Health inspection·June 7, 2019

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. 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 allow one of one sampled resident (Resident 13) to self-administer medication when the facility failed to complete an assessment to determine if the resident was appropriate to self administer medication. Residents Affected - Few This deficient practice had the potential for psychosocial harm on the resident. Findings: Resident 13 was admitted on [DATE] with diagnoses including knee pain, and history of hip fracture (broken bone). The Minimum Data Set (MDS, an assessment tool) dated 3/28/19 indicated a Brief Interview of Mental Status (BIMS, a brief scanner of cognitive impairment) score of six (meaning severe cognitive impairment). Resident 13 required assistance with activities of daily living such as transfer and ambulation (walking). During the initial tour on 6/3/19 at 10:11 AM, Resident 13 was in bed, awake, verbally responsive, and aware of the current date, time, and place. During an interview on 6/5/19 at 9:50 AM, Resident 13 stated, I have pain on my right shoulder. I told the staff that I want to keep the aspercreme (medication applied on the skin to relieve pain) here in my room so I can use it when I need it. The nurse takes an hour before she can bring the aspercreme to me. I bought three aspercremes and [name of staff and pointing to Staff 3] took it away at three different times. [Staff name] told me you cannot have medication in your room. I bought another aspercreme that I now keep in my room. I didn't tell anyone. During an interview on 6/6/19 at 10:30 AM, Staff 3 stated, They're not allowed to have medications in their room so I took them away. We did not perform assessment for self-administration of medication for Resident 13. During an interview on 6/6/19 at 11:30 AM, Staff 13 stated, Resident 13 usually complains of pain to her back and knees. I reported it to the nurse. During an interview on 6/6/19 at 12 PM, Staff 12 stated, Resident 13 cannot keep the aspercreme in her room. We have to keep it in the treatment cart. During a review of Staff 4 notes dated 4/8/19, it indicated, Resident is alert and oriented times 3 [aware of the current date, time, and place]. Page 1 of 43 555657 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0554 She is capable of making her own health decisions and is able to make her needs known Level of Harm - Minimal harm or potential for actual harm During a review of facility policy and procedure titled, Medication Administration Self-Administration by Resident, dated 2007, on 6/6/19, it indicated under Policy, Resident who desires to self-administer medications, are permitted to do so with prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe. Residents Affected - Few 555657 Page 2 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0608 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. Based on interview and record review, the facility failed to inform all employed mandated reporters of their abuse reporting duties, annually, when the facility did not give information on elder abuse reporting duties to all disciplines, such as social services and licensed nurses, within one year of previously covering the information (last given February, 2018). This deficient practice had the potential to put residents at risk for abuse. Findings: A review of the in-service attendance sheet for Elder Abuse Prevention and Reporting . dated April 2019, indicated only certified nurse assistants (CNAs) attended training on abuse reporting. Review of the facility policy and procedure titled: Abuse Prevention & Reporting, undated, indicated, All staff will be oriented at time of hire and in-serviced at least annually regarding the topic of Abuse Prevention & Reporting. During a record review and concurrent interview with Staff 3, on 6/5/19, at 10:09 AM, Staff 3 reviewed the undated facility policy and procedure titled: Abuse Prevention & Reporting, and stated, According to the policy, in-services on abuse prevention and reporting should be given education, at least annually, to all staff members on how to report abuse, including the time frame requirements and the form to send to the Ombudsman. Staff 3 reviewed the Abuse Prevention and Reporting . attendance sheet, dated April 2019, and stated only certified nursing assistance attended the in-service. After reviewing the 2018 and 2019 In-Service Record binders (containing such records as the list of 2018 and 2019 in-services), Staff 3 could not provide documentation of information on abuse reporting, such as in-services and monthly meeting records, provided to disciplines other than certified nursing assistance staff members between May, 2018 and June, 2019. Staff 3 also reviewed computer records, such as monthly in-service records, and denied abuse reporting information was given to disciplines other than certified nursing assistance staff members within the last year. During an interview with Staff 24, on 6/6/19, at 11:48 AM, Staff 24 was instructed to describe how to manage and report abuse. Staff 24 stated, I would first separate the individuals, call supervisor and the administrator, report the abuse to ombudsman . I'm not sure who completes the forms given to Ombudsman on the weekends - it's either the administrator or the Director of Nursing, but I'm not sure. It hasn't happened in a while, and we have a new Director of Nursing now . Staff 24 was asked when did the licensed nurses last receive information on abuse reporting, after orientation. Staff 24 responded, I don't know, and denied receiving information, e.g. in-services, on abuse reporting after orientation within the last year. A review of the List of Current Employees, dated 6/3/19, indicated three licensed nurses were hired prior to 1/1/2018. During a record review and interview with Staff 7 and Staff 3, on 6/6/19, at 1:45 PM, Staff 7 and Staff 3 stated the information on abuse reporting is given to employees and is documented in the 2018 and 2019 In-Service Record binders or on the computer, but not in the employee file. Staff 7 and Staff 3 reviewed the 2018 and 2019 training paper and electronic records and were unable to provide 555657 Page 3 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0608 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some documentation of information given to all mandated reporters, other than certified nursing assistants, less than one year ago (since February, 2018). During a record review and interview with Staff 2, on 6/7/19, at 1:20 PM, Staff 2 reviewed the undated facility policy and procedure: Abuse Prevention & Reporting, and stated, all employees must receive abuse preventing and reporting training from the facility annually, So the employee understands the reporting process. Staff 2 reviewed the in-service records, including the Abuse Prevention and Reporting In-Service Attendance sheets and stated all mandated reporters, excluding Certified Nursing Assistance, had not received information on their duty in abuse reporting since the last in-service in February, 2018. 555657 Page 4 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS - a resident assessment tool) for one of 16 residents (Resident 53) when the MDS for Resident 53, dated 5/28/19, indicated a presence of a stage two pressure ulcer (partial or full loss of skin-thickness to a localized, intact or shallow opened area), when Resident 53 did not have a pressure ulcer. Residents Affected - Few This deficient practice could result in Resident 53 receiving inappropriate care and services. Findings: A review of the clinical record of Resident 53 indicated the resident was admitted on [DATE] for rehabilitation following a joint replacement surgery; his medical diagnoses included a fractured right femur (broken right leg), sepsis (a life threatening infection of the blood stream), difficulty walking, and prediabetes (a condition involving high blood sugar with no other presenting clinical signs or symptoms). Resident 53 is his own responsible party. A review of MDS for Resident 53, dated 5/28/19, indicated Resident 53 acquired a stage two pressure ulcer in the facility. The Functional Status section of the MDS indicated Resident 53 required a one person to physically assist him with transfers (moving between surfaces, e.g. the wheel chair to the bed), and toileting (the capability to transfer on and off the toilet, use the toilet, and groom after toileting). Resident had a Brief Interview for Mental Status (BIMS - an aide in detecting cognitive impairment) score of 15 (meaning no cognitive impairment). During an observation and a concurrent interview with Resident 53, on 6/3/19, at 9:14 AM, in the room of Resident 53, Resident 53 sat in a cushioned seated wheel chair, beside an empty urine bottle. Resident 53 stated he was admitted to the facility for a broken leg, which made it difficult to move, stand up, and use the bathroom. During a concurrent record review and interview with Staff 24, on 6/4/19, at 10:20 AM, Staff 24 reviewed the binder with the Treatment records and gathered the wound care treatment supplies. Then Staff 24 stated, The [Clotrimazole] cream was ordered for redness in the middle of buttocks [coccyx] - not the left buttock. Originally, the left buttock was thought to have a pressure sore, but it's actually a cyst [a closed pockets of tissue that can be filled with fluid, pus, or other material] . The middle of his buttocks is red and intact [no open areas]. He says the area [the mid buttocks] isn't painful, just itchy . A review of the Treatment binder records for Resident 53 indicated the Non-Pressure Sore Skin Problem Report, the Therapeutic Measures, and the Treatment Administration Record [TAR] . The Non-Pressure Sore Skin Problem Report, dated 5/14/19, indicated the left buttock had redness unrelated to pressure. The Therapeutic Measures reports for Resident 53 indicated all three entries, 5/11/19, 5/15/19, and 5/23/19, documented a stage two pressure ulcer on the mid buttocks, measuring 2.5 centimeter (cm) x 1.5 cm on 5/11/19 and 5/15/19, and 2.8 cm x 1.7 cm on 5/28/19, had redness and excoriation [damage or remove part of the surface of the skin] with no odor or drainage. On 5/15/19 and 5/23/19, the area received an application of Clotrimazole Cream 1% [an antifungal cream] twice a day. All three entries on the Therapeutic Measures report did not include whether the areas had presence of blanching (the fading of the skin's color when pressed) or non-blanching (a pressure ulcer indicator characterized by damaged tissue areas that do not lose color when pressed). The TAR, between 6/1/19 and 555657 Page 5 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0641 6/30/19, indicated the Clotrimazole Cream 1% was applied twice a day to the gluteal folds for redness. Level of Harm - Minimal harm or potential for actual harm During an interview with Resident 53, on 6/4/19, at 10:41 AM, Resident 53 was asked about the condition of his buttock. Resident 53 answered, The doctor said I have a cyst on the left side [of the buttocks] . The middle of my bottom feels itchy . Residents Affected - Few During a concurrent observation and interview with Resident 53 and Staff 24, on 6/4/19, at 10:43 AM, in the room of Resident 53, Resident 53 grunted while changing from a sitting to a right side-lying position in bed. The gluteal folds had diffuse, irregular patches of blanchable redness with no open areas. When the pressure was applied to the area, the redness disappeared. The hard dark reddened area on the left buttock was intact and blanchable. Resident 53 denied pain during the wound care to both areas, but reported itchiness. Staff 24 confirmed these findings. A review of the Skin Assessment Record of Resident 53, dated 3/17/19, indicated the resident did not have pressure ulcers. A review of the Progress Notes for Resident 53, between 3/17/19 and 3/25/19, indicated no documentation of a pressure ulcer, and on 3/22/19, blanchable redness was first observed on the coccyx. A review of the Nursing Weekly Assessment records of Resident 53, dated 3/26/19 and 4/4/19, indicated the coccyx had a description of blanchable redness. A review of the Progress Notes for Resident 53, between 3/25/19 and 6/3/19, indicated no documentation of a stage 2 pressure ulcer. The note on 5/10/19 indicated, Redness noted on his buttocks. Moisturizing body shield cream was applied by this writer. ADLs [activities of daily living, such as toileting] [for Resident 53 requires] one-person maximum assist [meaning, one staff member must physically assist the resident to perform an activity]. On 5/11/19, the attending physician gave an order for wound treatment for redness on the coccyx. On 5/20/19, the physician determined the skin condition on the left buttock was a cyst, not a pressure ulcer. A review of the Nursing Weekly Assessment records for Resident 53, between 5/2/19 and 5/31/19, indicated no documentation of a stage two pressure ulcer. A review of the Comprehensive Care Plan for Resident 53 indicated a care plan for the red hardened area on the left buttock, and another care plan addressing the skin integrity of a blanchable redness on coccyx, but no documentation of a care plan involving a stage two pressure ulcer. During a concurrent record review and interview with Staff 24, on 6/4/19, at 11:09 AM, Staff 24 reviewed the clinical record of Resident 53 and the resident's records in the Treatment binder again; Staff 24 was unable to provide documentation a skin assessment of a stage two pressure ulcer or the mid buttock performed before 5/11/19 or after 5/23/19. Staff 24 stated, .Those three dates in May are the only documented skin assessments I can find . There's no other place we chart skin assessments, other than the TAR and the skin assessment sheets in the binder . We [the staff] are supposed to document skin assessments for pressure areas, or pressure sores, every Wednesday . Staff 3 added the care plan should have been revised to reflect the current status of the coccyx. During a concurrent record review and interview with Staff 20, on 6/5/19, at 