Health inspection·November 19, 2021

F 0584 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Residents Affected - Few 1. Dresser surfaces covered with Formica (a thin plastic laminate glued onto furniture to provide a durable surface) in rooms [ROOM NUMBERS] were free of chipped damage. 2. The chipped and cracked surface of an enameled sink (metal sink coated with a shiny hard ceramic layer) in room [ROOM NUMBER] was repaired and/or replaced. These failures had the potential for surfaces not to be cleaned in a sanitary manner and may negatively impact residents' psychosocial health when they have to live in an unmaintained room that is not homelike. Findings: During observation and concurrent interview on 11/16/21, at 9:11 AM, the Maintenance Director stated, the Formica covering the bottom of the dresser in room [ROOM NUMBER] was chipped and the damaged area was approximately 2 inches by 4 inches. The Maintenance Director stated, the sink in room [ROOM NUMBER] had a ¼ inch by ¼ chip on the enamel surface with spider web like cracks next to the chip. In room [ROOM NUMBER], the Maintenance Director stated, there was a 1 inch by 6 inch damage on the Formica covering the dresser. The Maintenance Director stated, they were aware of the Formica/dresser problem and started replacing some dressers in 2016 (approximately five years ago). The Maintenance Director stated, the facility ran out of funds to replace other dressers. During a review of the facility's policy titled Preventative Maintenance Program (not dated), the policy indicated .2. The Maintenance Director shall assess all aspects of the physical plant to determine if Preventative Maintenance (PM) is required. Required PM may be determined from manufacturer's recommendations, maintenance requests, grand rounds, life safety requirements, or experience. 3. If preventative maintenance is required, the Maintenance Director shall decide what tasks need to be completed and how often to complete them. Page 1 of 29 555657 555657 11/19/2021 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. 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 residents are protected from abuse when a verbal abuse allegation incident that involved Resident 42 and Resident 44 was not identified and reported to appropriate agencies within two hours after knowledge of the allegation. Residents Affected - Few This failure put residents at risk from from further abuse. Findings: Resident 44 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia (loss of cognitive functioning such as thinking, remembering, and reasoning) with behavioral disturbance, hypertension (high blood pressure) and glaucoma (an eye condition that can cause loss of vision and blindness). Resident 42 was admitted to the facility on [DATE] with diagnoses that included Type II Diabetes Mellitus (high blood sugar levels), atrial fibrillation (irregular heart rhythm) and chronic kidney disease (gradual loss of kidney function). During a concurrent observation and interview on 11/15/21, at 12:20 PM, with Resident 42, in her bed, Resident 42 was awake and alert. Resident 42 stated, she was upset and reported that her roommate [Resident 44] curses, yells . the language she [Resident 44] uses, it's filthy . During an observation on 11/15/21, at 12:38 PM, Resident 44 was in bed with eyes closed. During a record review of Resident 42's social services progress notes, the progress notes dated 10/15/21 indicated, Resident . alert and oriented x 4 [person, place, time, and situation]. She still has mental capacity to make decisions for herself . About two weeks ago, resident [Resident 42] had a new roommate . New roommate has a dementia with behavioral disturbance during ADLs (activities of daily living). Resident 42 [name redacted] is very upset about the new roommate's behavior and yet she does not want to be moved to a different room which was also offered to her . During an interview on 11/18/21, at 11:03 AM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated, she was familiar with Resident 42. CNA 1 stated, Resident 42 did not want a roommate. CNA 1 stated, Resident 42 thought her roommates had a mental problem. CNA 1 stated, every day her [Resident 42] mood [was] different . up and down behavior . when angry, she starts yelling . During a record review of Resident 42's social services progress notes, the progress notes dated 10/27/21 at 3:11 PM indicated, Social Services met with resident [Resident 42] after CNA reported her [Resident 42] making foul verbal comments to her roommate [Resident 44] during ADLs this afternoon. Resident [Resident42] made comments such as you belong in a mental hospital and when roommate [Resident 44] asked where she was going to CNA, resident [Resident 44] said to a waste basket. SSD [Social Services Director] talked with resident [Resident 42] about inappropriate language and even if her roommate cannot hear her and is not aware of what is being said, it does not make it okay . During a concurrent interview and record review of Resident 42's social worker's progress notes on 11/19/21, at 9:22 AM, with the Social Services Director (SSD), SSD stated, her understanding of verbal abuse was use of harmful language, profanity . SSD stated, verbal abuse meant there was an intent 555657 Page 2 of 29 555657 11/19/2021 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to harm, intentional, malicious . causing emotional, psychological distress resulting in feeling unsafe and uncomfortable . SSD stated, verbal abuse allegation had to be reported to CDPH [state agency], Ombudsman and police within 2 hours of knowledge of the incident. When asked about Resident 42's social progress notes dated 10/27/21 regarding foul verbal comments made by Resident 42 towards her roommate, Resident 44, SSD stated, yes, it's considered verbal abuse. SSD stated, the incident happened around 11AM on 10/27/21 and was reported to her by CNA 3. SSD stated, she discussed the incident with the administrator at the time and they determined that the incident was not a reportable allegation of verbal abuse. SSD stated, moving forward, this [verbal abuse incident] would be a reportable incident. During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention & Reporting, last revision dated 1/13, the P&P indicated, I. PURPOSE - A. To ensure that residents are free from abuse . The facility has a ZERO TOLERANCE for any/all types of abuse directed toward any resident, patient or dependent adult within its care. B. To provide guidelines to all staff regarding their roles and responsibilities in the prevention and reporting of resident abuse . II. POLICY - A. DEFINITIONS 1. ABUSE: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . Types of Abuse: a. Verbal abuse: any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families or are made within their hearing distance, regardless of their age, ability to comprehend, or disability . F. The facility Administrator will be responsible for: Ensuring that a thorough investigation of all suspected, reported, or observed abuse is completed in a timely manner and documented appropriately . Involving the Interdisciplinary Team to ensure that interventions, review and follow up are initiated in a timely manner. Ensuring that the resident is protected from further episodes of abuse during the investigation of an alleged abuse . Timely and accurate reporting to the appropriate agencies of any/all abuse incidents according to state and federal regulations . 555657 Page 3 of 29 555657 11/19/2021 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an allegation of abuse to appropriate agencies within the required timelines when a verbal abuse allegation incident that involved Resident 42 and Resident 44 was not identified. This failure may result in further potential abuse of residents in the facility. Findings: Resident 44 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia (loss of cognitive functioning such as thinking, remembering, and reasoning) with behavioral disturbance, hypertension (high blood pressure) and glaucoma (an eye condition that can cause loss of vision and blindness). Resident 42 was admitted to the facility on [DATE] with diagnoses that included Type II Diabetes Mellitus (high blood sugar levels), atrial fibrillation (irregular heart rhythm) and chronic kidney disease (gradual loss of kidney function). During a record review of Resident 42's social services progress notes, the progress notes dated 10/27/21 at 3:11 PM, indicated, Social Services met with resident [Resident 42] after CNA reported her [Resident 42] making foul verbal comments to her roommate [Resident 44] during ADLs this afternoon. Resident [Resident42] made comments such as you belong in a mental hospital and when roommate [Resident 44] asked where she was going to CNA, resident [Resident 44] said to a waste basket. SSD [Social Services Director] talked with resident [Resident 42] about inappropriate language and even if her roommate cannot hear her and is not aware of what is being said, it does not make it okay . During a concurrent interview and record review of Resident 42's social worker's progress notes on 11/19/21 at 9:22 AM with the Social Services Director (SSD), SSD stated that her understanding of verbal abuse was use of harmful language, profanity . SSD stated verbal abuse meant there was an intent to harm, intentional, malicious . causing emotional, psychological distress resulting in feeling unsafe and uncomfortable . SSD stated verbal abuse allegation had to be reported to CDPH [state agency], Ombudsman and police within 2 hours of knowledge of