCRs pre dialysis facility assessment dated 5/18 and 5/25/21, and indicated Resident 53 had an arteriovenous fistula (AVF, surgically created connection between an artery and vein on a person's limb to allow dialysis to occur) shunt on the left. During a concurrent observation and interview with UM P on 7/7/21 at 10:43 a.m., she checked Resident 53's dialysis site and confirmed access site location is on the left upper chest (Perma Cath, placement of a special (Intravenous) IV line into the blood vessel in the neck or upper chest just under the collarbone, the catheter is then threaded into the right side of the heart (right atrium). 555487 Page 15 of 24 555487 07/12/2021 Mission DE LA Casa 2501 Alvin Avenue San Jose, CA 95121

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3. Review of Resident 53's care plan dated 6/23/21, indicated she had episodes of removing the perma catheter from her left upper chest. During a concurrent interview and record review with UM P on 7/7/21 at 10: 51 a.m., she reviewed Resident 53's dialysis short term care plan dated 6/23/21 and confirmed that the care plan indicated Resident 53 had episodes of removing perma catheter on her left upper chest. During a concurrent observation and interview with the UM P on 7/7/21 at 11:11a.m., She checked the medication room, medication cart, crash cart and confirmed that there was no emergency dialysis kit in the unit. She further stated that the emergency dialysis kit should have been available in the unit for Resident 53. 4. During a concurrent interview and record review with UM P on 7/7/21 at 11: 10 a.m., she reviewed Resident 53's dialysis care plan initiated on 5/14/21 and indicated the resident had left upper chest (Perma Catheter) placement.The interventions indicated do not use the access site arm to take blood samples, administer IV fluids, or give injections and protect the shunt by using the other arm when taking blood pressure, inserting IV line or injecting medications. UM P further stated that care plan was not resident-person centered. Review of the facility's policy and procedure revised date October 1, 2020 titled Dialysis Management indicated that the facility assures that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. To provide for residents who require dialysis care, services consistent with professional standards of practice, a comprehensive person-centered care plan which meet the residents' goals and preferences. The dialysis unit and facility staff coordinate the development and implementation of the dialysis care plan, including the ongoing provision of assessment of the resident and care plan revision as necessary. The facility has an agreement with a contracted Dialysis Unit(s) which operate in accordance with current standards of practice, including communication and collaboration. 555487 Page 16 of 24 555487 07/12/2021 Mission DE LA Casa 2501 Alvin Avenue San Jose, CA 95121

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation with unit manager B (UM B) on 7/6/21 at 10:32 a.m., an A&D ointment (skin protectant) was found inside Resident 41's bedside table drawer. The UM B confirmed the observation. During an observation with UM B on 7/6/21 at 10:37 a.m., there were two A&D ointments found at Resident 43's bedside table. UM B confirmed the observations and stated the A&D ointments should not be in residents' table drawers. Review of the facility's undated policy, Medication Administration, indicated Medications shall not be left at the bedside. Based on observation, interview, and record review the facility failed to properly store medication when: 1. One of two medication refrigerators were not within the facility's acceptable temperature range of 36 to 36 degrees Fahrenheit (F); 2. A&D ointments were found at Resident 41 and Resident 43's bedside tables. These failures had the potential for medications to lose their potency and effectiveness when administered to the residents. Findings: 1. Record review of the Temperature Log, on 7/6/21 at 12:31 p.m., for the medication refrigerator in medications room one indicated for the month of May 21 the temperature written on the log was out of range eight times. The form indicated the acceptable range was 36 to 46 degrees Fahrenheit (F) and if outside the range to call maintenance. During observation, interview, and concurrent record review with Unit Manager B (UM B), on 7/6/21 at 12:32 p.m., the UM B confirmed refrigerator temperatures were to be checked by staff twice daily and confirmed medications including insulin, eye drops, and vaccines were stored in medication room [ROOM NUMBER]'s refrigerator. The UM B confirmed the temperature log indicated for May 21 the temperature was below the acceptable range eight times. The UM B indicated the nurse should adjust the refrigerator temperature dial and should document on the temperature log under comments what action was taken. The UM B confirmed the comments section of the temperature log was blank for the eight times the temperature was out of range in May 21. The UM B confirmed continued storage of medications in the refrigerator in a temperature out of range can impact the medication's effectiveness. During a telephone interview with the director of nursing (DON), on 7/7/21 at 10:25 a.m., the DON stated best practice is to remove the medications, notify pharmacy, and follow pharmacy recommendations. The DON confirmed the integrity of the medications can be damaged if the temperature is out of the acceptable range. During an interview with the maintenance supervisor (MS), on 7/7/21 at 9:45 a.m., he stated he was 555487 Page 17 of 24 555487 07/12/2021 Mission DE LA Casa 2501 Alvin Avenue San Jose, CA 95121