3:11 PM, Staff 20 stated she coded the MDS information. Staff 20 was asked to describe her process coding the Skin 555657 Page 6 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Condition section of the MDS. She replied, Information is gathered from assessment and input from the health care team . I also use the hospital discharge paperwork, the physician orders, the skin assessments sheets in the TAR, the care plan, and the nursing notes .The skin assessment [records] in the Treatment binder gives a good idea of the resident's skin condition. Staff 20 reviewed the MDS, dated [DATE], and stated the stage two pressure ulcer listed on the MDS was located on the mid-buttocks, not the left buttock. When asked to provide additional documentation on the presence of a pressure ulcer, Staff 20 reviewed the clinical record of Resident 53 and provided the Therapeutic Measures report. Staff 20 acknowledged the Therapeutic Measures report had missing information [the presence of blanching]. When asked to provide additional skin assessments, Staff 20 provided the physician's notes. Staff 20 reviewed the physician's notes and stated there was no documentation of a stage two pressure ulcer noted. Staff 20 acknowledged the coccyx was described as a blanchable in the care plan titled: Altered Skin Integrity r/t [related to] . blanchable redness on coccyx, revised 3/24/19, the progress notes, and the Nursing Weekly Assessment on 3/24/19 and 4/4/19, not a pressure ulcer. Staff 20 also acknowledged the Nursing Weekly Assessment did not contain documentation of the coccyx in May of 2019. During a concurrent interview and record review with Staff 2, on 6/7/19, at 12:20 PM, Staff 2 reviewed the MDS, dated [DATE] and acknowledged the MDS indicated Resident 53 had a stage two pressure ulcer. Staff 2 stated the stage two pressure ulcer was located on the resident's mid-buttocks. Staff 2 reviewed the clinical record of Resident 53. Staff 2 acknowledged the progress notes, two Nursing Weekly Assessment on 3/24/19 and 4/4/19, and the care plan indicated the coccyx was red blanchable area. Staff 2 further stated the Therapeutic Measures report contained documentation of a pressure ulcer, but the Therapeutic Measures report did not document the presence of blanching, which was necessary. Staff 2 added there was no policy on the accuracy of the MDS. A review of the Physician Progress Note for Resident 53, dated 5/28/19, indicated, Wound Clinic Note: Gluteal fold rash improving. Review of the facility policy and procedure titled: Skin Assessment, dated 2018, indicated the policy required, .A full body, or head to toe, skin assessment . upon admission .daily for three days, and weekly thereafter . for pressure injury prevention and management. The policy and procedure further indicated the Skin Assessment documentation was to include the presence of blanchable or non-blanchable redness and other observations. 555657 Page 7 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a copy of the baseline care plan was offered to one of 16 sampled residents (Resident 44) when there was no evidence a copy of the baseline care plan was offered to his responsible party (decision maker). This deficient practice had the potential to leave the responsible party unaware of the care and services provided to Resident 44. Findings: A review of the clinical record of Resident 44 indicated he was admitted on [DATE] with a diagnoses including benign neoplasm of the brain (abnormal cell growth in the brain) and cataracts (blurred vision due to the clouding of the lens). The Minimum Data Set (MDS - a resident assessment tool) for Resident 44, dated 2/5/19, indicated a Brief Interview for Mental Status (BIMS - an aide in detecting cognitive impairment) score of 8 (meaning moderate cognitive impairment). A family member is Resident 44's responsible party. During the initial tour, on 6/3/19, at 9:43 AM, Resident 44's door was closed with a sign to not disturb the resident prior to 10 am. A review of the baseline care plan for Resident 44, on 6/6/19, at 2:40 PM, indicated blank sections under the Signature of Resident and Representative. There was no documented evidence the facility offered a copy of the baseline care plan to the resident's representative. During a record review and concurrent interview with Staff 26, on 6/6/19, at 2:42 PM, Staff 26 reviewed clinical record and found an unsigned signed copy of the baseline care plan. Staff 26 stated the resident, or their representative, was supposed to sign the copy of the baseline care plan. When asked where the documentation the baseline care plan was offered, Staff 26 was unable to provide the documentation and stated, There is none. During a record review and concurrent interview with Staff 20 and Staff 26, on 6/6/19, at 2:46 PM, Staff 20 and Staff 26 provided an unsigned signed copy of the baseline care plan. Staff 20 stated, It should've been in there [documentation indicating the staff offered the resident's representative a copy of the baseline care plan], but it's not. There's nowhere else it would be. His representative did not receive a copy. It's [the baseline care plan] supposed to be signed within 48 hours of admission to prove a copy was offered to the resident or their responsible party [representative]. During an observation and a concurrent interview with Resident 44, on 6/7/19, at 11:52 AM, in the Room of Resident 44, Resident 44 laid in bed with the covers on top of him. Resident 44 denied his representative attended a meeting with the staff. During a record review and concurrent interview with Staff 2, on 6/7/19, at 12:44 PM, Staff 2 stated The resident and their representative should be involved in a discussion of the baseline care plan within 48 hours after admission. The baseline care plan needs a signature from the resident or the [resident's] representative. A telephone conference with the family needs to be documented too. Staff 2 reviewed the baseline care plan for Resident 44, dated 2/1/19, and could not find a signature 555657 Page 8 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0655 Level of Harm - Minimal harm or potential for actual harm from Resident 44's representative, or documentation the meeting occurred via telephone or the representative was offered a copy of the baseline care plan. Staff 2 reviewed the facility policy and procedure titled: Policy for Baseline Care Plan, revised 7/30/18, and stated, .the medical record must contain evidence that the summary was given to the resident and resident representative . Residents Affected - Few 555657 Page 9 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview and record review, the facility failed to develop and implement the comprehensive care plan for two of 16 sampled residents (Resident 51 and 17). Residents Affected - Some 1. For Resident 51, the facility did not implement care plan interventions for catheter monitoring. 2. For Resident 17, the facility did not develop a care plan for the use of Lexapro (a medication used to treat depression and generalized anxiety disorder). This deficient practice had the potential for unmet care needs. Findings: 1. During a review of the clinical record, the Minimum Data Set (MDS, a resident assessment tool), for Resident 51, dated 5/6/19, it indicated a Brief Interview for Mental Status (BIMS, a brief assessment to help detect cognitive impairment) score of 15 indicating resident is cognitively intact. The MDS also indicated Resident 51 had an indwelling catheter and required 2-person extensive assist with toileting. During an observation on 6/3/19 at 10:06 AM in Resident 51's bedroom, Resident 51 was lying in bed and watching television. There was a urinary drainage bag hanging on the side of the bed. During a review of the clinical record for Resident 51, the care plan, dated 5/7/19, indicated use of suprapubic catheter due to neurogenic bladder (a bladder dysfunction which includes overflow incontinence, frequency, urgency, urge incontinence, and retention. ) and neuromuscular impairment, and .Interventions . Catheter check every shift for patency, placement, kinks . monitor urine output every shift . During an interview and concurrent record review on 6/6/19 at 10:04 AM, when asked about facility policy for residents with Foley catheter, Staff 12 responded that staff monitor catheter by checking placement, patency and color of the urine. Staff reviewed Resident 51's clinical record and was unable to find documentation of staff doing catheter check every shift for patency, placement, and kinks. Staff 12 further stated there should have been a physician order for monitoring the catheter, then the staff would sign the catheter monitoring order in the treatment administration record (TAR). During a review of the clinical record for Resident 51, the intake and output (I&O) sheet from 5/20/19 to 6/2/19, indicated, there were 10 instances the licensed staff did not document I&O for Resident 51 during their shift. For two out of two weeks (5/20-5/26 and 5/27-6/2), the I&O weekly evaluation were not completed by the evening shift charge nurse. During an interview with Staff 2 on 6/6/19 at 2:20 PM, she reviewed Resident 51's I&O sheet and acknowledged that the sheet had missing documentation and the weekly evaluation was not done. She further stated they will modify the form to address output monitoring for residents with catheter. 2. During a review of the clinical record for Resident 17, the Order Summary Report was reviewed. A physician's order dated 11/26/17, was noted for Lexapro (antidepressant medication) Tablet 20 mg (milligrams) by mouth one time a day for chronic pain on both legs. 555657 Page 10 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0656 During a review of the care plans for Resident 17, there was no care plan developed for the use of Lexapro. Level of Harm - Minimal harm or potential for actual harm During an interview with Staff 20 on 6/6/19, at 11 AM, Staff 20 acknowledged there should be a care plan developed for the use of Lexapro. After reviewing the clinical record for Resident 17, Staff 20 was unable to find a care plan for the Lexapro. Residents Affected - Some Review of the facility policy and procedure titled, COMPREHENSIVE CARE PLAN, dated 8/24/18, indicated, .The plan of care shall be individualized, based on diagnosis, resident assessment and personal goals of the resident and his/her family .The needs of the resident, goals, time frames, required services and the service settings are critical considerations in determining the plan of care. 555657 Page 11 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0657 Level of Harm - Minimal harm or potential for actual harm Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on observation, interview and record review, for one of 16 sampled residents (Resident 24), the facility did not revise Resident 24's care plan on infection. Residents Affected - Few This failure had the potential to cause further spread of infection in the facility. (Cross Reference F880) Findings: During a review of the clinical record for Resident 24, the Minimum Data Set (MDS, a resident assessment tool), dated 3/21/19, indicated a Brief Interview for Mental Status (BIMS, a brief assessment to help detect cognitive impairment) score of 4, indicating Resident 24 had severely impaired cognition. The MDS also indicated Resident 24 required one-person supervision to extensive assistance with Activities of Daily Living (ADLs). During a review of the clinical record for Resident 24, the Resident Face Sheet, dated 4/1/19, indicated diagnoses that included dementia (group of symptoms associated with a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities). During an observation on 6/3/19 at 10:22 AM, a contact precaution sign was by Resident 24's room entrance. There were no personal protective equipment (PPE) set-up by Resident 24's room entrance. During an observation on 6/3/19 at 10:54 AM, Staff 23 entered Resident 24's room. Staff 23 did not don gloves, mask or gown before entering the room. During an interview with Staff 23 on 6/3/19 at 11:08 AM, she stated that she helped Resident 24 with morning care including brushed her teeth, wiped her face and combed her hair. During a review of the clinical record for Resident 24, the Emergency Department Patient Discharge Instructions dated 6/2/19 at 6:36 PM, indicated, .Discharge Diagnosis: Herpes zoster ophthalmicus of right eye . Blister and rash care .Keep your rash covered with a loose bandage (dressing) . During a review of the clinical record for Resident 24, the Progress Notes dated 6/2/19 at 6:44 PM, indicated, .Resident returned to facility at 1920 [7:20 PM] via gurney . During a review of the clinical record for Resident 24, the Progress Notes dated 6/2/19 at 8 PM, indicated, .Infection Nurse notified. Instructed to put resident under contact precaution for shingles. Endorsed to next shift . During a review of Resident 24's care plan dated 6/3/19, it indicated, . Focus . The resident has Herpes Zoster ophthalmicus of right eye . Interventions . Standard precautions . During a staff interview with Staff 21 on 6/3/19 at 11:23 AM, when asked about the facility policy for contact precautions for Resident 24, she replied that Staff 23 should have worn gown, gloves and mask before entering the room to avoid spread of infection to other residents. When asked about the PPEs, Staff 21 responded that the evening nurse endorsed to the night nurse to set-up the PPEs, 555657 Page 12 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few however, it was not set-up yet because the PPE tray cart was kept by the Housekeeping Department in a locked storage. During an interview with Staff 3 on 6/4/19 at 1:08 PM, when asked about the facility policy for cohorting residents on contact precautions, she responded that staff isolate the resident with infection or cohort the resident with another resident with the same type of infection. During an interview with Staff 7 on 6/5/19 at 1:53 PM, she stated that the evening staff should have taken the PPE's from the supply room and placed the PPE on a chair or bedside table by Resident 24's room entrance. Staff 7 further stated that Resident 24's infection care plan should have been revised to include contact isolation. Review of the facility policy and procedure titled, Procedure for Isolation: Initiation of Isolation, no date, indicated, .Transmission-Based Precautions . 