the incident. When asked about Resident 42's social progress notes dated 10/27/21 regarding foul verbal comments made by Resident 42 towards her roommate, Resident 44, SSD stated, yes, it's considered verbal abuse. SSD stated the incident happened around 11AM on 10/27/21 and was reported to her by CNA 3. SSD stated she discussed the incident with the administrator at the time and they determined that the incident was not a reportable allegation of verbal abuse. SSD stated, moving forward, this [verbal abuse incident] would be a reportable incident. During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention & Reporting, last revision dated 1/13, the P&P indicated, I. PURPOSE - A. To ensure that residents are free from abuse . The facility has a ZERO TOLERANCE for any/all types of abuse directed toward any resident, patient or dependent adult within its care. B. To provide guidelines to all staff regarding their roles and responsibilities in the prevention and reporting of resident abuse . F. The facility Administrator will be responsible for: Ensuring that a thorough investigation of all suspected, reported, or observed abuse is completed in a timely manner and documented appropriately . Ensuring that the 555657 Page 4 of 29 555657 11/19/2021 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0609 Level of Harm - Minimal harm or potential for actual harm resident is protected from further episodes of abuse during the investigation of an alleged abuse . Timely and accurate reporting to the appropriate agencies of any/all abuse incidents according to state and federal regulations . Residents Affected - Few 555657 Page 5 of 29 555657 11/19/2021 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the colostomy (surgical opening in the intestine) care plan and the self-care/Activities (ADL, Activities of Daily Living) care plan for one of 17 sampled residents [Resident 11] were implemented and updated in accordance with Resident 11's current assessed needs. Failure to implement care plan interventions to teach Resident 11 how to manage her colostomy had the potential for Resident 11 to be continually dependent on staff for colostomy care. Failure to update Resident 11's care plan indicated staff was not following the facility's policies and procedures regarding updating care plans on a quarterly basis. This had the potential for outdated and/or inaccurate information to remain in Resident 11's care plans. Definitions: Person-Centered- means the facility focuses on the resident as the center of control and supports each resident in meeting his or her own choices and having control over their daily lives. Cognitive impairment is when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life. Cognitive impairment ranges from mild to severe. Findings: During a review of Resident 11's face sheet, the face sheet indicated Resident 11 was admitted on [DATE], with diagnoses that included Lumbago with sciatica (chronic, ache in the lower back that goes down the leg), colostomy, and hypertension. During a review of Resident 11's Minimum Data Set (MDS- a standardized resident assessment tool), dated 8/7/21, indicated a score of 13 on her Brief Interview for Mental Status (BIMS, an assessment to detect cognitive impairment). Score of 13 indicated Resident 11 had no cognitive impairment. During a concurrent observation and interview on 11/18/21, at 10:30 AM, Resident 11 was in her room and Resident 11 stated, she had a colostomy in her left lower abdomen. Resident 11 stated, she did not receive any teaching about her colostomy care. Resident 11 stated, she does not think she can take care of her colostomy by herself and, it usually takes two people to do it. Resident 11 stated, the concern I have is not getting help timely when the colostomy leaks because the facility is shorthanded. During a review of Resident 11's care plan for colostomy, the care plan indicated, it was initiated on 1/27/20, with interventions such as teach ostomy care with return demonstration. Also initiated on 1/27/20, was a care plan for potential decline in self-care/ADL (activities of daily living) due to pain, colostomy status, hearing deficit, and advancing age. Interventions to manage self-care included: staff to assist the resident with ADLs daily in a way that maximizes participation and minimizes dependence. Both these care plans were initiated on 1/27/20 (23 months ago), and there was no documented evidence these interventions were implemented as of 11/19/21. 555657 Page 6 of 29 555657 11/19/2021 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review Resident 11's MDS, dated [DATE], MDS indicated Resident 11 required the extensive assistance of one staff for toileting/colostomy care. During a concurrent interview, on 11/18/21 at 10:55 AM, with LVN 2 and record review of Resident 11's care plans, LVN 2 stated, sometimes Resident 11 may have to wait for assistance with her colostomy bag because of medication pass or staff may be assisting other residents. LVN 2 further stated, she has not tried to teach Resident 11 how to manage her colostomy and was not sure if any other staff did. LVN 2 could not find documented evidence that staff tried to teach Resident 11 how to care for her colostomy for the last 23 months. During a concurrent interview and record review on 11/18/21, at around 3:10 PM, the DON was asked about the interventions to teach ostomy care with return demonstration. The intervention that was initiated on 1/27/20, for Resident 11, was still there. DON stated, the MDS coordinator is the one who updates the care plan 90 days, but the MDS coordinator was busy. During a concurrent interview and record review on 11/19/21, at 2:05 PM, with DON, DON acknowledged the care plans were not updated. DON stated, they update the baseline care plan first, then the comprehensive. DON stated, the MDS coordinator usually is the one who update the care plan for residents, when doing quarterly MDS. DON stated, the charge nurses are focused on medication and wound care and don't update the care plan; the night nurses initiate the care plan but updating is secondary to them. DON stated, she too sometimes updates the care plans. DON stated, the MDS coordinator is responsible for updating the care plans, but the MDS coordinator was busy. Duting a review of the facility's policy and procedure (P & P) titled, Comprehensive Care Plans, dated 2021, the P & P indicated, It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, . The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 555657 Page 7 of 29 555657 11/19/2021 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement restorative nursing program (RNP, exercises or activities designed to maintain or improve residents' abilities to the highest practicable level such as: range of motion exercises, splint or brace assistance, training and skills practice in bed mobility, transfers, walking, dressing, grooming, eating, communication, etc.) for 3 out of 29 sampled residents (Resident 9, Resident 59, and Resident 45 on RNP when: 1. RNP physician's orders for Resident 9, Resident 59, and Resident 45 were unclear. 2. RNP was not provided to Resident 9, Resident 59, and Resident 45 as ordered by the physician. These failures had the potential for residents to decline or not maintain their highest practicable physical, mental, and psychosocial well-being. Findings: 1. Resident 9 was admitted to the facility on [DATE], with diagnoses that included unspecified dementia (loss of cognitive functioning such as thinking, remembering, and reasoning), hemiplegia and hemiparesis (weakness or paralysis on one side of the body) following cerebral infarction (also known as stroke due to interrupted or reduced blood supply to the brain). During an observation on 11/18/21, at 9:55 AM, Resident 9 was in her bed, with her eyes open. Resident 9 did not respond when greeted. Resident 9's right hand appeared contracted(stiff and fist closed tight). During an interview on 11/18/21, at 10 AM, with Certified Nursing Assistant (CNA) 5, CNA 5 stated Resident 9 was fully dependent on staff for care. CNA 5 stated, Resident 9 was provided restorative nursing program services either in bed or chair. During a review of Resident 9's physician order dated 3/13/20, the order summary indicated, RNA (Restorative Nursing Assistant, a person trained to provide specific treatment to residents to restore and maintain strength, coordination, and skills to perform functional activities of daily living) [services] for range of motion (ROM, measure of movement around a joint or body part) 5x a week. During a review of Resident 9's physician order dated 7/17/19, the order summary indicated, .RNA for ROM a splint 3-5x/week . During a concurrent interview and record review of Resident 9's RNP physician orders on 11/19/21 at 11:31 AM, with the Director of Nursing (DON), DON confirmed the RNP orders were current. DON stated the physician orders for Resident 9's RNP were incomplete. DON stated the orders were not clarified with the physician regarding type of range of motion exercises (i.e., active or passive ROM), body part/s (i.e., upper and/or lower extremities, etc.), side of the body (i.e., right, left, or bilateral) and duration of services (i.e., time in minutes). Further, the DON stated, she did not understand and was unable to explain Resident 9's RNP order for the splint. 2. During a review of Resident 9's physician order, dated 3/13/20, the order summary indicated, RNA 555657 Page 8 of 29 555657 11/19/2021 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0688 for range of motion 5x a week. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 9's physician order dated 7/17/19, the order summary indicated, .RNA for ROM a splint 3-5x/week . Residents Affected - Few During a review of Resident 9's RNA progress notes from 9/1/21 through 11/17/21, progress notes indicated, restorative nursing services were provided on the following dates: For September 2021: 9/1/21, 9/6/21, 9/8/21, 9/9/21, 9/14/21, 9/15/21, 9/16,21, 9/21/21, 9/26/21, 9/29/21, and 9/30/21. There were only 11 total restorative nursing program sessions in September 2021. For October 2021: 10/4/21, 10/5/21, 10/6/21, 10/7/21, 10/9/21, 10/11/21, 10/15/21, 10/17/21, 10/20/21, 10/21/21, 10/25/21, and 10/29/21. There were only 12 total restorative nursing program sessions in October 2021. For November 1 through 17, 2021: 11/9/21, 11/10/21, 11/11/21, 11/12/21, 11/13/21, 11/15/21, 11/16/21, and 11/17/21. There were only 8 total restorative nursing program sessions from November 1 through November 17, 2021. During a concurrent interview and record review of Resident 9's restorative nursing progress notes from September 1, 2021 through November 17, 2021 on 11/19/21, at 11:08 AM with Certified Nursing Assistant (CNA) 2, CNA 2 stated both him and CNA 6 performed RNP services to Resident 9. CNA 2 stated, he documented completion and refusals of RNP services in the resident's progress notes. CNA 2 stated, RNP services were not consistently provided to Resident 9 as ordered by the physician. During a concurrent interview and record review of Resident 9's restorative nursing progress notes from September 1, 2021 through November 17, 2021, on 11/19/21, at 11:35 AM, with the DON, DON confirmed Resident 9's RNP services were not provided as ordered by the physician. DON stated, she had oversight of the RNP services in the facility. DON stated, the facility had only 2 Restorative Nursing Assistants (RNAs). DON further stated, when the facility was short of staff on the nursing floor, they used agency staff and, also borrowed the designated RNA staff to work on the nursing floor. DON acknowledged, she had to review RNP process and services to residents in the facility. During an observation on 11/15/21, at 10:18 AM, Resident 59 who was admitted on [DATE], was still in bed sleeping with a blanket covering up to his head. During an interview on 11/19/21, at 11:18 AM, with CNA2, CNA2 stated, CNA4 will give me the order for RNA next week. CNA4 is the RNA. She is off today. During a review of the clinical record for Resident 59, the order summary report dated 11/19/21, diagnoses included: glaucoma (an eye condition that damage the optic nerve which is vital to good vision); acquired absence of right foot (amputated right foot); acquired absence of left leg below the knee (amputation below the knee), type 2 diabetes mellitus ( a disorder in which the body does not produce enough or respond normally to insulin, causing blood sugar (glucose) levels to be abnormally high), and more. During a review of the clinical record for Resident 59, the order summary dated 9/22/21, at 14:07, Order summary indicated: RNA 3-5 x per week: 1. Bilateral upper extremities (BUE) range of motion 555657 Page 9 of 29 555657 11/19/2021 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (ROM) to patient's tolerance, 2. Omni-cycle BUE/ Right lower extremity (RLE) at resistance level for 15 minutes or as tolerated. During a review of the clinical record for Resident 59, the progress notes dated 11/19/21, indicated Resident 59 received only four treatments from an RNA since July 29, 2021. The RNA notes are dated: 7/29/21 at 19:23; 9/28/21 at 16:53; 10/19/21 at 16:34 and 11/19/21. During a concurrent observation and interview of Resident 45 on 11/18/21, at 1:15 PM, who was admitted on [DATE], Resident 45 was awake sitting on the foot part of bed. She stated, hello. When asked if it is possible to come inside her room for an interview, she raised her arm with her hand signaling stop and said no! During an interview with CNA2 on 11/19/21, at 11:11 AM,. He stated, Lately, she (Resident 45) does not want to go out too much. I cannot recall the last I worked with her. Sometimes she gets a little agitated. During a review of the clinical record for Resident 45, the order summary report dated 11/19/21, her diagnoses included: atrial fibrillation (is an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart, Acute Respiratory Failure (ARF) [occurs when fluid builds up in the air sacs in your lungs. When that happens, your lungs can't release oxygen into your blood], Anxiety disorder (is a type of mental health condition. If you have an anxiety disorder, you may respond to certain things and situations with fear and dread), and more. During a review of the clinical record for Resident 45, the order summary dated 10/29/21, at 15:59 PM, the order summary indicated: RNA Clarification Orders: Functional maintenance -3-5x a week for gait training with stand by assist (SBA) <> SUP, Front wheel walker (FWW) and vital signs and Oxygen monitoring pre/during/post activity. BLE and BUE cycle ergometer training as tolerated. During a review of the clinical record for Resident 45, the RNA documentation indicated, treatments on 11/2/21, 11/4/21, 11/9/21, 11/10/21, 11/11/21, 11/13/21, 11/15/21, and 11/18/21. Resident 45 received no RNA treatment in October, and only 2x per week RNA treatment in the first week of November, 2021. During a review of the facility's policy and procedure (P&P) titled, Restorative Nursing Programs, dated 2021, the P&P indicated, Policy: It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level . Policy Explanation and Compliance . Residents, as identified during the comprehensive assessment process, will receive services from restorative aides when they are assessed to have a need for restorative nursing services . A resident's Restorative Nursing plan will include: a. The problem, need or strength the restorative tasks are to address. b. The type of activities to be performed. c. Frequency of activities. d. Duration of activities. e. Measurable goal and target date . Restorative aides will implement the plan for a designated length of time, performing the activities and documenting on the Restorative Aide Documentation Form. The Restorative Nurse or designated licensed nurse, will provide oversight of the restorative aide activities, review the documentation at least weekly, and evaluate the effectiveness of the plan monthly . 555657 Page 10 of 29 555657 11/19/2021 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. 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 Resident 44's behavior was appropriately monitored and evaluated by staff since admission into the facility. Residents Affected - Few This failure had the potential for Resident 44 to not attain or maintain her highest practicable physical, mental and psychosocial well-being. Findings: Resident 44 was admitted to the facility on [DATE], with diagnoses that included unspecified dementia (loss of cognitive functioning such as thinking, remembering, and reasoning) with behavioral disturbance, hypertension (high blood pressure) and glaucoma (an eye condition that can cause loss of vision and blindness). During an initial tour observation on 11/15/21, at 12:18 PM, in the resident room hallway, Resident 44 and Resident 42 were noted to share one room. During a concurrent observation and interview on 11/15/21, at 12:20 PM, with Resident 42, in her bed, Resident 42 was awake and alert. Resident 42 stated, she was upset and reported that her roommate [Resident 44] curses, yells . the language she [Resident 44] uses, it's filthy . Resident 42 also stated, Resident 44 would scream, hit, punch, and call staff with inappropriate names. During an observation on 11/15/21, at 12:38 PM, Resident 44 was in bed with eyes closed. During a concurrent observation and interview on 11/16/21, at 10:14 AM, with Resident 44, Resident 44 was awake and in her bed, watching television. Resident 44 stated, she did not want to speak with the surveyor and said, maybe later, not right now. During a concurrent observation and interview on 11/18/21, at 10:50 AM, with Resident 44, Resident 44 was awake and in her bed. When asked how she was doing, Resident 44 said, I'm getting better. The surveyor asked Resident 44 if she could talk to her for a few minutes. Resident 44 replied, some other time. During an interview on 11/18/21, at 11:15 AM, with CNA 1, CNA 1 stated, Resident 44 did not want to be bothered. CNA 1 stated, Resident 44 had behaviors that included hitting staff and using bad words such as [expletive]. CNA 1 stated, Resident 44's behavior of physical and verbal aggression happened almost every day. During a review of Resident 44's Care Plan (CP), created on 9/29/21, the CP indicated, Focus - The resident has impaired cognitive function/dementia or impaired thought processes r/t [related to] dementia . Goal . The resident will maintain current level of cognitive function through the review date . During a review of Resident 44's Care Plan (CP), created on 10/13/21, the CP indicated, Focus - Behavior Care Plan Physical Behavior-Hit, Kick, Combative, Resisting Care -ADL (Activities of Daily Living), Verbal Behavior (patient will scream and yells and curses). Patient has disruptive behavior . 