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not notified the temperature of medication room [ROOM NUMBER]'s refrigerator was out of range in May 21 and stated nurses make the adjustment and .should fix it themselves. During an interview with the assistant director of nursing (ADON), on 7/6/21 at 1:47 p.m., the ADON confirmed medications continued to be stored in medication room [ROOM NUMBER]'s refrigerator throughout May 21 and during the times when the temperature was out of acceptable range. The ADON stated the medications should have been removed and action taken to resolve the issue should have been documented in the comments section of the Temperature log form. Record review of the facility's policy Storage of drugs and biologicals, revised 6/1/2020, indicated safe medication storage included appropriate environmental controls such as temperature. 555487 Page 18 of 24 555487 07/12/2021 Mission DE LA Casa 2501 Alvin Avenue San Jose, CA 95121

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 ensure the kitchen staff are aware of the process to measure the sanitizer level of the dishwasher, when cook E (KC E) did not dip the test strip in the sanitizer water for the directed length of time. This failure had the potential to cause food-borne illness in the already immune compromised residents. Findings: During an observation and concurrent interview on 7/07/21 at 1:55 p.m., KC E dipped the chlorine test paper in the water of the dishwasher, which contained the chlorine sanitizer, for approximately three seconds, then took it out and compared the color to the insert of the strip container. KC E stated she had the test strip in the water for longer than three seconds. During a review of the direction insert of the test strip container on 7/07/21 at 1:57 p.m., the directions indicated to dip the strip into the solution to be tested, without agitation and compare immediately with the color chart on the label. The directions also indicated Time of Test - one second. 555487 Page 19 of 24 555487 07/12/2021 Mission DE LA Casa 2501 Alvin Avenue San Jose, CA 95121

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to properly store food for one of 24 sampled residents (Resident 74) when a family member brought food from home and the resident did not consume it within one (1) hour after receiving it. This failure had the potential to lead to Residents Affected - Few food-borne illness (an illness caused by food contaminated with bacteria, viruses, parasites, or toxins) and could compromise the medical condition of the resident. Findings: Review of Resident 74's clinical record indicated she had diagnoses including diabetes (increased blood sugar), hypertension (increased blood pressure), dysphagia (difficulty in swallowing) and hyperlipidemia (an abnormal high concentration of fats and lipids in the blood). Review of Resident 74's physician order dated 5/31/21, indicated Resident 74 was on CCHO (controlled carbohydrate) and NAS (no added salt) diet. During an observation and interview with the resident on 7/6/21 at 11:58 a.m., Resident 74 was observed eating food from home and she stated she would also eat the food for dinner. Resident 74 stated she would keep the food on the table for her dinner. During an observation and interview with unit manager B (UM B) on 7/9/21 at 11:39 a.m., UM B observed Resident 74's food was fish, vegetable, rice, and a bag of fruits. UM B stated Resident 74's food was kept in her room for dinner. During an interview with the dietary manager (DM) on 7/9/21 at 3:59 p.m., DM confirmed Resident 74's food from home should have been consumed within two hours. Review of the facility's 2018 policy, Food For Residents From Outside Sources, indicated to make sure the food was within the guidelines of the diet order and prepared food brought in for resident must be consumed within one hour of receiving it in an effort to prevent food borne illness. 555487 Page 20 of 24 555487 07/12/2021 Mission DE LA Casa 2501 Alvin Avenue San Jose, CA 95121