3. Contact Precautions . use Contact Precautions for residents known or suspected to be infected with microorganisms that can be easily transmitted by direct or indirect contact, such as handling surfaces or resident care items . The above includes . highly transmissible infections such as . herpes (simplex or zoster) . IV. Gather Equipment . A. Obtain table/cart for 24 hour supply of masks, gown, etc. needed to maintain isolation . Points to Remember . Gather all equipment and supplies needed before going into the room . Review of the facility policy and procedure titled, Procedures for Airborne, Contact, and Droplet Isolation, undated, indicated, .Contact Precautions . Wear clean gloves when entering the resident's room or unit if a multi-bed room . 555657 Page 13 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide the necessary care and services for one of 16 sampled residents (Resident 53) when the facility did not remove the surgical site staples per the physician's orders; the facility did not assess the surgical site per the plan of care and the facility policy and procedure; or revise the comprehensive care plan to address a change in skin integrity and infection at the surgical site. Residents Affected - Few This deficient practice resulted in an infected surgical site for Resident 53. Findings: During a review of the clinical record of Resident 53, it indicated he was admitted on [DATE] for rehabilitation following a joint replacement surgery. Resident 53's medical diagnoses included a fractured right femur (broken right leg), sepsis (a life threatening infection of the blood stream), difficulty walking, and prediabetes (a condition involving high blood sugar with no other presenting clinical signs or symptoms). Resident 53 is his own responsible party. A review of the Minimum Data Set (MDS - a resident assessment tool) for Resident 53, dated 3/24/19, indicated the Skin Condition section of the MDS reflected the resident had a surgical wound upon admission. Resident 53 had a Brief Interview for Mental Status (BIMS - an aide in detecting cognitive impairment) score of 15 (meaning no cognitive impairment). During an observation and a concurrent interview with Resident 53, on 6/3/19, at 9:14 AM, in the room of Resident 53, Resident 53 sat in a chair and stated he was admitted to the facility for a broken leg, which made it difficult to move, stand up, and use the bathroom. During a concurrent record review and interview with Staff 24, on 6/4/19, at 10:20 AM, Staff 24 reviewed the binder of treatment records and stated, There's no wound care treatment performed to his surgical site today. The Treatment Administration Record [TAR] for Resident 53, between 6/1/19 and 6/30/19, indicated an order effective 5/31/19 through 6/4/19 to cleanse the area and pat dry the surgical site on the right distal femur, and apply a nickel sized amount of Santyl ointment (an ointment that removes dead tissue) to the right distal femur surgical site's wound bed avoiding contact with surrounding skin, apply wet gauze (dressings are used to help maintain a moist wound healing environment) to the wound or Hydrogel gauze (a dressings used for packing deep wounds and maintaining a moist wound), and cover the area with a dressing, every other day. During a concurrent record review and interview with Staff 24, on 6/4/19, at 10:20 AM, Staff 24 reviewed the skin assessment records in the Treatment binder for Resident 53, such as the Non Pressure Sore Skin Report[s] from admission until present (6/4/19), the TAR, dated 6/1/19 and 6/30/19, and the initial skin assessment, dated 3/17 /19. Staff 24 stated, The last time a skin assessment sheet was completed was on 5/23/19, but the skin assessments records in the binder don't address the surgical site on the right lower femur. When asked if all skin assessments for surgical sites should be documented in the ''.Treatment binder, Staff 24 stated, They [the records in the Treatment binder] should [address the surgical wound] . The skin assessment sheets [reports] should be done every week . During a concurrent observation and interview with Resident 53, on 6/4/19, at 10:43 AM, in the room of Resident 53, a clean and dry dressing covered his right femur. Resident 53 declined an 555657 Page 14 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0684 observation of his wound care for the surgical incision on the next day. Level of Harm - Actual harm A review of the Skin Assessment Record for Resident 53, dated 3/17/19, indicated 22 staples on the surgical site. There was no other documentation on the characteristics (such as redness and Residents Affected - Few measurements) of the right femur surgical site or the signs or symptoms of infection present. A review of the Progress Notes for Resident 53, between 3/17/19 and 3/24/19, indicated a dressing covered the surgical incision site upon admission. No documentation of a physician or orthopedist (a medical specialty which focused on the skeletal system) notification on the staple removal from the surgical site 3/17/19 through 3/24/19. The notes indicated no documentation of an assessment or treatment performed to the surgical site between 3/18/19 and 3/24/19. A review of a Nursing Weekly Assessment for Resident 53, dated 3/24/19, indicated a description of surgical wound with 22 staples in the Skin Assessment section. A review of the Comprehensive Care Plan of Resident 53 included care plans to address the skin integrity of the surgical site and potential for infection related to the surgical site. The care plan for Resident 53 titled: .Altered Skin Integrity r/t [related to] Surgical Wound . with 22 staples . revised 3/24/19, indicated goal and interventions, such as assessing the site for signs and symptoms of infection (redness, swelling, pain, and drainage, the liquid produced by the body in response to tissue damage), to identify and prevent wound complications, such as infection. Another care plan for Resident 53 titled: .Potential for infection . surgical wound site, revised 3/17/19, indicated measures to address the risk for infection. A review of a Physician's Order for Resident 53, dated 3/25/19, indicated the physician ordered laboratory testing in one week (4/1/19). A review of the Progress Notes for Resident 53, dated 3/25/19, indicated the physician ordered a complete blood count [laboratory testing to evaluate the composition of the blood] for 4/1/19 without a documented reasoning for ordering the test. There was no documentation of a notification or communication to the physician or the orthopedic surgeon regarding the surgical staple removal. A review of the Progress Notes for Resident 53, dated 3/26/19, indicated, . at 10:30 [am] 22 staples were removed from his right thigh, applied skin closure strips and island dressing [a dressing used to absorb fluid from wounds, such as surgical sites] . A review of the Progress Notes for Resident 53, dated 3/27/19, indicated the nurse called the physician regarding surgical site drainage and redness noted at 16:01 PM. A note at 22:09 PM indicated no frequency of the New order to cleanse surgical incision on right thigh with . apply triple atb [antibiotic medication used against bacterial infections] ointment and cover with island dressing. A review of the TAR for Resident 53, between 3/1/19 and 3/31/19, indicated three orders unrelated to any treatments, e.g. the order for the removal of the surgical staples, or assessments or monitoring of the site. A review of the Laboratory Result Report for Resident 53, received 4/1/19, indicated a WBC (white blood cell - cells in the immune system involved in fighting infection) level of 9.3, higher than the Reference Range of 4.2 9.1 K/uL (cubic milliliter). 555657 Page 15 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0684 According to Medline Plus, 2019, infection is a cause of a high white blood cell count. Level of Harm - Actual harm [https://medlineplus.gov/ency/article/003657.htm]. Residents Affected - Few A review of a Progress Note for Resident 53, dated 4/2/19, indicated the nurse notified the physician of serosanginous/yellow [a combination of both blood and serous fluid] drainage noted on old dressing . The note also indicated, Resident denied pain, but [reported] tenderness. Warm to touch, right leg brace kept on. Received [a physician's] order to start Keflex [a medication used against bacterial infections] . Order carried out. A review of the Medication Administration Record [MAR] for Resident 53, between 4/1/19 and 4/30/19, indicated an order to give one capsule (containing 250 milligrams) of Keflex by mouth four times a day for a wound infection, from 4/2/19 until 4/9/19; order for Keflex repeated from 4/10/19 until 4/12/19. A review of the TAR for Resident 53, between 4/1/19 and 4/30/19, indicated three orders, none of which addressed an assessment or wound care orders for the surgical site. A review of the Physician's Progress Note for Resident 53, dated 4/3/19, indicated the right femur fracture had redness and slough [yellow or white colored dead skin tissue] on the incision site and an order to .add Santyl to the area of slough on 4/3/19. A review of the Nursing Weekly Assessment for Resident 53, dated 4/ 4/19, indicated one surgical site listed on the right trochanter [upper portion of the leg] had a description of a Surgical Wound with 22 staples. There was no documentation of a surgical site on the right distal femur included. A review of the Physician's Progress Note for Resident 53, dated 4/8/19, indicated the Santyl [was] not working well; will refer to orthopedic surgeon for debridement [a procedure that removes dead tissues]. Continue on Keflex . A review of the Physician's Order for Resident 53, dated 4/8/19, indicated an order to Refer back to orthopedic surgeon to debride wound at incision. During a concurrent record review and interview with Staff 3, on 6/5/19, at 10:09 AM, Staff 3 was asked to detail the skin assessments process and documentation. Staff 3 stated the nurses were trained to conduct skin assessments of a surgical site on admission and document a skin assessment in the Treatment binder once a week. When asked to describe the documentation for a skin assessment, Staff 3 answered, Nurses must document the wound's size, drainage, wound bed appearance, odor . Staff 3 reviewed the clinical record of Resident 53 and stated Resident 53 had a surgical site on the right distal femur. Staff 3 further reviewed the resident's records in the Treatment binder, the TARs, the Physician's Orders, the Non Pressure Sore Skin Report[s] recorded from admission until present (6/4/19), the Progress Notes, between 3/17/19 and 6/4/19, and acknowledged wound infection and orders for Keflex, wound care, and wound debridement began in the facility and were not present on admission. In addition, Staff 3 acknowledged there was no documentation of a skin assessment between 3/18/19 and 3/25/19. When asked if the Nursing Weekly Assessments incorporate a skin assessment of the surgical site, she stated, No due to the lack of information, such as the wound's measurements and drainage, in all the records (including 3/24/19 and 4/4/19). Staff 3 further stated, .The first assessment isn't even right, the surgical site is on the right lower leg, not the trochanter . Staff 3 also acknowledged the Progress Notes did not contain documentation of an assessment or treatment of the right 555657 Page 16 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0684 Level of Harm - Actual harm distal femur surgical site between 3/18/19 and 3/25/19. Staff 3 reviewed the comprehensive care plan and stated the care plan on the skin integrity of the surgical site [on the right femur] and the potential for infection needs to be revised as no update occurred since March 24th [2019] [prior to the surgical staple removal and the surgical site infection]. Residents Affected - Few During a concurrent record review and interview with Staff 20, on 6/5/19, at 3:11 PM, Staff 20 stated Resident 53 was admitted to the facility with a surgical wound. Staff 20 reviewed the Inter Facility Transfer Report (the general acute care hospital [GACH] discharge summary) for Resident 53, dated 3/17/19, and the clinical record of Resident 53. Staff 20 stated Resident 53 received discharged orders from the GACH's physician to remove the surgical staples on the right femur on 3/24/19. Staff 20 stated the progress notes did not document a skin assessment or treatment performed to the surgical site on the right femur between 3/18/19 and 3/25/19, and a Progress Note for Resident 53, on 3/26/19, was the first documentation covering the removal of the right femur's surgical staples. Staff 20 reviewed the Progress Notes, between 3/17 /19 and 3/25/19, and was unable to find documentation of a notification to the physician or orthopedist regarding the removal of the right femur's surgical site staples, or any documentation to remove the surgical site staples on different date than 3/24/19, ordered by the GACH physician. Staff 20 stated the surgical staples were removed late, and the resident's surgical site became infected, which required antibiotics, wound care treatments, and wound care debridement. Staff 20 acknowledged the Progress Notes for Resident 53, between 3/17/19 and 3/25/19, indicated no documentation of an assessment or treatment performed to the surgical site on the right femur between 3/18/19 and 3/25/19 or a notification to a physician or orthopedist (a medical specialty which focused on the skeletal system) regarding the removal of the surgical staples on the right femur's surgical site between 3/17 /19 through 3/25/19. Staff 20 reviewed the Initial Assessment, dated 3/17/19, and the Weekly Nursing Assessment, dated 3/24/19 and 4/4/19, and stated the records lacked the assessment information, such as the