555657 Page 11 of 29 555657 11/19/2021 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Goal - Episodes of disruptive behavior will be reduced to less screaming, yelling, combativeness during ADL . During a concurrent interview and record review of Resident 44's electronic medical records on 11/18/21, at 2:27 PM, with Registered Nurse (RN) 1, RN 1 stated, Resident 44 had episodes of disruptive behavior that included screaming, yelling and cursing. When asked how the staff monitored and evaluated Resident 44's behavior to identify any changes, improvement or deterioration, RN 1 was unable to respond nor show data on behavior monitoring. When asked if there were physician notes related to Resident 44's behavior, RN 1 did not find any information. RN 1 also did not find information regarding an Interdisciplinary Team meeting that discussed Resident 44's behavior. During a review of the facility's policy and procedure (P&P) titled, Behavioral Assessment, Intervention and Monitoring, revision dated 3/2019, the P&P indicated, .Policy Interpretation and Implementation . 2. As part of the comprehensive assessment, staff will evaluate, based on input from the resident, family and caregivers, review of medical record and general observations: a. The resident's usual patterns of cognition, mood and behavior . 3. The nursing staff will identify, document, and inform the physician about specific details regarding changes in an individual's mental status, behavior, and cognition, including: a. Onset, duration, intensity and frequency of behavioral symptoms; b. Any recent precipitation or relevant factors or environmental triggers . and c. Appearance and alertness of the resident and related observations. 4. New onset or changes in behavior that indicate newly evident or possible serious mental disorder, intellectual disability, or a related disorder .Cause Identification - 1. The interdisciplinary team will thoroughly evaluate new or changing behavioral symptoms in order to identify underlying causes and address any modifiable factors that may be contributed to resident's change in condition .Management 1. The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly .Interventions and approaches will be based on a detailed assessment of physical, psychological and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for the behavior . Monitoring - 1. If the resident is being treated for altered behavior or mood, the IDT will seek and document any improvements or worsening in the individual's behavior, mood, and function. 2. The IDT will monitor the progress of individuals with impaired cognition and behavior until stable. New or emergent symptoms will be documented and reported. 3. Interventions will be adjusted based on the impact on behavior and other symptoms, including any adverse consequences related to treatment . 555657 Page 12 of 29 555657 11/19/2021 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility had a 27.5 % medication error rate when eight medication errors out of 29 opportunities were observed during medication pass for Residents 29, 55, 56, and 325. These medication errors resulted in Resident 29 not receiving his blood pressure medication in a timely manner. Residents Affected - Few Additionally, staff failed to follow the manufacturers' recommendations and/or the facility policies and procedures for eye drop and inhaler administrations. These failures may result in sub-therapeutic administration of eye drops to Resident 29, 55, 56, and 325, and sub-therapeutic administration of inhalers to Residents 29 and 325. Findings: 1. During a Medication Pass (Med Pass is the process through which medication is administered to resident) observation on 11/16/21, at 8:02 AM, Licensed Vocational Nurse (LVN) 1 prepared and administered the following medications to Resident 29: one tablet Ferrous Sulfate (iron supplement) 325 milligrams (mg), one tablet Glipizide (blood sugar control medication) 5 mg, and one tablet Vitamin C 500 mg. There were total of three tablets administered to Resident 29. During a review of the November 2021 Physician's Order (PO), the PO indicated an order to give Metoprolol 25mg one tablet by mouth twice a day for Hypertension(high blood pressure). During concurrent record review of November 2021 Medication Administration Record (MAR) and an interview on 11/16/21, at 10:16 AM, with LVN 1, the November 2021 MAR had the initial of LVN 1 on Metoprolol indicating it was administered on 11/16/21, to the resident during 8:00-10:00 AM medication pass. LVN 1 verified there were only three (3) tablets administered and Metoprolol was not one of them. LVN 1 acknowledged he placed his initial on Metoprolol on the November 2021 MAR dated 11/16/21, but did not administered it during Med Pass and stated, I did not give it . missed administering the Metoprolol . got distracted. He also admitted that he did not go back to give it after the med pass between 8:02 and 10:16 AM During a review of the facility's Policy and Procedure (P&P) titled Medication Administration General Guidelines dated 09/10 indicated Medication Administration: 1. Medications are administered in accordance with written orders of the prescriber ., 14. Medications are administered with 60 minutes of schedule time, except before or after meal orders, which are administered based on mealtime. 2. During a Med Pass observation, on 11/16/21 at 8:06 AM, LVN 1, administered Azopt 1% (eye medication used to treat high pressure inside the eye due to glaucoma) one drop in each eye to Resident 29, LVN 1 did not pull the lower eyelid down and away from the eyeball to form a pocket, did not remove excess drops on the resident's face, did not instruct resident to look downward and gently close her eyes for 1- 2 minutes for the medication to be absorbed and did not ensure resident applied gentle pressure to the inner corner of the eye to prevent the medication from draining out to the sinuses. During a review of the November 2021 PO, the PO indicated an order to administer Azopt 1% 1 eye 555657 Page 13 of 29 555657 11/19/2021 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few drop in each eye two times a day for glaucoma(increased pressure in the eyeball that may cause gradual loss of eyesight). During an interview on 11/16/21, at 10:16 AM, LVN 1 stated, I forgot to instruct the resident to close her eyes. forgot to pull the lower eyelid.I had the training on eye medication administration when I started here 2-3 years ago. During a review of the facility's P&P titled Medication Administration Eye Drops dated 10/07, the P&P indicated, .8. Pull the lower eyelid down and away from the eyeball to form a pocket, 10. Instruct the resident to look upward, and place one drop into the pocket, continuing to hold the eyelid for a moment to allow medication to distribute, 11. Release the eyelid and instruct the resident to close the eye for one to two minutes, 12. Use gauze or tissue to remove excess drops on the resident's face. According to Manufacturer's Product Information (MPI) for Azopt 1% eye drop, . after placing one drop into the pouch, . Look downward and gently close eyes for 1-2 minutes. Place one finger at the corner of the eye (near the nose) and apply gentle pressure. This will prevent the medication from draining out. During a Med Pass observation on 11/16/21, at 8:08 AM, LVN 1 was administering Advair (a medication to treat lung disease) HFA 230-21 micrograms (mcg) 2 puffs by mouth to Resident 29. After administering the first puff, LVN 1 did not instruct the resident to hold his/her breath for 5-10 seconds, did not wait for 1-2 minutes before administering the second inhaler(device used to administer medication through breathing) dose, and did not shake the inhaler in between administrations. During a review of the November 2021 PO for Resident 29, PO indicated, Advair HFA 230-21mcg/actuation 2 puffs daily for a chronic lung disease. During an interview on 11/16/21, at 10:06 AM, with LVN1, about his oral inhalation administration techniques, LVN 1 stated I forgot the procedure. During a review of the facility's P&P titled Medication Administration Oral Inhalations, dated 09/10 indicated, . 12. Hold breath for 5-10 seconds or as long as possible to allow medication to reach deeply into lungs, 14. If another puff of the same or different medication is required, wait at least 1-2 minutes between. According to MPI for ADVAIR HFA .shaking well for 5 seconds before each spray. During a Med Pass observation on 11/16/21, at 8:22 AM, Registered Nurse (RN) 3, administered two eye medications to Resident 325. The two eye medications Dorzolamide HCl-Timolol Maleate Ophthalmic solution 2%/0.5% (eye medication used to reduce elevated pressure inside the eye) one drop in each eye and Lumigan 0.01% (eye medication used to reduce elevated pressure inside the eye due to) one drop in each eye. RN 3 administered Dorzolamide HCl-Timolol Maleate Ophthalmic solution 2%/0.5% in each eye, did not wait a sufficient contact time of 3-5 minutes before applying Lumigan 0.01% to each eye. RN 3 did not pull the lower eyelid down and away from the eyeball to form a pocket to administer Dorzolamide HCl-Timolol Maleate Ophthalmic solution 2%/0.5% and Lumigan 0.01%, did not remove excess drops of the two eye medications on the resident's face, did not instruct resident to look downward and gently close her eyes for 1- 2 minutes for the medications to be absorbed, did not place a finger at the corner of the eye to apply gentle pressure to prevent the medications from draining out to 555657 Page 14 of 29 555657 11/19/2021 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0759 the sinuses. Level of Harm - Minimal harm or potential for actual harm During a review of the November 2021 PO for Resident 325, PO indicated, Dorzolamide HCl-Timolol Maleate Ophthalmic solution 2%/0.5% one drop in each eye twice a day for glaucoma and Lumigan 0.01% one drop in each eye once a day for glaucoma. Residents Affected - Few During an interview on 11/16/21, at 10:40 AM, with RN3, about her eye medication administration technique, RN 3 stated, Sometimes we are kind of in a hurry, we know the rules but sometimes we forgot. It has been a long time since we had in-service. During a review of the facility's P&P titled Medication Administration Eye Drops dated 10/07, P&P indicated, . 