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** 7. During an activity observation on 7/12/21 at 10:50 a.m., the activity assistant did not cover her nose with her face mask when assisting the residents in the activity room. Residents Affected - Some During an observation and interview with the minimum data set coordinator (MDS C) on 7/12/21 at 10:54 a.m., she confirmed the activity assistant did not cover her nose with the face mask 8. During an observation on 7/12/21 at 11:02 a.m., certified nursing assistant O's (CNA O) face mask was below her nose after providing care to the resident. During an observation and interview with LVN C on 7/12/21 at 11:08 a.m., CNA O was talking to the resident and her face mask was not covering her nose. LVN C confirmed CNA O should wear the face mask properly which covere her nose. According to the CDC's website https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, Health Care provider (HCP) should wear well-fitting source control (e.g face masks or respirators) at all times while they are in the health care facility. 9. During an observation on 7/6/21 at 9:02 a.m., with CNA Q she dropped the face cloth on the floor, picked it up, and continued assisting the resident with meals without doing hand hygiene. During a concurrent observation and interview on 7/6/21 at 9:04 a.m., with CNA Q, she confirmed the above observation and stated she should have done hand hygiene before assisting the resident with meals. During an observation on 7/6/21 at 9:30 a.m., with CNA R came out from the bathroom wearing gloves with a plastic bag containing dirty linens. She went straight to the bedside table of the resident and picked up the used bib and put it inside the bag. CNA R took off the gloves before leaving the room and walked in the hallway without doing hand hygiene. During a concurrent observation and interview on 7/6/21 at 9:34 a.m., with CNA R, she confirmed the above observation and stated she should have done hand hygiene after taking off the gloves and leaving the resident's room. Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Licensed vocational nurse L (LVN L) did not wear face mask properly while in the nurses station with other staff; 2. A certified nursing assistant was wearing a disposable face mask underneath another disposable facemask; 3. Clean linen in the hallway was not covered; 4. Gloves were worn in the hallway; 555487 Page 21 of 24 555487 07/12/2021 Mission DE LA Casa 2501 Alvin Avenue San Jose, CA 95121

F 0880 5. Housekeeping staff did not properly wear a face mask; Level of Harm - Minimal harm or potential for actual harm 6. Resident 119 was not monitored daily for signs and symptoms of COVID 19 (corona virus disease 19; a highly contagious respiratory disease); Residents Affected - Some 7. Activity assistant did not wear face mask properly; 8. Certified nursing assistant did not wear face mask properly; and 9. Certified nursing assistant did not provide hand hygene after care. These failures could result in the spread of infection and cross-contamination that could affect the 119 residents that reside in the facility. Findings: 1. During a concurrent observation and interview on 7/6/21 at 3:21 p.m., LVN L was sitting with another staff without social distancing (six feet apart). LVN L's face mask was not covering her nose and mouth. LVN L confirmed the observation and stated she was not wearing her facemask because she was on the phone. During an interview with the infection preventionist (IP) on 7/6/21 at 3:38 p.m., the IP stated staff should not remove their facemask in the nurses station. 2. During an observation with the IP on 7/6/21 at 3:40 p.m., one staff in the station X hallway was wearing a disposable face mask underneath another disposable face mask. The infection preventionist (IP) confirmed the observation and stated the facility did not implement double masking. Review of the Centers for Disease Control and Prevention (CDC) guidance, Improve How Your Mask Protects You updated 4/6/21 indicated do not combine two disposable masks, wearing two does not improve the fit. 3. During an observation on 7/7/21 at 10:21 a.m., in the station X hallway, there was a linen cart that was not covered. During a concurrent observation and interview with unit manager B (UM B) on 7/7/21 at 10:26 a.m., UM B confirmed the above observation and stated the linen cart should be covered. Review of the facility's undated policy, Laundry and Linen indicated facility shall ensure all laundry is handled, stored, processed and transported in a safe and sanitary method. 4. During a concurrent observation and interview on 7/8/21 at 7:12 a.m., the laundry staff (LS) was wearing gloves and pushing a covered barrel. The LS confirmed the observation and removed her gloves. During a concurrent observation and interview on 7/8/21 at 3:57 p.m., licensed vocational nurse J (LVN J) was wearing gloves in the station X hallway. LVN J confirmed the observation and stated he was about to remove the gloves. 555487 Page 22 of 24 555487 07/12/2021 Mission DE LA Casa 2501 Alvin Avenue San Jose, CA 95121