characteristics of the surgical site. When Staff 20 was asked to provide additional skin assessment of the surgical site on the right femur, Staff 20 was unable to provide additional documentation. Staff 20 acknowledged revision dates for the care plans on the potential for infection and the surgical wound's skin condition, were outdated and required revision. During a concurrent record review and interview with Staff 12, on 6/6/19, at 3:14 PM, Staff 12 was asked about performing and documenting skin assessments. Staff 12 replied, Skin assessments for surgical wounds are documented once a week in the Treatment binder . An assessment for a surgical wound includes noting the redness, appearance of the dressing . a wound infection assessment consists of documenting the amount and appearance of the drainage, the smell of the wound, the drainage, the temperature of the resident . Staff 12 was asked when care plans on wounds and infection were revised. Staff 12 answered, .The care plans are revised when there is a change in the wound or when there is a new infection present . Staff 12 reviewed the skin assessment records for Resident 53 in the Treatment binder and was unable to provide documentation of a surgical wound assessment. After reviewing the clinical record of Resident 53, Staff 12 acknowledged the surgical staples removal was late and the skin assessments records on the surgical wound's condition didn't have enough entries or details. In addition, upon further review of the care plan, Staff 12 stated the care plan addressing the skin integrity of the surgical site, revised 3/24/19, indicated the care plan still shows when the resident has surgical staples, and the care plan on the potential for infection is overdue for a revision. Staff 12 added both care plans had interventions and goals created no more than two weeks after he came here [was admitted to the facility]. Staff 12 added the comprehensive care plan needs to be revised as the resident was no longer at risk for infection, but had a diagnosis of infection at surgical site. Staff 555657 Page 17 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0684 Level of Harm - Actual harm Residents Affected - Few 12 acknowledged without the necessary care (the lack of skin assessments, late surgical staple removal and care plan revisions) the surgical site became infected, which required Keflex, wound care treatment, and debridement. During a record review and interview with Staff 2, on 6/7/19, at 12:12 PM, Staff 2 was asked about the skin assessment process. Staff 2 answered nurses assess surgical wounds once a week and document the findings in the Treatment binder. Staff 2 continued, To assess a wound, a nurse looks at the drainage, the redness, the location, the measurements of the wound . signs and symptoms of infection include odor, drainage . Staff 2 was asked when care plans for the skin integrity of surgical wounds and an infection were revised. Staff 2 stated care plan revisions should be completed when a wound, or infection, occurs or worsens. Staff 2 reviewed the clinical record of Resident 53. Staff 2 stated Resident 53 was admitted with orders from the GACH (General Acute Care Hospital) to remove the surgical staples following surgery on the right femur. Staff 2 was unable to provide documentation the staples were removed per the orders, and Staff 2 was unable to provide documentation supporting the staff notified the physician or orthopedic surgeon regarding the surgical staples prior to removal. When asked to provide additional documentation of a skin assessment for the surgical site, Staff 2 was unable to do so. Staff 2 reviewed the Weekly Nursing Assessments and was asked if the Weekly Nursing Assessments contained documentation which included a surgical site skin assessment. Staff 2 stated, No. Staff 2 acknowledged the (potential for) infection and skin integrity of the surgical site care plans required revisions to reflect the changes in the resident's condition. Staff 2 stated there was no policy and procedure on assessing and documenting a surgical wound, or removing surgical staples. Review of the facility policy and procedure titled: Wound Care Management, dated 2018, indicated the wound documentation assessments must contain characteristics of the wound and treatment performed to the wound. Review of the facility policy and procedure titled: Comprehensive Care Plan dated 8/24/18, indicated, .The plan of care shall be individualized, based on diagnosis, resident assessment and personal goals of the resident and his/her family .The needs of the resident, goals, time frames, required services and the service settings are critical considerations in determining the plan of care. 555657 Page 18 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 address the risk of developing a pressure ulcers [loss of skin due to pressure] for one of sixteen sampled residents (Resident 53) when Resident 53 did not receive skin assessments per the plan of care, interventions ordered by the physician, or a care plan to prevent pressure ulcers, despite the Minimum Data Set (a resident Assessment tool) for Resident 53, dated 3/24/19, identifying the resident was at risk for developing pressure ulcers. Residents Affected - Few This deficient practice increased the risk for Resident 53 to acquire a pressure ulcer. Findings: A review of the clinical record of Resident 53 indicated the resident was admitted on [DATE] for rehabilitation following a joint replacement surgery; his medical diagnoses included a fractured right femur (broken right leg), sepsis (a life threatening infection of the blood stream), difficulty walking, and prediabetes (a condition involving high blood sugar with no other presenting clinical signs or symptoms). Resident 53 was his own responsible party. A review of the Minimum Data Set (MDS - a resident assessment tool) for Resident 53, dated 3/24/19, indicated Resident 53 was at risk for pressure ulcers. The functional status section of the MDS indicated Resident 53 required a one person to physically assist him with transfers (moving between surfaces, e.g. the wheel chair to the bed), and toileting (the capability of transferring on and off the toilet, and using and grooming himself after toileting). Resident 53 had a Brief Interview for Mental Status (BIMS - an aide in detecting cognitive impairment) score of 15 (meaning no cognitive impairment). During an observation and a concurrent interview with Resident 53, on 6/3/19, at 9:14 AM, in the room of Resident 53, Resident 53 sat in a cushioned seated wheel chair, beside an empty urine bottle. There was no pressure relieving device on the resident's bed such as a waffle overlay mattress or a low air loss mattress. Resident 53 stated he was admitted to the facility for a broken leg, which made it difficult to move, stand up, and use the bathroom. During a record review and concurrent interview with Staff 24, on 6/4/19, at 10:20 AM, Staff 24 reviewed the binder with the Treatment records and gathered the wound care treatment supplies. The records in the Treatment binder for Resident 53, included documents such as skin assessment reports (for pressure and non-pressure related skin conditions) and the Treatment Administration Record [TAR], between 6/1/19 and 6/30/19. The Non-Pressure Sore Skin Problem Report, indicated the skin assessments for non-pressure related areas were conducted during May, 2019. The Therapeutic Measures reports for Resident 53 indicated three entries documented the skin was assessed for pressure ulcers entries on 5/11/19, 5/15/19, and 5/23/19. All three entries of the Therapeutic Measures report had missing documentation of blanching versus non-blanching areas (blanching is the fading of the skin's color when pressed; whereas non-blanching is a characteristic of pressure ulcers where the damage area will remain the same color when pressed). The TAR indicated the resident received a wheelchair seat cushion on 5/14/19, Clotrimazole Cream 1% [a medicated cream used against fungal infections] on the gluteal folds was applied twice a day for redness starting 5/28/19, and Dimethicone ointment [ointment used to protect the skin] on both lower extremities once a day from 3/17/19 until 6/3/19. During an interview with Resident 53, on 6/4/19, at 10:41 AM, Resident 53 was asked about the 555657 Page 19 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0686 Level of Harm - Minimal harm or potential for actual harm condition of his buttocks and the treatment. Resident 53 answered, .I got a wheel chair cushion, ice, some medicated creams and dressings applied to the middle and left side of my bottom, but that's about it . Review of the Skin Assessment Record for Resident 53, dated 3/17/19, indicated the resident did not have pressure ulcers. Residents Affected - Few A review of the Nursing Weekly Assessment records of Resident 53, between 3/24/19 and 5/31/19, indicated the resident was at risk for pressure ulcers. A review of the Comprehensive Care Plan for Resident 53 indicated no documentation of a care plan to address the risk for pressure ulcers, and did not include documentation of a pressure relieving device for the bed or chair, or other non-pharmacologic measures to prevent pressure ulcers. The Care Plan for Resident 53 titled: . Altered Skin Integrity r/t [related to] Surgical Wound . blanchable redness on coccyx, revised on 3/24/19, indicated to Assess for healing process of wound to include progressive resolution of redness and edema, absences of necrosis [dead tissue] . Assess for signs and symptoms of infection such as redness, edema, pain, purulent [puss filled] drainage . During a concurrent record review and interview with Staff 24, on 6/4/19, at 11:09 AM, Staff 24 reviewed the clinical record of Resident 53, and the records in the Treatment binder again, and was unable to provide documentation of treatments to prevent pressure ulcers and skin assessments other than the admission skin assessment and in the Therapeutic Measures Report. Staff 24 stated, .There's no other place we chart skin assessments other than in the TAR and the skin sheets [skin assessment reports] in the binder . We [the staff] are supposed to document skin assessments for pressure areas, or pressure sores, every Wednesday . Staff 24 further stated the care plan should have been revised to reflect the current status of the coccyx. Review of the TAR for Resident 53, between 3/1/19 and 5/31/19, and the Medication Administration Record [MAR], for Resident 53, between 3/1/19 and 5/31/19, indicated no additional documentation of a skin assessment or interventions implemented to prevent pressure ulcers, such as a pressure relieving device for the bed. During a concurrent record review and interview with Staff 3, on 6/5/19, at 10:09 AM, Staff 3 was asked to detail the skin assessment process and documentation. Staff 3 responded the nurses are trained to conduct skin assessments on admission and once a week to prevent pressure ulcers and nurses must document their assessments in the Treatment binder records. When instructed to describe the documentation for a skin assessment, Staff 3 answered, Nurses document the wound's size, drainage, wound bed appearance, blanching, odor . Staff 3 acknowledged the MDS, dated [DATE], indicated Resident 53 was at risk for pressure ulcers. Staff 3 reviewed the clinical record of Resident 53 and stated the care plan should have contained a care plan to prevent the risk of pressure ulcers when the risk was identified. Staff 3 added the MAR and TAR did not have orders to prevent pressure ulcers, other than the application of Dimethicone to the bilateral extremities once a day, until the middle of last month [the order for the wheel chair seat cushion 5/15/19] . Staff 3 was unable to provide documentation of skin assessments performed before 5/11/19 or after 5/23/19 to pressure related areas. When asked if the documentation in the description of the Skin Assessment in the Nursing Weekly Assessments is a skin assessment, Staff 3 replied, No. It doesn't have the components of a skin assessment I mentioned earlier . During a concurrent record review and interview with Staff 20, on 6/5/19, at 3:11 PM, Staff 20 555657 Page 20 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated she coded the MDS information for Resident 53. Staff 20 was instructed to describe her process for coding the Skin Condition section in the MDS. She replied she gathered information from her assessments, Treatment binder records, the hospital discharge paperwork, physician orders, the TAR, care plans, nursing notes, and input from her coworkers and the resident. When asked how a resident's risk for pressure ulcers is determined and when are pressure ulcer prevention care plans initiated, Staff 20 answered, A care plan is developed after the resident is said to be at risk for pressure ulcers . Aside from the documents I review, I look at the resident's mobility function [at the time of the assessment], nutritional status, and their history with pressure ulcers . When instructed to provide details on the Resident 53's risk of pressure ulcers, Staff 20 responded, . He [Resident 53] was at risk for pressure ulcers on admission. He used a wheelchair . He needed help with transfers, turning and repositioning . When asked what pressure relieving device(s) are used for Resident 53's bed, Staff 20 denied Resident 53 received a pressure relieving device for his bed or a special mattress. After reviewing the Skin Condition section of the MDS, dated [DATE], Staff 20 stated the resident was identified at risk for pressure ulcers due to immobility. Staff 20 acknowledged the MDS indicated Resident 53 received a pressure relieving device for his bed and chair. After Staff 20 reviewed the Inter-Facility Transfer Report (the general acute care hospital [GACH] discharge summary) for Resident 53, dated 3/17/19, Staff 20 acknowledged a wound care order from the hospital for a waffle overlay mattress [a mattress that redistributes pressure]; Staff 20 then stated, We don't use a waffle overlay here [in the facility]. Staff 20 reviewed the clinical record for