8. Pull the lower eyelid down and away from the eyeball to form a pocket, 10. Instruct the resident to look upward, and place one drop into the pocket, continuing to hold the eyelid for a moment to allow medication to distribute, 11. Release the eyelid and instruct the resident to close the eye for one to two minutes, 12. Use gauze or tissue to remove excess drops on the resident's face. During a Med Pass observation on 11/16/21, at 8:33 AM, Registered Nurse (RN) 3, administered Fluticasone Propionate 110mcg/activation 2 puffs for asthma to Resident 325. RN 3 did not instruct resident to hold breath for 5-10 seconds after first inhalation for medication to reach deeper part of the lungs, did not wait 1-2 minutes between inhalation, and did not shake inhaler in between administration. During a review of the November 2021 PO for Resident 325, PO indicated, Fluticasone Propionate HFA 110mcg/activation 2 puffs twice a day for asthma. During an interview on 11/16/21, at 10:40 AM, with RN3, about her oral inhalation administration technique, RN 3 stated I know the rules but sometimes forgot it. During a review of the facility's P&P titled Medication Administration Oral Inhalations, dated 09/10, P&P indicated, . 12. Hold breath for 5-10 seconds or as long as possible to allow medication to reach deeply into lungs, 14. If another puff of the same or different medication is required, wait at least 1-2 minutes between. According to MPI for Fluticasone Propionate HFA . shaking well for 5 seconds before each spray. During a Med Pass observation on 11/16/21, at 8:46 - 10:00 AM, Registered Nurse (RN) 2, administered Artificial Tears one drop in each eye for dry eyes to Residents 55 and 56. RN 2 did not pull the lower eyelid down of Resident 55 and 56 and away from the eyeball to form a pocket and did not instruct residents to look downward and to gently close eyes for 1- 2 minutes for the medication to be absorbed. During an interview on 11/16/21, at 9:01 AM, with RN2, about his eye medication administration technique, RN 2 stated, just forgot the techniques. During review of the facility's P&P titled Medication Administration Eye Drops dated 10/07, P&P indicated, . 8. Pull the lower eyelid down and away from the eyeball to form a pocket, 10. Instruct the resident to look upward, and place one drop into the pocket, continuing to hold the eyelid for a moment to allow medication to distribute, 11. Release the eyelid and instruct the resident to close 555657 Page 15 of 29 555657 11/19/2021 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0759 the eye for one to two minutes. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555657 Page 16 of 29 555657 11/19/2021 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 store medications and biologicals (biologicals are made from variety of natural sources- human, animal or microorganisms, may include a wide range of products such as vaccine, blood and blood components) in a safe condition when the temperature of two of two sampled medication refrigerators were out of range in accordance with Federal, State, and CDC vaccine storage and handling guidelines. This failure had the potential to compromise the integrity and effectiveness of medications and biologicals and could potentially cause harm to the residents. Findings: During an observation of the Medication Refrigerator 1 (MR 1) in the Medication Storage Room Area 1 (MSRA 1), on 11/16/21, at 1:45 PM, with the Registered Nurse (RN) 4, the temperature reading of MR 1 indicated, 32 degrees Fahrenheit (F). Inside MR I, a Novolin N FlexPen (a single-dose packet of medication to which a needle has been fixed by manufacturer) of NPH insulin (a hormone that lowers the level of blood sugar) for Resident # 59, the manufacturer ' s instruction written on the medication label, . Keep in a cold place. Store at 36 degrees to 46 degrees F, do not freeze. In a concurrent record review, the Refrigerator and Freezer Temperature Log 1 (RFTL 1) indicated, the temperature of MR 1 was .2 on 11/11/21 at 6 AM and 6 PM, no scale of temperature (Fahrenheit scale or Celsius scale. Celsius is a temperature scale based on the freezing point of water), recorded. The RFTL 1 indicated that MR 1 ' s temperature on 11/13/21, at 6 AM and 6 PM was both .0 (zero) ., with no temperature scale recorded. In a concurrent interview, RN 4 acknowledged the observation and stated, . Will refer this to maintenance . When asked about which temperature scale staff was using on the temperature log, RN 4 was unable to provide an answer. During an observation in the Medication Refrigerator 2 (MR2) in the Medication Storage Room Area 2 (MSRA 2) on 11/16/21, at 2:30 PM, with RN 2, the temperature reading of MR 2 indicated, 32 degrees Fahrenheit (F). Inside MR 2, an Influenza Vaccine, single dose, pre-filled syringe for resident use. The manufacturer ' s instruction on the label, . Store between 36 degrees - 46 degrees F. Do not freeze. Discard if the vaccine has been frozen . In a concurrent record review, the Refrigerator and Freezer Temperature Log 2 (RFTL 2) indicated, the temperature of MR 2 was .0 (zero) with no scale of temperature (Fahrenheit scale or Celsius scale. Celsius is a temperature scale based on the freezing point of water), recorded on 11/01- 11/16/21 at 6 AM and 6 PM. In a concurrent interview, RN 2 acknowledged the observation and stated, . will discard this vaccine now . During an interview on 11/16/21, at 2:15 PM, with the Director of Maintenance (DOM), DOM stated, . Every morning I checked the maintenance logbook, but there is no request to check refrigerator. I did not come to fix it . During an interview on 11/16/21, at 4:00 PM, with RN 1, RN stated, . staff to report to maintenance if the temperature is out of range . During an interview on 11/18/21, at 11:00 AM, with the Director of Nursing (DON), DON stated, . checked the thermometer, but did not check the log . 555657 Page 17 of 29 555657 11/19/2021 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of the facility pharmacy Policy and Procedure (P&P) titled, Medication Storage, Storage of Medication dated 09/10, the P & P indicated, . 11. Medication requiring refrigeration or temperature between 36 to 46 degrees F are kept in a refrigerator with a thermometer to allow temperature monitoring.A daily recorded temperature should be documented and signed off . temperature should be recorded twice daily.A facility policy should be developed which describes the steps that will be followed if temperature falls out of the range . 555657 Page 18 of 29 555657 11/19/2021 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0802 Level of Harm - Minimal harm or potential for actual harm Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview and record review, the facility failed to ensure competency of one dietary aide (DA) when: Residents Affected - Some 1. Standardized recipes for pureed foods were not followed for three lunch menu items on 11/16/21. 2. Scoop sizes for pureed foods were not followed during lunch tray line service on 11/16/21. Failure to ensure staff competency in kitchen related duties could negatively impact provision of prescribed diets and preferences for 13 residents who received pureed food from the kitchen. Findings: 1. During a review of the facility document titled, GOOD FOR YOUR HEALTH MENUS . November 15-21, 2021 - Week 3, the lunch menu indicated, .TUESDAY November 16 . Fish Fillet with Garlic Butter, [NAME] Pilaf, Ginger Carrots, Wheat Roll, Peanut Butter Cake . During an observation of food production activities in the kitchen on 11/16/21, that began at 10:30 AM, with the Assistant Dietary Supervisor (ADS) present, Dietary Aide (DA) 1 was observed to prepare pureed ginger carrots recipe. After proper hand hygiene and clean gloves worn, DA 1 used a slotted spoon to scoop and drain boiled crinkle-cut carrots from a pot into a plate then placed the boiled carrots in the blender, added a total of 4.5 cups of water that was used to boil the carrots and pureed the mixture for 5 minutes. During a concurrent interview with DA 1, the surveyor asked how the boiled carrots in the pot were prepared. DA 1 stated, he used 2 pounds of frozen crinkle cut medium carrots and boiled them with water. DA 1 then emptied contents of blender container and transferred the pureed carrot mixture into a rectangular, steam table container pan and set it aside on the counter. During an observation on 11/16/21, at 10:40 AM, with ADS present, DA 1 was observed to prepare pureed rice pilaf. DA 1 transferred cooked rice pilaf from a container vessel in the blender, added 2 cups of hot water and pureed the mixture for 5 minutes. During a concurrent interview with DA 1, the surveyor asked how much cooked rice pilaf was used for the pureed mixture. DA 1 stated, he used 2 pounds. DA 1 then transferred the pureed rice mixture from the blender into a rectangular steam table container pan, covered it with a transparent plastic wrap, and wrote puree rice 11/16/21 as label. During a concurrent observation and interview on 11/16/21, at 11 AM, the surveyor asked DA 1 how he prepared the pureed fish fillet on a rectangular steam table container pan that was set aside on the kitchen counter