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 5. During an observation with the director of staff development/back up IP (DSD/BUIP) on 7/12/21 at 3:24 p.m., the housekeeping staff (HS) was sitting in the clean laundry room area and his face mask was not covering his nose and mouth. The HS confirmed the observation and stated he should wear his face mask. During an interview with the DSD/BUIP on 7/12/21 at 3:26 p.m., the DSD/BUIP stated the HS should have worn his face mask. 6. Review of Resident 119's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including hydronephrosis (swelling of the kidney due to urine build up). During a concurrent interview and record review with licensed vocational nurse M (LVN M) on 7/12/21 at 1:46 p.m., LVN M reviewed Resident 119's physician order and confirmed there was no order for daily monitoring for daily signs and symptoms of COVID 19. During an interview with the assistant director of nursing (ADON) on 7/12/21 at 1:48 p.m., the ADON stated there should be daily monitoring for signs and symptoms of COVID 19. According to the CDC's website, https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes updated March 29, 2021 indicated, evaluate residents atleast daily with signs and symptoms consistent with COVID 19. 555487 Page 23 of 24 555487 07/12/2021 Mission DE LA Casa 2501 Alvin Avenue San Jose, CA 95121

F 0881 Implement a program that monitors antibiotic use. 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 ensure appropriate use of antibiotic (medication for the infection) for one of 24 sampled residents (Resident 66). This failure had the potential for the resident to take unnecessary antibiotics which could lead to resistance to the antibiotic. Residents Affected - Few Findings: Review of Resident 66's clinical record indicated he was admitted on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body), dementia (memory problem), hypertension (increased blood pressure), and a history of falling. Review of Resident 66's surveillance data collection form for urinary tract infection dated 7/1/21, indicated Resident 66 was on Amoxicillin 500 milligrams every eight hours for 10 days. It also indicated Resident 66 had a urine culture on 6/28/21 with invalid results and the criteria for urinary tract infection was not met for the antibiotic. During an interview with the infection preventionist (IP) on 7/721 at 2:26 p.m., she confirmed Resident 66 was on Amoxicillin 500 milligrams and the criteria for urinary tract infection was not met for the appropriate use of the antibiotic. Additional review of Resident 66's surveillance data collection form indicated on 7/7/21 Resident 66's culture and sensitivity (C&S, a test to find out what bacteria is causing the infection and what kind of medicine (such as antibiotic) will work best) was followed-up, nine days after the start of Resident 66's antibiotic treatment. Further review of Resident 66's surveillance data collection form, did not indicate any non-pharmacological attempt before using an antibiotic treatment when the criteria was not met. During an interview with the director of staff development/back up infection preventionist (DSD/BUIP) on 7/12/21 at 4:39 p.m., the DSD/BUIP stated the infection preventionist should have followed-up Resident 66's C&S result. Review of the Centers for Disease Control and Prevention (CDC), The Core Elements of Antibiotic Stewardship for Nursing Homes indicated infection prevention coordinators have key expertise and data to inform strategies to improve antibiotic use. 555487 Page 24 of 24