Resident 53 and was unable to provide documentation addressing waffle overlay mattress or an alternative pressure ulcer relieving device for the bed until 6/5/19. Staff 20 reviewed the physician order for Resident 53, dated 6/5/19, indicating Low Air Loss Mattress .Check proper functioning every shift and stated, I don't remember this order for this bed. Staff 20 acknowledged the clinical record contained no documentation of the resident used the low air loss mattress throughout his stay in the facility, or the wheel chair seat cushion prior to 5/15/19. Staff 20 was also unable to provide documentation of the risk for pressure ulcers in the Comprehensive Care Plan and stated the care plan did not address pressure ulcer prevention. During a concurrent record review and interview with Staff 12, on 6/6/19, at 3:14 PM, Staff 12 was asked about performing and documenting skin assessments. Staff 12 responded, An assessment of a wound includes documenting the redness, discharge, pain, measuring it . Skin assessments must be documented every week in treatment book . Staff 12 was asked when a care plan addressing the risk for pressure ulcers is initiated. Staff 12 responded, As soon as the risk is identified . When asked where the use of a pressure relieving device on the bed or an air mattress is documented, Staff 12 answered, In the progress notes and the TAR . there definitely needs to be an order. After reviewing the clinical record of Resident 53, Staff 12 stated the MDS was accurate in identifying Resident 53 as a risk for pressure ulcers. When instructed to provide documentation Resident 53 received a pressure relieving device for his bed, e.g. the low air flow mattress, Staff 12 stated, No. He's [Resident 53] had simple mattress - always. I don't know about these orders [the GACH discharge summary orders for the waffle overlay mattress and the physician orders on 6/5/19 for a low air loss mattress]. I don't think they were carried out. Staff 12 acknowledged the missing skin assessments and stated the only order to prevent pressure ulcers prior to May, 2019, on the MAR, the TAR, and Physician's Order's, is the Dimethicone ointment applied to the lower extremities. Staff 12 added, The skin assessments records only show the skin was inspected in May for pressure ulcers. If the skin assessment wasn't documented, it [the assessment] wasn't done. After reviewing the comprehensive care plan, Staff 12 stated no care plan addressed the risk for pressure ulcers. During an 555657 Page 21 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few observation and concurrent interview with Staff 28, on 6/5/19, at 4:06 PM, in the room of Resident 53, Staff 28 noted Resident 53's unoccupied bed. When asked to describe Resident 53's mattress, and any pressure relieving device used for the resident's bed, Staff 28 stated, He [Resident 53] always had this [point to the regular mattress]. He didn't have any [pressure relieving] device . During an observation and concurrent interview with Staff 27, on 6/5/19, at 4:08 PM, in the room of Resident 53, Staff 27 noted the bed of Resident 53 was unoccupied and stated, The resident had a regular mattress without any air flow . there wasn't any [pressure relieving] device for his bed, or any other device for the chair, aside from his wheelchair cushion . During a record review and interview with Staff 2, on 6/7/19, at 12:12 PM, Staff 2 was asked about the process for skin assessments and identifying a resident at risk for pressure ulcers. Staff 2 answered, Nurses assess the wound every Wednesday . To assess a wound a nurse looks at the drainage, measurements of the wound . The nurse documents the wound assessments on the sheets in the Treatment binder . The risk for pressure ulcers is determined by the nutritional status of the resident, dietary, mobility, friction . Staff 2 was asked when area care plan to address the risk for pressure ulcers initiated. Staff 2 responded, The risk for developing pressure ulcers should be in the care plan once the risk is known . When asked if a pressure relieving device on a bed, such as mattress, need to be incorporated in the care plan or in the TAR, Staff 2 stated, Yes. When asked where a concern or clarification of orders from a GACH are documented, Staff 2 answered, .In the nurses notes . After reviewing the clinical record of Resident 53, Staff 2 stated, .The MDS and hospital discharge records are right, the resident is at risk for pressure ulcers . There's no care plan to address it [the risk for pressure ulcers] . Staff 2 was unable to provide a care plan addressing the resident's risk for pressure ulcers. Staff 2 could not provide documentation Resident 53 received the pressure relieving device for the bed ordered from the hospital and written in the MDS; Staff 2 denied the order for a low air loss mattress was implemented. When asked whether the Nursing Weekly Assessment[s] contains a skin assessment, Staff 2 shook her head No, and stated, It didn't include how the resident responded to the treatment or the description of wound . Staff 2 could not provide any documentation in the clinical record of pressure ulcer skin assessments performed. Review of the facility policy and procedure titled: Skin Assessment, dated 2018, indicated to approach Pressure injury prevention and management is to conduct .A full body, or head to toe, skin assessment . upon admission .daily for three days, and weekly thereafter .Documentation skin assessment . Document[s] observation (e.g. skin condition, how the resident tolerated the procedure . Describe[s] [the] wound (measurements, color .). 555657 Page 22 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

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. Based on observation, interview and record review, the facility did not ensure that one of 16 sampled resident (Resident 160) environment was free from accident hazards when facility did not complete an assessment and obtain informed consent prior to initiating the use of bed alarm. This deficient practice had the potential for Resident 160 to be at risk for accidents which could result in unnecessary injuries. Findings: During a review of the clinical record, the Minimum Data Set (MDS, a resident assessment tool), for Resident 160, dated 6/4/19, indicated a Brief Interview for Mental Status (BIMS, a brief assessment to help detect cognitive impairment) score of 5 indicating resident had severely impaired cognition. The Resident Face Sheet indicated diagnoses that included fractured neck of femur. During an observation and concurrent interview on 6/3/19 at 11:10 AM, Resident 160 was sitting in a wheelchair positioned adjacent to the bed. Resident 160 stated that he had this alarm that goes off everytime he changes position in bed and the sound of the alarm made it hard for him to go to sleep. Resident 160 demonstrated how he can successfully turn off the alarm by turning the alarm's switch to off. During a review of the clinical record for Resident 160, the care plan for falls dated 5/22/19, indicated, Focus . has the potential for falls related to . recent surgery, unsteady gait, weakness, hx [history] of falls . Interventions . Bed pad alarm as indicated . During an interview and concurrent record review on 6/3/19 at 11:23 AM, Staff 21 stated the staff applied the bed alarm after Resident 160 fell on 5/22/19. When asked about the policy of bed alarm, Staff 21 responded that the staff should have completed an assessment, obtained a consent from the resident, and afterwards, get a physician's order. Staff 21 reviewed Resident 160's clinical record and acknowledged there was no evidence that an assessment was completed, consent and physician's order were obtained by staff, prior to the use of the bed alarm. During an interview with Staff 2 on 6/6/19 at 2 PM, she stated the bed alarms are considered restraints, therefore, assessments, consents, and proper monitoring were necessary. Review of the facility policy and procedure titled, Resident Alarms dated 2018, indicated, .Policy Explanation and Compliance Guidelines: . 2. The facility shall establish and utilize a systematic approach for the safe and appropriate use of resident alarms, including efforts to identify risk; evaluate and analyze risk; implement interventions to reduce risk; and monitor for effectiveness of the interventions and modifying interventions when necessary . 7. When alarms are used, the interdisciplinary team shall determine whether the alarm meets the definition of a restraint . a. The Resident's assessment to determine whether the alarm meets a definition of a restraint shall be documented . b. If the alarm is considered a restraint for the resident, procedures for restraints shall be implemented . Review of the facility policy and procedures titled, Use of Restraints, dated 5/19, indicated, PROCEDURE: . All residents will be assessed upon admission or change of condition for physical or 555657 Page 23 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few behavioral triggers which may necessitate the temporary use of restraint . Informed consent will be obtained from the alert resident or his/her Responsible Party prior to the initial use of a restraint . The physician will write an order that indicates a specific reason for the use of the restraint, the type of restraint to be used, and when it should be used . The resident's care plan will indicate the type and indications for use of the restraint as well as resident-specific observations and considerations for its use . The effectiveness of the restraint will be documented regularly by the licensed nurse; and the continued utilization or discontinuation of the restraint will be reviewed every quarter (or earlier, if resident's situation changes.) 555657 Page 24 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on observation, interview and record review, the facility failed to utilize the services of a Registered Nurse (RN) for eight hours per day, seven days a week for three of 12 sampled days. Residents Affected - Some This deficient practice increased the risk for resident harm or jeopardy due to the shortage of RNs available to perform assessments, and other RN duties, on the weekends. Findings: During an initial tour observation, on 6/3/19, at 10:59 AM, in the nursing station, a double-sided sheet of paper titled: Census and Direct Care Service Hours Per Patient Day (DHPPD), was displayed on the counter. Review of the record titled: Census and Direct Care Service Hours Per Patient Day (DHPPD), dated 6/3/19, indicated the total and actual hours for the direct care staff (the combined hours of RNs, LVNs, and unlicensed personnel, such as Certified Nurse Assistance), but the records did not list the total and actual hours of the RNs, exclusively. During an observation and interview with Staff 24, on 6/3/19, at 11:01 AM, in the nursing station, Staff 24 was asked where the staffing information for the public was located. Staff 24 replied, You're looking at it [the Census and DHPPD record]. During an observation and record review, on 6/5/19, at 11:19 AM, in the nursing station, a white binder containing staffing information was on the counter. The binder contained a record titled: Actual Nursing Hours Sign-in Sheet. A review of the Actual Nursing Hours Sign-in Sheet, between 5/30/19 and 6/5/19, indicated one RN was scheduled on 6/1/19: Staff 26. The record for 6/2/19 listed no RNs were scheduled that day, and Staff 26 was identified as a Licensed Vocational Nurse (LVN), not an RN. A review of the Time Schedule, between 6/1/19 and 6/2/19, indicated an RN was not scheduled either date, and the schedule listed Staff 26 as an LVN, not an RN. A review of the List of Hire from 7/2018 - Present, dated 6/3/19, and the List of Current Employees, dated 6/3/19, indicated RN scheduled on 6/1/19 had the same name as Staff 26, LVN. A review of communications from the facility titled: Waivers, undated, indicated the facility had no waivers (addressing the facility's staffing levels or RN staffing coverage) as of 6/3/19. During an interview with Staff 7 and Staff 25, on 6/5/19, at 1:52 PM, Staff 7 stated she created the June staffing schedule. Staff 7 stated she is an RN and is available eight hours two to three days a week usually on Wednesday and Thursday. Staff 7 added the Director of Nursing (DON) and Director of Staff Development (DSD) are RNs who work Monday through Friday, and once in a while DSD will provide in-services on the weekend. When asked where RN hours were documented separately from other direct care staff (LVNs), Staff 7 stated the hours are on the Actual Nursing Hours Sign-in Sheet, and the Time Schedule, not on the Census and DHPPD records. Staff 7 and Staff 25 reviewed the Actual Nursing Hours Sign-in Sheet, between 5/30/19 and 6/5/19, and stated, We don't have the [total or actual] hours an RN worked [in each shift or a day] . Staff 7 and Staff 25 denied any employee signatures were unaccounted for on the sheet. Staff 7 and Staff 25 were asked to provide the hours an RN worked 555657 Page 25 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some on 6/1/19 and 6/2/19: their answer was, There weren't any [hours]. Staff 7 and Staff 25 reviewed the Time Schedule, between 6/1/19 and 6/30/19, and there was no documentation of an RN working on 6/1/19 and 6/2/19. When instructed to provide any additional documentation of RN hours worked on 6/1/19 or 6/2/19, Staff 7 and Staff 25 were unable to provide additional documentation and stated, .There wasn't an RN scheduled on 6/1/19 and 6/2/19. Staff 7 denied any hours worked remotely, using a telephone or other means, or by a consultant. During a concurrent record review and interview with Staff 24, on 6/6/19, at 11:48 AM, Staff 24 was asked about RN staffing on the weekends. She replied, We're short [staffed] of RNs on weekends. During a concurrent record review and interview with Staff 26, on 6/6/19, at 2:59 PM, Staff 26 stated he is an LVN. Staff 26 reviewed the Actual Nursing Hours Sign-in Sheet, dated 6/1/19, and stated he signed the record, but his title .is wrong on the sheet .I don't know why it says I'm an