next to the stove. DA 1 stated, he used 7 pieces of cooked fish fillets, added 8 ounces of the fish juice from the container pan used to cook the fish, added 1 cup of water and pureed the mixture for 5 minutes. During a concurrent interview and record review of the recipe binder on 11/16/21, at 11:10 AM with DA 1 and ASD present, the surveyor asked DA 1 to show the recipes for pureed ginger carrots, pureed rice pilaf and pureed fish fillets. DA 1 was not able to identify the recipes in the binder. ASD assisted DA 1 and DA 1 was later able to point out recipes for pureed food items on the lunch menu that day. The recipe binder for GINGER CARROTS, indicated, . Portion size: ½ cup . Ingredients . Serves 8 . Frozen sliced carrots 1 lb (pound) 10 oz (ounces), Margarine 2 Tbsp (tablespoon) (1 oz), 555657 Page 19 of 29 555657 11/19/2021 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0802 Level of Harm - Minimal harm or potential for actual harm Ginger, ground* 1 tsp (teaspoon), Salt ¼ tsp, Parsley flakes as desired . *Cook: Taste carrots and more ginger if desired. DIRECTIONS: 1. Steam or boil carrots in a small amount of water until tender. Drain. Place in steam table pan. 2. Combine melted margarine with ginger and salt. 3. Pour margarine mixture over carrots and mix to blend. Garnish with parsley flakes as desired . SPECIAL DIETS . PUREEDS: Puree and serve #12 [scoop measure #12]. Residents Affected - Some The recipe binder for RICE PILAF, indicated, .Portion size: 1/3 cup (#12) [scoop measure #12] . Ingredients . Serves 8 . [NAME] rice, uncooked . 1 cup (6 oz), Margarine, melted 2 ½ Tbsp, Boiling water 2 cups, Salt ½ tsp, [NAME] bell pepper, chopped ½ (inch) or less 1 oz, Onions, chopped ½ or less 1 oz, Fresh red bell pepper, chopped ½ or less 1 oz, Parsley, flakes As desired . DIRECTIONS: 1. Rinse vegetables well under cool running water. 2. Bring water and margarine to a boil in a pan and pour over rice in steam table pan. Combine all other ingredients, except parsley flakes with rice and stir to mix. 3. Cover with foil and bake for 45 minutes to 1 hour .Garnish with parsley flakes as desired .Fluff with fork, cover with towel and let sit for 5 minutes. Re-fluff . SPECIAL DIETS . PUREEDS/DYSPHAGIA: Puree and serve #12 [scoop measure #12]. (Small #16, [scoop measure # 16], large #8 [scoop measure #8]). See Binder # 1, misc. section for Puree Starch recipe . The recipe binder for FISH FILLET WITH GARLIC BUTTER, indicated, .Portion size: 3 oz fish + 1 tsp sauce (= 3 oz protein) . Ingredients . Serves 8 . Fish fillet of choice . thawed (About 4 servings/lb) 2 lbs, Lemon juice 1 TBSP + 1 tsp, Water ¼ cup, Dill, dried (optional) ½ tsp. Sauce: Margarine, melted 2 oz (2 Tbsp), [NAME] cooking wine or chicken broth, 1 Tbsp + 1 tsp, Garlic powder ¼ tsp, Onion powder ¼ tsp, Tartar Sauce ½ cup, Parsley: Sprinkle for color . DIRECTIONS: 1. Place pieces of fish close together in single layer on greased sheet pan. Combine lemon juice, water and dill, if using. Pour over fish. 2. Bake at 375 °F (Fahrenheit) approx. 10 minutes per inch of thickness . 3. Sauce: Combine sauce ingredients and simmer 3-5 minutes to blend flavors. Pour sauce over fish in steamtable pans. Sprinkle with parsley flakes for color. 4. Serve with 1 Tbsp. Tartar sauce per serving . SPECIAL DIETS . PUREEDS: Puree and serve hot #8 scoop. Use parsley flakes for color. Puree tartar sauce . Upon further interview and review of the recipes for pureed ginger carrots, pureed rice pilaf and pureed fish fillet with ASD, ASD confirmed and acknowledged DA 1 did not follow recipe directions. ASD stated DA 1 was a relatively new staff and began to work in the kitchen about 4 months ago. ASD stated a kitchen supervisor who no longer worked at the facility provided DA 1 with the required job training. During a review of the resident dietary tray tickets provided by the Dietary Supervisor (DS) on 11/16/21, there were 13 total residents who received pureed meals from the kitchen. 2. During a tray line service observation on 11/16/21, at around 12:08 PM, a large rectangular steam table pan moderately filled with water sat on top of lit stove. The large pan held three steam table pans that contained the prepared pureed fish fillets, pureed rice pilaf and pureed ginger carrots. Green-colored scoops were noted on all three pans. During a review of the facility document titled, Scoop Measurement Color Guide, undated, indicated, Number 12 - Color [NAME] - Measure 1/3 cup . During an observation on 11/16/21, at 12:10 PM, with the ASD present, the dietary tray ticket for Resident 28 was called for a regular diet, puree consistency and large portion. DA 1 used 555657 Page 20 of 29 555657 11/19/2021 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some green-colored scoops of pureed rice pilaf and pureed ginger carrots from the steam table pans into Resident 28's plate. During a concurrent interview with DA 1, DA 1 confirmed green-colored scoops were used instead of the gray-colored scoops. During a review of the recipe for RICE PILAF, indicated, .SPECIAL DIETS . PUREEDS . Puree and serve . large #8 [scoop measure #8]) . Review of the menu for Pureed [NAME] Pilaf, indicated, .Large #8 . During a review of the menu for Pureed Ginger Carrots, indicated, .Large ½ c (cup) . During a review of the facility document titled, Scoop Measurement Color Guide, undated, indicated, . Number 8 - Color Gray - Measure ½ cup . During a concurrent observation and interview on 11/16/21, at 12:13 PM with ASD, ASD acknowledged incorrect scoops were used by DA 1 for Resident 28. ASD placed a gray-colored scoop on steam table pans for the pureed rice pilaf and pureed ginger carrots. ASD replaced Resident 28's plate with corrected portions of pureed food items. During an observation on 11/16/21, at 12:18 PM, with the ASD present, the dietary tray ticket for Resident 43 was called for a pureed diet, small portion. DA 1 used green-colored scoop of pureed rice pilaf from the steam table pans into Resident 43's plate. During a concurrent interview with DA 1, DA 1 acknowledged incorrect scoop was used. During a review of the recipe for RICE PILAF, indicated, .SPECIAL DIETS . PUREEDS . Puree and serve . (Small #16, .) . Review of the menu for Pureed [NAME] Pilaf, indicated, .Small #16 . During a review of the facility document titled, Scoop Measurement Color Guide, undated, indicated, . Number 16 - Color Blue - Measure ¼ cup . During a concurrent observation and interview on 11/16/21 at 12:22 PM with ASD, ASD confirmed the wrong scoop was used by DA 1 for Resident 43. ASD got a blue-colored scoop for the pureed rice pilaf pan and replaced Resident 43's plate with the corrected portion size. During a concurrent interview on 11/17/21, at 10:03 AM, with the Dietary Supervisor (DS) and Registered Dietitian (RD), DS stated, she had oversight of the kitchen operations. RD stated, he provided consultant services to the facility since September 2021. RD stated, he worked 8 hours, one day a week at the facility. When asked about an approximate percentage of time spent on kitchen-related responsibilities, RD said, can't say with certainty. RD stated, when in the facility, his time was spent mostly on clinical work. The surveyor discussed observed food and nutrition service practices in the facility that included pureed food preparation and tray line service noted on 11/16/21. During a concurrent record review of pureed diet menu and recipes for fish fillet, rice pilaf and ginger carrots with DS, DS stated, staff were expected to follow directions as indicated on the approved menus and recipes. RD stated, it was important that staff followed pureed recipe directions because it would affect the consistency and palatability of foods. RD stated, he had not yet done tray line service observations in the kitchen. During a review of the facility's policy and procedure (P&P) titled, FOOD PREPARATION, dated 2018, the P&P indicated, POLICY: Food shall be prepared by methods that conserve nutritive value, flavor and appearance. PROCEDURE: 1. The facility will use approved recipes, standardized to meet the resident census . 2. Recipes are specific as to portion yield, method of preparation, amounts of 555657 Page 21 of 29 555657 11/19/2021 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0802 ingredients, and time and temperature guide . Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, FOOD PREPARATION, dated 2018, the P&P indicated, PORTION CONTROL - POLICY: To provide specific portion control information. PROCEDURE: To be sure portions served equal portion sizes listed on the menu, portion control equipment must be used. A variety of portion control equipment should be available and utilized by employees portioning food. 1. Scoops are sized by number . Scoop numbers and amounts are listed in the RDs for Healthcare recipe book . Residents Affected - Some During a review of the facility document titled, .DEPARTMENT OF FOOD AND NUTRITION SERVICES CONSULTANT (CONSULTANT DIETITIAN) JOB DESCRIPTION, dated 2018, indicated, POLICY . The Registered Dietitian provides consultation to the facility for the purpose of providing nutrition care and oversight of the operations of the Department of Food and Nutrition Services, which will result in optimal health of the resident/patient . RESPONSIBILITIES . Evaluates and monitors the food service department to assure that the department is providing adequate, acceptable quality food. Evaluates and monitors the meal delivery system. Monitors and recommends food service standards for sanitation, safety, and infection control. Advises and counsels Director of Food and Nutrition Services in all areas of food service and nutritional care . During a review of the facility document titled, JOB DESCRIPTION, dated 2018, indicated, POSITION: FNS (Food and Nutrition Service) Director . DUTIES AND RESPONSIBILITIES . Is responsible for the preparation and service of all food and ensures that approved menus and accompanying recipes are followed . Check trays to ensure diets are served as ordered . Review, update and follow policies & procedures . During a review of the facility document titled, JOB DESCRIPTION, dated 2018, indicated, POSITION: [NAME] A . QUALIFICATIONS . Ability to accurately measure food ingredients and portions . Knowledge of basic principles of quantity food cooking and equipment use . DUTIES AND RESPONSIBILITIES . Responsible for the preparation of food for breakfast and noon meals . During a review of the facility document titled, JOB DESCRIPTION, dated 2018, indicated, POSITION: Dietary Aide . DUTIES AND RESPONSIBILITIES .Assist with tray line . All other duties as assigned by the FNS (Food and Nutrition Service) Director . LIMITATIONS . Does not cook . 555657 Page 22 of 29 555657 11/19/2021 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 store, prepare, and distribute food in a safe and sanitary manner when: Residents Affected - Some 1.Food items stored in kitchen refrigerators were expired, not labeled and dated, had labels beyond dates of use, produce discolored and fruits had mold-like substance 2. Food item brought in by family member for a resident was stored in the kitchen refrigerator 3. Food items stored in dry storage room were not dated and stored properly 4. Equipment and food service trays were not cleaned and maintained properly, and dietary staff did not perform proper hand hygiene 5. Temperature in freezer was out of range This deficient practice had the potential to put residents at risk for foodborne illnesses. Findings: 1.During an initial kitchen tour observation and concurrent interview on 11/15/21 that began at 10:08 AM, in the kitchen, with Assistant Dietary Supervisor (ADS) present, ADS confirmed the findings below and stated these food items had to be discarded. ADS stated food items had to be labeled and dated. 1.1) In refrigerator 1, an opened jar of clam base paste labeled with use by date 9/15/21 1.2) In refrigerator 1, a container of cut, orange-colored lettuce leaves with use by date 11/16/21 1.3) In refrigerator 1, a container of sliced tomatoes and green bell pepper with use by date 11/14/21 1.4) In refrigerator 1, an undated cup of sliced strawberries 1.5) In refrigerator 1, 2 unopened yogurts with expiration date 11/10/21 1.6) In refrigerator 2, an undated glass of milk 1.7) In refrigerator 2, 2 unopened yogurts with expiration date of 11/10/21 1.8) In refrigerator 2, 4 packages of strawberries dated 11/15/21 that had mold-like substances During a review of the facility's policy and procedure (P&P) titled, LABELING AND DATING OF FOODS, dated 2018, the P&P indicated, POLICY: All food items in the storeroom, refrigerator, and freezer need to be labeled and dated. PROCEDURE: Food delivered to facility needs to be marked with a received date. Note that the delivery sticker is dated, and it can serve as the delivery date of the product . Newly opened food items will need to be closed and labeled with an open date and used by date . 555657 Page 23 of 29 555657 11/19/2021 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0812 All prepared foods need to be covered, labeled and dated . Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, PROCEDURE FOR REFRIGERATED STORAGE, dated 2018, the P&P indicated, . Produce will be delivered frequently and rotated in the order it is delivered to assure that a fresh product is used, free of any wilting or spoilage . Residents Affected - Some During a review of the facility's policy and procedure (P&P) titled, GENERAL RECEIVING OF DELIVERY OF FOOD AND SUPPLIES, dated 2018, the P&P indicated, . POLICY: Food deliveries will be inspected to assure high quality food and supplies. They are to be received in proper condition. PROCEDURE . Carefully inspect deliveries for proper labeling, temperature and appearance .Produce is to be fresh and free of any wilting or spoilage . Label all items with delivery date or a use-by date . 2. During a kitchen tour observation and concurrent interview on 11/15/21, at 10:25 AM, with ADS present, a plastic container of soup with lid labeled 11/14/21 soup, use by 11/19/21 was found in refrigerator 1. The label indicated Resident 10's last name. ADS stated, the soup was store-bought and brought in by Resident 10's family member. ADS stated, kitchen staff would heat and serve the soup for Resident 10 during meals. During a review of the facility document, titled, Bringing in Food for A Resident, dated 7/19, the document indicated, .If you plan to bring food into the Facility for a resident, please be sure to follow these food safety guidelines . Resident should plan to consume prepared food within 2-3 hours of it being received into Facility. If food is to be eaten later, it should be taken immediately to the Activity Room where staff will label the food with the resident's name, date and time - and refrigerate it for up to 24 hours . Please consult facility staff regarding re-heating foods that have been refrigerated . 3. During an observation of the dry storage room located next to the kitchen, and concurrent interview on 11/15/21 that began at 11:08 AM, with ADS present, ADS acknowledged the findings below: 3.1) An opened, undated package of gelatin mix 3.2) An opened, undated package of polenta 3.3) 1 unused, undated package of cherry gelatin mix 3.4) An opened, package of pasta with use by date 10/16/22 was not tightly closed 3.5) 10 pieces of partly rotten bananas were found in plastic bin that was not kept clean and had had several brown-colored stains During a review of the facility's policy and procedure (P&P) titled, STORAGE OF FOOD AND SUPPLIES, dated 2017, the P&P indicated, POLICY: Food and supplies will be stored properly and in a safe manner. PROCEDURES FOR DRY STORAGE . The storeroom should be well-lighted, .dry and clean at all times . All food will be dated - month, day, year . Dry food items which have been opened . will be tightly closed, labeled and dated . During a review of the facility's policy and procedure (P&P) titled, GENERAL RECEIVING OF DELIVERY OF FOOD AND SUPPLIES, dated 2018, the P&P indicated, . POLICY: Food deliveries will be inspected to assure high quality food and supplies. They are to be received in proper condition. PROCEDURE . 555657 Page 24 of 29 555657 11/19/2021 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Carefully inspect deliveries for proper labeling, temperature and appearance .Produce is to be fresh and free of any wilting or spoilage . Label all items with delivery date or a use-by date . During a review of the facility's policy and procedure (P&P) titled, LABELING AND DATING OF FOODS, dated 2018, the P&P indicated, POLICY: All food items in the storeroom . need to be labeled and dated. PROCEDURE: Food delivered to facility needs to be marked with a received date. Note that the delivery sticker is dated, and it can serve as the delivery date of the product . Newly opened food items will need to be closed and labeled with an open date and used by date . 4.1 During a concurrent observation and interview on 11/15/21, at 10:31 AM, with ADS present, a gray-colored electric fan was on the counter of a three-compartment sink in the kitchen. The fan ran and blew air in the food production counter next to the stove. The fan's blade guards had significant accumulation of dust-like debris. The base of the fan was also wet. ADS confirmed the observations. ADS stated, the fan had been used in the same location for a while now. ADS acknowledged the blade guards were not clean, and location of the fan was unsafe. 4.2 During a follow-up observation and concurrent interview on 11/16/21, at 9:39 AM, with ADS, in the kitchen, a stack of 6 service trays used to hold clean beverage cups were inspected. The trays had sticky residues of paper tapes attached on the edges. There was also a stack of 5 resident food trays used during meal service that had several pieces of plastic tapes attached on the edges. ADS acknowledged the observations and stated, the tape and tape residues had to be removed to ensure the trays were washed and cleaned properly. During a concurrent interview on 11/17/21, at 10:20 AM, with the Registered Dietitian (RD), RD stated, the tapes and residues noted by the surveyor on food service trays were an infection control concern. 