RN . Staff 26 denied an RN worked on 6/1/19 and 6/2/19. During an interview with Staff 12, on 6/6/19, at 3:14 PM, Staff 12 was asked for the hours the Director of Nursing (DON) worked. Staff 12 responded, The DON works Monday through Friday during business hours [9 am to 5 pm], but she is new. Staff 12 denied the new DON worked this weekend, or since she's been here [employed at this facility]. Staff 12 was asked about RN staffing on the weekends, and this weekend. She replied, There's no RN [working] on the weekends, even when I worked this past weekend [6/1/19 and 6/2/19]. A review of staffing records produced by the facility for the nine dates: 6/2/19, 6/1/19, 5/25/19, 5/19/19, 5/18/19, 5/12/19, 5/11/19, 5/5/19, and 5/4/19, included one document: Actual Nursing Hours Sign-in Sheet. Three of the nine records, 6/2/19, 6/1/19, and 5/25/19, did not include an RN on the schedule; zero of the nine Actual Nursing Hours Sign-in Sheet records noted the total and actual RN hours worked. During a concurrent record review and interview with Staff 7 on 6/7/19, at 10:15 AM, Staff 7 reviewed the Actual Nursing Hours Sign-in Sheet, dated 6/2/19, 6/1/19, 5/25/19, 5/19/19, 5/18/19, 5/12/19, 5/11/19, 5/5/19, and 5/4/19, and stated there were no hours worked by an RN on 5/25/19, 6/1/19, and 6/2/19. During an interview with Staff 2, on 6/7/19, at 12:20 PM, Staff 2 was asked about her employment and the facility. Staff 2 stated the facility is licensed for 60 or more beds. Staff 2 stated she works 40 hours a week during the week day . Staff 2 denied working hours on the weekend, or remotely, since starting her employment at the facility in May, 2019. Staff 2 denied any hours worked remotely, using a telephone or other means, or by a consultant. Staff 2 further stated an RN must work eight hours everyday, seven days a week. During an interview with Staff 7, on 6/7/19, at 12:33 PM, Staff 7 stated all the information on RN staffing hours was provided. During a record review and concurrent interview with Staff 2, on 6/7/19, at 1:20 PM, Staff 2 reviewed the staffing records, the Department Response to Issues ., and the document titled: Waivers. Staff 2 was unable to provide new documentation of staffing hours worked by an RN (exclusively) and acknowledged no documentation of any RN hours worked on 5/25/19, 6/1/19, and 6/2/19. Staff 2 stated, I think we don't have a waiver, but I'll ask around and see if any information is posted . 555657 Page 26 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with Staff 20 and Staff 2, on 6/7/19, at 1:35 PM, Staff 20 stated the facility application for a staffing wavier was denied last year. During an observation and a concurrent interview with Staff 2, on 6/7/19, at 1:37 PM, in the facility hallways, she toured the facility and could not find any additional information on staffing, including any waivers. Staff 2 stated the facility did not have any waivers related to staffing applications or approval. During a record review and a concurrent interview with Staff 1, on 6/7/19, at 2 PM, Staff 1 stated the facility had no current waivers, and the staffing waiver application was denied last year. Staff 1 reviewed the staffing records and the Department Response to Issues ., signed 1/28/19, and stated the facility is required to have an RN Eight hours a day, seven days per week . an RN did not work those dates [5/25/19, 6/1/19, or 6/2/19]. 555657 Page 27 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to display the total and actual hours worked by Registered Nurses (RNs), Licensed Vocational Nurses (LVNs) each shift, and the actual hours worked by the certified nurse aides (CNAs) each shift. Residents Affected - Many This deficient practice had the potential to cause inadequate staffing to care for the resident census in the building. Findings: During an initial tour observation, on 6/3/19, at 10:59 AM, in the nursing station, a double-sided sheet of paper titled: Census and Direct Care Service Hours Per Patient Day (DHPPD), was displayed on the counter. During an observation and interview with Staff 24, on 6/3/19, at 11:01 AM, in the nursing station, Staff 24 was asked where the staffing information for the public. Staff 24 replied, You're looking at it [the Census and DHPPD record]. Review of the record titled: Census and Direct Care Service Hours Per Patient Day (DHPPD), dated 6/3/19, indicated the total and actual hours for the direct care staff (the combined hours of RNs, LVNs, and unlicensed personnel, such as Certified Nurse Assistance), but the records did not list the total and actual hours of the RNs, exclusively. During an observation, on 6/5/19, at 11:19 AM, in the nursing station, a white binder containing staffing information was on the counter. The binder contained a record titled: Actual Nursing Hours Sign-in Sheet. A review of the Actual Nursing Hours Sign-in Sheet, between 5/30/19 and 6/5/19, indicated one RN was scheduled on 6/1/19: Staff 26. The record for 6/2/19 listed no RNs were scheduled that day, and Staff 26 was identified as a Licensed Vocational Nurse (LVN), not an RN. A review of the Actual Nursing Hours Sign-in Sheet, dated 5/30/19 and 6/5/19, indicated no documentation of the total and actual hours worked by RNs, LVNs, or CNAs, exclusively, each shift. During an interview with Staff 7 and Staff 25, on 6/5/19, at 1:52 PM, Staff 7 stated she was responsible for creating the June staffing schedule. When asked where RN hours were documented separately from other direct care staff (LVNs and CNAs). Staff 7 stated the hours are on the Actual Nursing Hours Sign-in Sheet, and the Time Schedule, not on the Census and DHPPD records. Staff 7 and Staff 25 reviewed the Actual Nursing Hours Sign-in Sheet, between 5/30/19 and 6/5/19, and stated, We don't have the [total or actual] hours an RN worked [in each shift or a day] . Staff 7 and Staff 25 were asked to provide the hours an RN worked on 6/1/19 and 6/2/19: the answer was, There weren't any [hours]. Staff 7 and Staff 25 reviewed the Time Schedule, between 6/1/19 and 6/30/19, and there was no documentation of the total or actual hours by the LVNs, or RNs, exclusively. A review of staffing records produced by the facility for the nine dates: 6/2/19, 6/1/19, 5/26/19, 5/25/19, 5/19/19, 5/18/19, 5/12/19, 5/11/19, 5/5/19, and 5/4/19, included one document: Actual Nursing Hours Sign-in Sheet. Zero of nine Actual Nursing Hours Sign-in Sheet records documented the total and actual hours worked by an RN, CNA, or LVN, exclusively. During a record review and concurrent interview with Staff 7 on 6/7/19, at 10:15 AM, Staff 7 555657 Page 28 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0732 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many reviewed the Actual Nursing Hours Sign-in Sheet, for 6/2/19, 6/1/19, 5/25/19, 5/19/19, 5/18/19, 5/12/19, 5/11/19, 5/5/19, and 5/4/19, and acknowledged the document did not include the total or actual hours worked by the CNAs, or other staff. When Staff 7 asked if all the documents requested on the staffing information was given, Staff 7 stated, .I'll bring 'Census and DHPPD' sheets later .The assignment sheets aren't typically posted for the visitors . When asked what happened to the Census and DHPPD forms, Staff 7 replied, .They need more information . A review of the Census and Direct Care Service Hours Per Patient Day (DHPPD) forms, dated, 5/25/19, 5/26/19, 6/1/19, and 6/2/19, indicated blank entries for the total CNA hours work listed under every shift on 6/1/19 and 6/2/19. No total or actual hours worked exclusively by an LVN or RN hours were recorded. During an interview with Staff 2, on 6/7/19, at 12:33 PM, Staff 7 entered the room and presented the Census and DHPPD form dated 5/25/19, 5/26/19, 6/1/19. Staff 7 reviewed the four Census and DHPPD forms and acknowledged the three of four dates (5/26/19, 6/1/19, 6/2/19) did not have a signature authorizing the accuracy of the records. Additionally, Staff 7 acknowledged the total CNA hours work listed under every shift on 6/1/19 and 6/2/19, and the sheet did not list the total or actual hours worked exclusively by an LVN or RN, or the actual CNA hours worked each shift. When instructed to provide additional staffing records, Staff 7 stated all the information on staffing hours were provided. During a record review and concurrent interview with Staff 2, on 6/7/19, at 1:20 PM, Staff 2 reviewed the staffing records and acknowledged the total and actual nursing hours were missing, and was unable to provide any new documentation of staffing hours worked by an RN (exclusively), or any other role or member. Staff 2 added the facility had already provided all the documents on staffing hours. During an observation and a concurrent interview with Staff 2, on 6/7/19, at 1:37 PM, in the facility hallways, Staff 2 toured the facility and could not find any additional information on staffing. During an interview and record review with Staff 26 and Staff 12, on 6/17/19, at 1:50 PM, they were asked where the total and actual nursing hours were posted. They answered the only staffing information displayed is the Census and DHPPD. Both staff members reviewed the Census and DHPPD, dated 6/7/19, they could only find the total number of hours worked by a CNA each shift, and the actual CNA hours work has not been calculated yet. A review of the facility policy: Calculating & Posting of Direct Care Staffing Hours, dated 6/19, indicated, Purpose: to ensure that [the] facility has adequate staffing to care for [the] resident census in building; to post the direct staffing hours per patient day in an accurate and timely manner; to document for residents and family members that [the] facility is meeting the mandatory direct care staffing hours . 555657 Page 29 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

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 observation, interview, and record review, the facility failed to ensure to monitor adverse consequences and effectiveness of Lexapro (an anti-depressant medication) for one of 16 sampled residents (Resident 17). This deficient practice had the potential for Resident 17 to receive unnecessary psychotropic medications and suffer from adverse consequences. Findings: During a review of the clinical record for Resident 17, the Order Summary Report dated 4/28/19, at 2:35 PM, indicated the following orders for pain: 1. Morphine Sulfate 20 mg/ml 0.125 ml to be given by mouth every three hours as needed for moderate pain and 0.25 ml by mouth every three hours to be given as needed for severe pain. 2. Tramadol HCL tablet 50 mg, to give half a tab (25 mg) by mouth every six hours as needed for leg pain. with a note, not to be given at same time with Morphine Sulfate. 3. Fioricet tablet 50-325-40 mg to give 2 tablets by mouth one time a day for migraine, not to exceed 6 tablets per day, and 1 tab by mouth every 3 hours as needed for headache. not to exceed 6 tablets per day, and 4. Depakote extensive release (ER) tablet250 mg, one tablet by mouth at bedtime for migraine was ordered. 5. Lexapro 20 mg to be given by mouth, one time per day for chronic pain on both legs. A review of the latest Minimum Data Set (MDS - an assessment tool) for Resident 17, dated 3/13/19, indicated Resident 17's brief interview for mental status (BIMS) score was 15 (13 to 15 score indicates intact cognition) and she required supervision to limited assistance on her activities of daily living. The MDS also indicated diagnoses included depression with symptoms of feeling tired or having little energy for several days on the time of the assessment. A review of the facility's PSYCHOPHARMACOLOGICAL [Psychopharmacology - is the study of how drugs effect behavior] DRUG SUMMARY RECORD (PDSR) for Resident 17, indicated Lexapro was used for behavioral symptoms for chronic pain on both legs. The PDSR also indicated there were no behavioral incident episodes and no side effects on Resident 17. A review of Medication Administration Record (MAR) for Resident 17 dated 3/1/19 - 3/31/19, 4/1/19 4/30/19 and 5/1/19 - 5/31/19, did not indicate monitoring for adverse side effects of Lexapro and it did not indicate monitoring for pain on both legs for Resident 17. The MAR dated 5/1/19 to 5/31/19, indicated Resident 17 complained of headache every day. During a concurrent interview and record review with Staff 20 on 6/6/19, at 11 AM, she reviewed Resident 17's clinical record. Staff 20 was unable to find the monitoring of adverse consequences for 555657 Page 30 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the use of Lexapro. Staff 20 acknowledged the findings. She stated there should be monitoring for adverse effects. Staff 20 further stated Staff 4 was responsible for monitoring for behavior and side effects. During a concurrent record review and interview with Staff 4 on 6/6/19 at 11:25 AM, she was unable to verify and identify where and how she gathered the information documented (monitoring of effectiveness and adverse effects ) on the PDSR of Resident 17's Lexapro use. During a concurrent record review and interview with Staff 21 on 6/7/19, at 12:30 PM, she reviewed the MAR of Resident 17, and was unable to find monitoring for chronic pain on both legs and adverse side effects for Lexapro used for Resident 17. She stated Resident 17 was monitored for generalized pain instead. According to https://online.[NAME].com accessed, 6/12/19, .older patients with depression being treated with an antidepressant should be closely monitored for response and adverse effects . Adverse Reactions . Central nervous system: Headache (24%) .Fatigue 2% to 8 %) . Review of the facility policy and procedure titled PSYCHOTROPIC DRUGS, undated, indicated .This facility will assess each resident for the need for behavior control, monitor the usage of psychotropic drugs, evaluate the effectiveness of such treatment and observe for side effects .An unnecessary drug is any drug used .without adequate monitoring . 6. The medication record logs the medication administration and observation on a daily basis the effectiveness of the medication. For daily medication, a notation under medication data will indicate the presence of the behavior to be controlled . 555657 Page 31 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review, the facility failed to ensure safety of medications, biologicals, and medical supplies when: A. Controlled medication was found in a medication refrigerator with no lock, in one of two medication rooms; B. Drugs and biologicals in one of two treatment carts had labels that did not include resident's name, instructions and precautions for use; C. Temperature was not monitored on the refrigerator containing vaccines in one of two medication rooms; and D. Expired drugs, biologicals and medical supplies were found available for use in one of two medication rooms, in one of two treatment carts, and in one of three medication carts. These deficient practices had the potential for drug diversion (illegal use), for residents to receive the wrong medication, and for residents not to receive the necessary care and treatments they need. Findings: A. During an observation and concurrent interview on 6/5/19 at 11:03 AM, an open bottle of liquid Ativan (medication to treat anxiety) 30 ml (milliliters, liquid unit measurement) was found in the medication refrigerator that had no lock in neighborhood 1/neighborhood 2 (N1/N2) medication room. Staff 3 acknowledged the medication refrigerator had no lock and contained an open 30 ml bottle of liquid Ativan in N1/N2 medication room. B. During an observation on 6/3/19 at 11:35 AM, the following drugs and biologicals were found with labels that did not include resident's name, instructions and precautions for use in N1/N2 treatment cart. 1. Two tubes of coloplast hydrophyllic dressing - used for managing wound drainage 2. 555657 Page 32 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0761 One tube of hydrogel wound dressing - used for treatment of dry wounds, Level of Harm - Minimal harm or potential for actual harm 3. One tube of skin protectant ointment - used for treatment of skin irritation and rashes Residents Affected - Some caused by wetness, 4. One tube of remedy clear aid skin protectant, 5. One tube of silvasorb - an antimicrobial (destroys bacteria) used to manage draining wounds. C. During an observation and concurrent interview on 6/5/19, at 11 AM, the 6/2019 temperature log for both the food and biologicals refrigerator in the N1/N2 medication room, had no entries. Staff 3 acknowledged the finding. D. During an observation and concurrent interview on 6/5/19, at 11:03 AM, the following were found in the N1/N2 medication room. 1. 11 pre-filled syringes of influenza (flu) vaccines with expiration date of 5/3/19, 2. One bottle of iodoform wound dressings with expiration date of 5/2019, 3. 47 normal saline bottles with expiration date of 5/15/19, 4. Three boxes of tracheostomy (airway opening through the neck) dressings with expiration date of 4/2018, 5. Two central line kits with expiration date of 11/30/2018. Staff 3 acknowledged the findings. 555657 Page 33 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0761 Level of Harm - Minimal harm or potential for actual harm - During an observation and concurrent interview on 6/3/19 at 11:35 AM, the following were found in N1/N2 treatment cart. 1. One bottle of providone-iodine solution (a skin disinfectant, an anti-bacterial cleaning solution) with expiration date of 7/2018. Residents Affected - Some 2. One bottle of Men-Phor (use to relieve itching) with expiration date of 1/2019 3. One open bottle of normal saline solution with expiration date of 5/15/19 Staff 3 acknowledged the findings. - During an observation on 6/5/19 at 8:56 AM, the following were found in neighborhood 3 (N3) medication cart. 1. One bottle of geri-tussin (cough medicine) with expiration date of 4/2019. 2. One bottle of Azopt Ophalmic suspension (medication used to lower the pressure inside the eye) with an open date of 4/29/19. Staff 11 acknowledged the findings and stated the Azopt Opthalmic suspension was good for 30 days after opening. - During an observation on 6/5/19 at 8:56 AM, the following was found in N3 medication cart. 1. One Combigan eye drop (medication used to reduce pressure in the eye) with no open date. Staff 11 acknowledged the findings During a review of facility policy and procedure titled, Medication Administration dated 2007, on 6/7/19, indicated under Procedures, Medication Preparation, c . the multi-use eye drops . should be disposed of 28 days after initial use . During a review of the facility policy and procedure titled, Medication Storage dated 2007, on 6/5/19, indicated under Procedures, 2. Schedule II controlled medications must be stored separately from non-controlled medications. The access system .used to lock Schedule II medications and other medications subject to abuse, cannot be the same access system to obtain the non-scheduled medications . 11.The temperature of any refrigerator that store vaccines should be monitored and recorded twice daily . 14. Outdated .medications .are immediately removed from stock. During a review of the facility policy and procedure titled, Medication Ordering and Receiving from Pharmacy Provider Medication and Medication Labels dated 2007, on 6/6/19, indicated under Procedures, 5. Non-prescription medications not labeled by the pharmacy are kept in the manufacturer's container. Nursing care center personnel may write the resident's name on the container or label as long as the required information is not covered . During a review of the facility policy and procedure titled, Medication with Special Expiration Date Requirements, on 6/6/19, indicated under Guidelines, 1. The date of opening should be noted on the container . 555657 Page 34 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure dietetic services were implemented in accordance with the acceptable standards of practice when: Residents Affected - Some 1. A loaf of bread in a shelf was found with gray-greenish substance; 2. A salad dressing was stored beyond used by date in the kitchen refrigerator, and three spices/herbs and sesame oil were stored beyond their used by date; 3. Multiple unlabeled liquid substances were stored in refrigerator 4; 4. There was a lack of an air gap for the food production sink in the kitchen; 5. Two uncovered garbage containers were in front of and touching the shelf of the clean utensils, bowls, trays and food containers by the dirty dishes area; 6. There was a lack of time/temperature monitoring during thawing of turkey meat; 7. Dietary staff were wearing unsecured dangling ear jewelry during food production activities; and 8. Dietary staff cleaned the stem of food thermometer, prior to use, with a damp cloth with visible stain and particles. These failures had the potential to place residents at risk for developing foodborne illnesses. Findings: 1. During the initial tour observation of the kitchen and concurrent interview on 6/3/19, at 9:32 AM, there was a loaf of bread with a date of 5/23/19 found with gray-greenish substance in the bread shelf area in the kitchen. Staff 19 verified and acknowledged the gray-greenish colored substance on the loaf of bread. Staff 19 stated it should be discarded. During an interview with Staff 15 on 6/5/19 at 2:40 PM, she verified the findings. Staff 15 stated the facility did not have a policy for expired food. She further stated when the food expired, the staff just discarded it. 2. During the initial tour observation of the kitchen and concurrent interview on 6/3/19, at 9:32 AM, there was one salad dressing with an open date of 2/28/19 stored in the refrigerator 1. Three bottles of spices/herbs (turmeric, ground glove, and nutmeg) each with a date of 5/18/18 were stored on the spices shelf. One sesame oil with open date of 12/17/18 was stored in the counter shelf. Staff 19 verified and acknowledged the findings. He stated the salad dressing, the spices/herbs and the sesame oil were stored beyond their used by dates and should be discarded. A review of the facility policy and procedure titled, PROCEDURE FOR REFRIGERATED STORAGE, dated 2018, indicated, . All refrigerated foods are to be kept the amount of time per Refrigerated Storage Guidelines . 555657 Page 35 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the facility policy on DRY GOODS STORAGE GUIDELINES, dated 2018, indicated opened shelf herbs, should be stored for six months and refrigerated salad dressing should be stored for two months only. 3. During the initial tour observation of the kitchen and concurrent interview on 6/3/19, at 9:32 AM, there were multiple different color (yellow, amber and red) liquid substances in plastic covered glasses that were unlabeled and stored in refrigerator 4. Staff 14 verified and acknowledged the findings. Staff 14 stated the liquid substances in the glasses were different kinds of juices taken from the original packages and should be labeled. A review of the facility policy and procedure titled, LABELING AND DATING OF FOOD, dated 2018, indicated, .All prepared foods need to be covered, labeled and dated . A review of the facility policy and procedure titled, PROCEDURE FOR REFRIGERATED STORAGE, dated 2018, indicated, .Individual packages of refrigerated or frozen food taken from the original packing box need to be labeled and dated, 4. During the initial tour observation of the kitchen and concurrent interview on 6/3/19, at 9:32 AM, there was a lack of an air gap for the food production sink. Staff 14 verified the findings. During an interview with Staff 8 on 6/5/19 at 7:45 AM, he acknowledged the findings. He stated he used a drain snake (a slender, flexible auger used to clear a clogged drain pipe) when there was a backflow or clog on one of the kitchen sink. Staff 8 was unable to recall the date of the incident. During a Quality Assurance and Performance Improvement meeting (QAPI) on 6/6/19, at 2:45 PM, Staff 1 and Staff 2 verified and acknowledged the findings. Staff 1 stated the facility did not have an air gap policy. 5. During the initial tour observation of the kitchen and concurrent interview on 6/3/19, at 9:32 AM, there were two uncovered garbage containers in front of and touching the shelf of the clean utensils, bowls, trays and food containers located by the dirty dish area. Staff 18 verified and acknowledged the findings. 6. During the food preparation observation on 6/4/19 at 8:30 AM, there were two individually wrapped whole turkey meat in the sink placed in a deep container under running water. During an interview with Staff 19 on 6/4/19, at 8:45 AM, he stated, he was thawing the turkey meat to cook for the next day (6/5/19) for residents' lunch. He stated he was going to put back the turkey meat in the refrigerator after thawed. He added he never took the temperature of the turkey meat. During an interview with Staff 14 on 6/3/19 at 11:30 AM, she stated the facility does not take temperatures when thawing meat. Staff 14 added they cook the meat on the same day it's thawed. During an interview with Staff 15, on 6/5/19, at 2:40 PM, she verified and acknowledged the findings. Staff 15 stated the facility's thawing policy was to cook the thawed meat on the same day. A review of the facility policy and procedure titled, FOOD PREPARATION, dated 2018, indicated, .THAWING OF MEATS . Thawing meat properly can be done in these four ways . 3. Submerge under running potable water at temperature of 70 degrees Fahrenheit (F) or lower, with a pressure sufficient to flush 555657 Page 36 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some away loose particles. a. The food product cannot remain in the temperature danger zone (41° F to 140° F) for more than four hours, which includes the time the food is thawed. Use immediately. 7. An additional hazard associated with jewelry is the possibility that pieces of the item or the whole item itself may fall into the food being prepared. Hard foreign objects in food may cause medical problems for consumers, such as chipped and/or broken teeth and internal cuts and lesions (United States Department of Agriculture Food Code, 2013 Annex 3). During food production observation and interview with Staff 16 and Staff 17 on 6/5/19, at 11:28 AM, Staff 16 was observed in food production activities. She was observed wearing unsecured, dangling, yellow colored jewelry on both ears. She stated she was preparing soup for residents' lunch. Staff 17 was observed preparing the tray carts and dishes to be used for lunch. She stated she helped in food preparation such as cutting the fruits and preparing the juices. Staff 17 was also observed wearing unsecured, dangling, yellow colored jewelry on both ears. During an interview with Staff 15 on 6/5/19, at 2:45 PM, Staff 15 acknowledged the above findings. A review of the facility policy and procedure titled, DRESS CODE, dated 2018, indicated, PURPOSE: Appropriate dress in Food & Nutrition Department Personal Hygiene and appropriate dress are very important part of the total appearance of the Food & Nutritional Services Department .7. No excessive jewelry, just wedding rings on hand, non-dangling earrings on ears, and wrist-watch . 8. During tray line observation and interview with staff 19 on 6/5/19 at 12:10 PM, Staff 19 was wiping the stem of the food thermometer with alcohol pads, then proceeded to wipe it again with a damp cloth with visible stains and wet particles. Staff 19 verified and acknowledged the findings. He stated he thought the damp cloth was clean. A review of the facility policy and procedure titled, MEAL SERVICE, dated 2018, indicated, .The Food and Nutrition Services staff member will take the food temperatures prior to service of the meal with a thermometer that has been cleaned and sanitized .The same thermometer may be used for all the hot foods, wiping the stem with an alcohol swab, clean cloth or paper towel between each food item. 555657 Page 37 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