4.3 During an observation of food production activities in the kitchen on 11/16/21, that began at 10:30 AM, with the Assistant Dietary Supervisor (ADS) present, Dietary Aide (DA) 1 was observed to prepare pureed ginger carrots recipe. After proper hand hygiene and clean gloves worn, DA 1 used a slotted spoon to scoop and drain boiled crinkle-cut carrots from a pot into a plate then placed the boiled carrots in the blender, added a total of 4.5 cups of water that was used to boil the carrots and pureed the mixture for 5 minutes. DA 1 then emptied contents of blender container and transferred the pureed carrot mixture into a rectangular, steam table container pan and set it aside on the counter. With the same gloves worn, DA 1 removed the food container and cover from the blender base, washed them with water in the sink and re-attached the blender parts back to the base. With used wet gloves still worn, DA 1 then held and touched the interior container of the prepared pureed carrot mixture on the counter. ASD noted the observations and stated the pureed carrot mixture had to be discarded. DA 1 removed his used gloves. DA 1 did not perform proper hand hygiene and was about to proceed with preparation for another pureed food item. DA 1 acknowledged he did not wash his hands after glove removal. ASD acknowledged the blender parts were not properly washed. DA 1 and ASD confirmed dirty gloves had to be removed after use, and appropriate hand hygiene must be performed after glove removal. During a review of the facility's policy and procedure (P&P) titled, SANITATION, dated 2018, the P&P indicated, POLICY: The Food & Nutrition Services (FNS) Department shall have equipment of the type . for proper preparation, serving and storing of food . All equipment shall be maintained as necessary and kept in working order . PROCEDURE . The FNS Director is responsible for instructing Food and Nutrition Services personnel in the use of equipment. Each employee shall know how to operate and 555657 Page 25 of 29 555657 11/19/2021 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some clean all equipment in his specific area . All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks and chipped areas . Plastic ware, china and glassware that becomes unsightly, unsanitary or hazardous because of chips, cracks or loss of glaze shall be discarded .All Food & Nutrition service staff shall know the proper hand washing technique. The FNS Director is responsible for the proper training of this . The FNS Director is responsible for instructing employees in the fundamentals of sanitation in food service and for training employees to use appropriate techniques . During a review of the facility's policy and procedure (P&P) titled, HAND WASHING PROCEDURE, dated 2018, the P&P indicated, Hand washing is important to prevent the spread of infection . PROCEDURE: 1. Use warm running water . and soap, preferably from a dispenser. 2. Wet hands . Add soap and rub hands together . 3. Rinse thoroughly and dry hands . WHEN HANDS NEED TO BE WASHED: 1. Before starting work in kitchen 2. After handling soiled dishes and utensils . 4. Before and after handling foods with hands (cutting, peeling, mixing, etc.) . 5. During a concurrent observation and interview on 11/16/21, at 9:28 AM, with ADS present, the kitchen freezer #2 temperature was checked. There were ice cream cups and breads stored inside. The thermometer inside the freezer #2 indicated, 7° Fahrenheit (F). ADS stated the temperature was supposed to be zero or below. During a follow-up observation and concurrent interview on 11/16/21 at 11:29 AM, with ADS present, the kitchen freezer #2 temperature was checked. The thermometer inside the freezer #2 indicated, 10° Fahrenheit (F). During a follow-up observation and concurrent interview on 11/16/21 at 12:48 PM, with ADS present, the kitchen freezer #2 temperature was checked. The thermometer inside the freezer #2 indicated, 5° Fahrenheit (F). ADS stated she will notify the maintenance department. During a review of the facility's policy and procedure (P&P) titled, COLD STORAGE TEMPERATURE LOGGING, dated 2018, the P&P indicated, Food and Nutrition Services staff shall review and record temperatures of all refrigerators and freezers to ensure they are at the correct temperature for food storage and handling. PROCEDURE: 1. Food and Nutrition services staff will check the inside temperature of refrigerators and freezers . If temperatures are not withing standards, Food & Nutrition services staff will notify the FNS Director . Freezer temperature standards are 0° F (Fahrenheit) or below . 555657 Page 26 of 29 555657 11/19/2021 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 brought to residents by family members and other visitors. Residents Affected - Few This failure had the potential to expose residents to food-borne illnesses. Findings: During a concurrent observation and interview on 11/16/21, at 9:54 AM, with the Activity Staff (AS), in the Activity Room, the refrigerator designated for residents was inspected. The freezer compartment of the refrigerator had significant frost and ice build up. No drain pan was noted underneath the freezer compartment, and directly below it were two labeled food items belonging to residents. The temperature control dial was also missing from the temperature control box. AS acknowledged the findings and stated, the freezer compartment had to be defrosted. AS stated, activity staff were responsible to clean and maintain the resident refrigerator. During a review of the facility's policy and procedure (P&P) titled, PROCEDURE FOR RECEIVING FOOD BROUGHT INTO FACILITY FROM OUTSIDE SOURCES, undated, the P&P indicated, Procedure/task . Recording and maintenance .Clean-up maintenance . Who will do it? Activity Staff . When? Every Sunday . During a review of the facility's policy and procedure (P&P) titled, PROCEDURE FOR REFRIGERATED STORAGE, dated 2018, the P&P indicated, .Refrigeration equipment should be routinely cleaned . 555657 Page 27 of 29 555657 11/19/2021 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff followed their infection control practices, when two staff members did not perform hand hygiene before entering Residents' rooms. Residents Affected - Few This deficient practice had the potential for staff to spread infectious agents to residents within the facility. Findings: 1.During an observation on 11/15/21, at 10:25 AM, in room [ROOM NUMBER], Certified Nurse Assistant (CNA) 4, entered room [ROOM NUMBER] [Room of Resident 11 and Resident 68] to perform resident care, without performing hand hygiene. CNA took a Hoyer lift, stationed it at the entrance by bed 212 A and told CNA1 that she did not know CNA 1 already had another Hoyer lift for the resident, CNA 4 proceeded to 212 B to assist CNA 1 who was assisting resident in bed. During an interview on 11/15/21, at 10:30 AM, with CNA 4, CNA 4 acknowledged that she was supposed to use the hand sanitizer by the wall before entering the residents' room. CNA 4 stated, I'm sorry, I was rushing because I want to help CNA 1. 2. During an observation on 11/15/21, at 10:40 AM, in room [ROOM NUMBER]. Licensed vocational nurse (LVN) 1 knocked at the door of room [ROOM NUMBER], opened the door and entered room [ROOM NUMBER][room of Resident 63 and Resident 62], without performing hand hygiene. A functioning hand sanitizer cannister was on the wall by the right-hand side close to the door. During an interview on 11/15/21, at 10:42 AM, in front of room [ROOM NUMBER], LVN 1 stated, he was told a resident in room [ROOM NUMBER] need something, and he [LVN 1] came from another room. Informed LVN 1 he was being watched. LVN 1 confirmed he knocked at door of the room [ROOM NUMBER], opened the door and went into room [ROOM NUMBER], and was supposed to perform hand hygiene before entering the residents' room. During an interview on 11/15/21, at 12 PM, with RN 4, the designated Infection Preventionist [IP], RN 4 stated, their policy is for hand sanitizer use before entering Resident's room and after exiting, and during certain procedures in the room. The IP stated, staff were supposed to be doing that, as they had the training. During a review of the facility's policy and procedure titled, Procedure for Handwashing, undated, indicated, .When to Use alcohol Hand sanitizer: .Before entering the residents' room. Before exiting the residents' room .Advantages of Alcohol hand Sanitizer: Active against all bacteria and most clinically important viruses and fungi . 555657 Page 28 of 29 555657 11/19/2021 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0908 Keep all essential equipment working safely. 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 call lights for six residents were maintained to ensure call lights were functioning as intended. Five call lights did not light up inside the resident's room when activated (Residents 21, 27, 38, 46, and 60). Resident 35's call light was not functioning when checked. Residents Affected - Some Failure to maintain indicator lights had the potential to increase a resident's anxiety when there was no visual indication to let a resident know if their call light was functioning. Failure to ensure Resident 35's call light was functioning had the potential to delay staff's response to Resident 35's request for assistance. Findings: During a concurrent observation and interview on [DATE], at 10:00 AM, the Maintenance Director was asked to check call lights for Residents 21, 27, 38, 46, and 60. The Maintenance Director stated, there was an indicator light next to where the call light plugs into the wall. The Maintenance Director confirmed these indicator lights were not working for Residents 21, 27, 38, 46, and 60. The Maintenance Director checked Resident 35's call light and stated, the call light was not functioning and he would change the call light cord. The Maintenance Director said the facility had known about these call light indicators not working for one to two years. The Maintenance Director said this was an old system and replacement bulbs are not available. The Maintenance Director said the call light system needs to be replaced because he was unable to find companies with the knowledge to repair the facility's call light system. The Maintenance Director did not offer any alternative solution for the indicator lights. During a review of the facility's policy and procedure titled Call lights: Accessibility and Timely Response (not dated) indicated, .Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied. 555657 Page 29 of 29