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 ensure a safe and sanitary storage, handling, and consumption of food items when foods were brought to residents by family and visitors. Residents Affected - Some These failures had the potential to expose residents to food-borne illnesses and to limit the resident's rights Findings: During an interview with Staff 3 on 6/5/19, at 2:40 PM, she stated the residents and staff shared food storage refrigerator located in the staff breakroom. During an observation of the residents and staff food storage refrigerator on 6/5/19, at 2:45 PM, the following were observed: 1. There was no thermometer for temperature monitoring. 2. There were multiple unlabeled containers with food and snack bags. 3. There were spillage on the door shelves of the refrigerator. 4. There was one salad dressing with no lid, with dried sticky debris on the top area of the container. 5. There was undated food belonging to a resident who was already discharged from the facility in the freezer. 6. There was no refrigerator cleaning schedule documentation. Staff 15, Staff 8, and Staff 9 verified and acknowledged the findings. During an interview with Staff 15 on 6/5/19, at 2:25 PM, regarding the facility procedure for handling food brought to residents by family and other visitors, Staff 15 stated she was not sure where the residents' food storage refrigerator was located and who was responsible for sharing the facility policy with residents, families, and visitors. During an interview with Staff 9 on 6/5/19, at 2:47 PM, she stated, staff in housekeeping department did the cleaning of the refrigerator every two days. Staff 9 stated there was no cleaning log documentation for the storage refrigerator. During an interview with Staff 8 on 6/5/19, at 2:50 PM, he stated there should be a thermometer in the refrigerator for temperature monitoring. During an interview with Staff 11 on 6/5/19, at 2:55 PM, she stated she was not aware of the facility's residents' food brought from outside policy nor was she in serviced about it. Staff 11 acknowledged that it was important for the resident's family and friends to be informed regarding the risk and benefits of the food they bring for the residents, and proper storing. She added some residents 555657 Page 38 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0813 preferred the food cooked from home and sometimes would like to eat the food the next day. Level of Harm - Minimal harm or potential for actual harm During an interview with Staff 1 and Staff 2 on 6/6/19, at 2:30 PM, Staff 1 stated the residents were allowed to have foods from the outside but had to consume the food within a few hours. She stated the facility was not responsible for storing the foods brought from outside for the residents. Staff 1 and Staff 2 acknowledged that their policy may not be updated with the regulation. Residents Affected - Some A review of the facility policy and procedure titled, FOOD FOR RESIDENTS FROM OUTSIDE SOURCES FOR [facility name], dated 2018, indicated, .food brought in for resident's consumption from outside the kitchen will be monitored to be sure the food is within the guidelines of the diet order .3. Prepared food brought in for the resident (deemed suitable) must be consumed within 2 hours of receiving in an effort to prevent food borne illness. Storage of the food will not be the responsibility of the facility. Any unused food will be disposed of immediately thereafter. A review of the facility policy and procedure titled, REFRIGERATOR AND FREEZER, dated 2018, indicated, Maintaining a clean refrigerator and freezer can improve the safety and quality of your foods .1. Refrigerator and freezer should be on a weekly cleaning schedule. 2. Wipe up spills immediately. 3 Check all foods at least weekly, being mindful of expiration and used by dates . 555657 Page 39 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0867 Level of Harm - Minimal harm or potential for actual harm Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on observation, interview, and record review, the facility failed to implement their plan of correction Residents Affected - Few 1) The comprehensive care plan for monitoring the patency, placement, color of urine and intake/output levels of urine was not completed, 2) The Physician's Order was not obtained to check and document in the Treatment Administration Record (TAR) each shift the suprapubic catheter (a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow) for correct placement, patency and color of urine, 3) The weekly monitoring of the comprehensive care plans was not done, and 4) The weekly audits of the TAR for the suprapubic catheter placement, patency, color of urine, and urine input/ouput levels were not done. This failure had the potential to impact the quality of life and care for Resident 51 and place her at risk for infection. Findings: Review of the Physician Progress Notes dated 1/8/19 indicated Resident 51 was admitted with diagnoses that included neurogenic bladder with suprapubic catheter in place, urinary retention, and pressure ulcer of sacrum. Review of the facility's completed Plan of Correction dated 7/15/19 indicated, Resident 51 was assessed by the licensed nurse, and a physician's order was obtained to check each shift for correct placement and patency of the Resident's suprapubic catheter as well as the color of urine. Results were documented in the TAR .The comprehensive care plans will be monitored on a weekly basis by the MDS (MDS - Minimum Data Set, a resident assessment tool) Consultant to ensure that all areas of care are care planned appropriately .the care plan will include all of the following: placement and patency of the catheter, color of urine and the resident's intake/output levels. The TAR has been updated accordingly and will be audited by Medical Records personnel on a weekly basis for six months to ensure compliance. 1) Review of the Care Plan for Resident 51's use of a suprapubic catheter for bladder elimination related to neurogenic bladder and neuromuscular impairment indicated no revision until 8/13/19 to include interventions of checking catheter every shift for patency, placement, kinks, position for drainage below bladder level, and ensuring bag or tubing did not touch the floor. 1, 3, 4) During interview and concurrent record review on 8/14/19 at 11:56 AM, Licensed Vocational Nurse (LVN) 2 acknowledged there was no evidence to support weekly monitoring of comprehensive care plans by the MDS Consultant (MDSC), and stated she had no audit sheets to indicate monitoring of compliance with TAR because she only documented if there was non-compliance and there was no TAR for monitoring of catheter patency. When asked if there were notes of monitoring in the progress notes, LVN 2 stated she did not know because she was only monitoring the Medication Administration Record 555657 Page 40 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (MAR) and TAR for compliance with completion to make sure there were no holes in the clinical record. The TAR for Resident 51 indicated no record of monitoring for patency of a suprapubic catheter for the month of July and August 2019. 2) During review of the Order Summary Report for Resident 51 dated 8/14/19 at 10:55 AM, indicated no record of a physician's order in the TAR for monitoring each shift the correct placement, patency, and color of urine for the suprapubic catheter. During an interview on 8/13/19 at 3 PM, the Director of Nursing (DON) stated they have been working hard to implement the plan of correction but did not have any of the audits from the MDS consultant who is working from an offsite location. The DON further stated she didn't know a Physician's order was needed for the monitoring in the TAR. 4) During a concurrent observation and interview on 8/15/19 at 1:54 PM, Resident 51 was sleeping in bed, the catheter bag was hanging below the level of the bed and the room had malodorous smell of urine. The LVN 1 stated the catheter bag currently had less than 100 cc (cubic centimeter) of urine, was dark amber in color, and stated staff have not been monitoring patency, placement or position of the catheter in the TAR, only monitoring for signs and symptoms of infection. Review of the policy and procedure titled, Policy for Suprapubic Catheter Care, undated, indicated, It is the policy of this facility that all residents with suprapubic catheters will receive catheter care at the site of insertion at least daily to prevent irritation and possible infection .Procedure for Suprapubic Catheter Care .document care given and observations about the condition of insertion site. 555657 Page 41 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 2. During a concurrent observation and interview with Staff 11 on 6/3/19, at 11 AM, Resident 46 was in bed, asleep. A suction machine was on his bedside table. It was connected with undated tubing, a collection container with condensed moisture inside, and a yaunkauer suction tube (an oral suctioning tool used in medical procedures) placed in an open package dated 5/14/19. Staff 11 verified the findings. Residents Affected - Some During an interview and concurrent observation with Staff 11 on 6/3/19 at 11:05 AM, she checked the components of the suction machine and acknowledged the findings. She stated the suction machine looked like It's been used. Staff 11 stated the tubing and the container should have been dated upon use. A review of the facility policy and procedure titled, Suction Policy, undated, indicated, The purpose of oral suctioning is to maintain a patent airway and to improve oxygenation by removing mucous secretions .3. If the machine and components have been used, the supplies should be dated upon use and discarded and replaced Q [every] shift. Based on observation, interview, and record review, the facility did not implement their Infection Control Program for 2 of 2 sampled residents (Residents 24 and 46) when: 1. Contact precautions were not followed for Resident 24. 2. Resident 46's Suction machine's components (tubing, and collection container) were not labeled and disposed after use. These failures had the potential to place residents at risk for infection. Findings: 1. During a review of clinical record for Resident 24, the Minimum Data Set (MDS, a resident assessment tool), dated 3/21/19, indicated a Brief Interview for Mental Status (BIMS, a brief assessment to help detect cognitive impairment) score of 4 indicating resident had severely impaired cognition. The MDS also indicated Resident 24 required one-person supervision to extensive assistance with Activities of Daily Living (ADLs). During review of clinical record for Resident 24, the Resident Face Sheet, dated 4/1/19, indicated diagnoses that included dementia (group of symptoms associated with a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities). During an observation on 6/3/19 at 10:22 AM, there was a contact precaution sign by Resident 24' room entrance. There were no personal protective equipment (PPE) set-up by Resident 24's room entrance. During an observation on 6/3/19 at 10:54 AM, Staff 23 entered Resident 24's room. Staff 23 did not don gloves, mask or gown before entering the room. During an interview with Staff 23 on 6/3/19 at 11:08 AM, she stated that she helped Resident 24 with morning care including brushed her teeth, wiped her face and combed her hair. 555657 Page 42 of 43 555657 06/07/2019 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of the clinical record for Resident 24, the Emergency Department Patient Discharge Instructions dated 6/2/19 at 6:36 PM, indicated .Discharge Diagnosis: Herpes zoster ophthalmicus of right eye . Blister and rash care .Keep your rash covered with a loose bandage (dressing) . During a review of the clinical record for Resident 24 titled, Progress Notes, dated 6/2/19 at 6:44 PM, indicated, .Resident returned to facility at 1920 [7:20 PM] via gurney . During a review of the clinical record for Resident 24, the Progress Notes dated 6/2/19 at 8 PM, indicated, .Infection Nurse notified. Instructed to put resident under contact precaution for shingles. Endorsed to next shift . During a review of Resident 24's care plan dated 6/3/19, it indicated, . Focus . The resident has Herpes Zoster ophthalmicus of right eye . Interventions . Standard precautions . During an interview with Staff 21 on 6/3/19 at 11:23 AM, when asked about the facility policy for contact precautions for Resident 24, she replied that Staff 23 should have worn gown, gloves and mask before entering the room to avoid spread of infection to other residents. When asked about the PPEs, Staff 21 responded that the evening nurse endorsed to the night nurse to set-up the PPEs, however, it was not set-up yet because the PPE tray cart was kept by the Housekeeping Department in a locked storage. During an interview with Staff 3 on 6/4/19 at 1:08 PM, when asked about the facility policy for cohorting residents on contact precautions, she responded that staff isolate the resident with infection or cohort the resident with another resident who had the same infection. During an interview with Staff 7 on 6/5/19 at 1:53 PM, she stated that the evening staff should have taken the PPE's from the supply room and placed the PPE on a chair or bedside table by Resident 24's room entrance. Staff 7 further stated that Resident 24's infection care plan should have been revised to contact isolation. A review of the facility policy and procedure titled, Procedure for Isolation: Initiation of Isolation, no date, indicated, .Transmission-Based Precautions . 3. Contact Precautions . use Contact Precautions for residents known or suspected to be infected with microorganisms that can be easily transmitted by direct or indirect contact, such as handling surfaces or resident care items . The above includes . highly transmissible infections such as . herpes (simplex or zoster) . IV. Gather Equipment . A. Obtain table/cart for 24 hour supply of masks, gown, etc. needed to maintain isolation . Points to Remember . Gather all equipment and supplies needed before going into the room . A review of the facility policy and procedure titled, Procedures for Airborne, Contact, and Droplet Isolation, undated, indicated, .Contact Precautions . Wear clean gloves when entering the resident's room or unit if a multi-bed room . 555657 Page 43 of 43