Health inspection·October 14, 2022

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to obtain a physician's order for the use of an indwelling urinary catheter (a thin sterile tube inserted into the bladder to drain urine to a collection bag outside of the body) for one of 7 sampled residents (Resident 19). This failure had the potential for insufficient and inadequate delivery of care. Findings: Resident 19 was readmitted to the facility on [DATE] with admitting diagnoses which included stage 4 pressure ulcer of the sacral region. During initial observation on 10/10/22 at 11:45 a.m., Resident 19 was in bed, and had an indwelling catheter drainage bag anchored to his bed frame. The connecting tube from the catheter to the collection bag had blood-tinged urine. During a concurrent record review and interview with licensed vocational nurse (LVN) 2, LVN2 stated, there was no order for the use of an indwelling catheter in Resident 19's electronic health record, and LVN 2 was not aware of Resident 19 having an indwelling catheter. During an interview on 10/11/22 at 11:05 a.m. ,with the nurse supervisor (RN) RN 1, RN1 stated, there should be a physician's order for the use and care of an indwelling catheter. RN 1 did not find a physician's order in Resident 19's electronic health record. The facility policy titled Foley catheter insertion, male resident dated October 2010 indicated .verify that there is a physician's order for this procedure. Page 1 of 8 555684 555684 10/14/2022 Legacy Post Acute Care 1790 Muir Road Martinez, CA 94553

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to assure oxygen supplies and equipment were maintained according to policy and the operator's manual for four (4) of five (5) sampled residents (Resident 16, Resident 54, Resident 1, Resident 56). Residents Affected - Few This deficient practice had the potential for the delivery of unclean and inadequate oxygen concentration to the residents. Findings: During the initial tour on 10/10/22 at 9:20 a.m., Resident 16 was using a concentrator (an electronically operated device that separates oxygen from room air and provides high concentration of oxygen directly through a nasal cannula, a lightweight tube with one end split into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows). The concentrator had a filter on its side which was covered with a thick layer of gray fluffy matter. Licensed Vocational Nurse 1 (LVN 1) stated, the filter was supposed to be cleaned regularly. During an observation on 10/11/22 at 9:30 a.m., Resident 54 was observed using a concentrator had a filter which was covered with a thick layer of gray fluffy matter. During an observation on 10/11/22 at 10:10 a.m., Resident 1 was observed using a concentrator had a filter which was covered with a thick layer of gray fluffy matter. Resident 56 was also observed using a concentrator on 10/11/22 at 10:45 a.m. using a concentrator had a filter which was covered with a thick layer of gray, fluffy matter. During an interview on 10/11/22 at 11:15 a.m. with IP, IP stated the filters of the concentrators needed to have a cleaning schedule, and this task should be appointed to a specific staff member. According to the facility's policy and procedure titled Concentrator Maintenance dated 8/5/09, it indicated .clean the gross particle filter. The Operator's Manual: Section 6-Maintenance, stated: 1. Remove each filter and clean at least once a week depending on environmental conditions. 555684 Page 2 of 8 555684 10/14/2022 Legacy Post Acute Care 1790 Muir Road Martinez, CA 94553

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications were stored and labeled appropriately when: 1. Resident 4's expired inhaler and Resident 56's undated opened inhaler were found in medication cart 2. 2. One opened and undated PPD 1 ml. (milliliter, unit of measure) vial was found in medication room in Station 1. 3. The temperature of a room used for medication storage was not being monitored. 4. Loose pills were found in medication cart 3. 5. Two bottles of blood glucose test strips in medication cart 3 were not dated when opened. 6. Four opened unlabeled and undated vials of Insulin (medication to lower blood sugar level) were found in medication cart 3. 7. Resident 21's opened Insulin Kwik Pen (a type of insulin) in medication cart 3 was not dated when opened. These failures had the potential for medication misuse, drug diversion and medication ineffectiveness. Findings: 1. During an observation and concurrent interview with Registered Nurse (RN 2) on [DATE], at 9:23 a.m., Resident 4's Breo Ellipta inhaler (medication administered by breathing in and helps with breathing issues) with an open date of [DATE], was found in the medication cart 2 drawer. Inhaler manufacturer's instructions on the medication box indicated, inhaler should be discarded in 6 weeks after opening. During an observation and concurrent interview with RN 2 on [DATE], at 9:23 a.m., Resident 56's Anoro Ellipta inhaler (medication administered by breathing in and helps with breathing issues) had no open date label found in medication cart 2 drawer. During a review of Anoro Ellipta Inhaler Inhaler manufacturer's instructions, instructions indicated, inhaler should be discarded 6 weeks after opening. RN 2 acknowledged resident 56's inhaler should have an open date label. During a review of the facility policy titled, Storage and Expiration Dating of Medications, Biologicals . dated 4/2022, indicated, Once any medication or biological package is opened, facility should follow manufacturer/ supplier guidelines with respect to expiration dates for open medications. Facility staff should record the date opened on the medication container when the medication has a 555684 Page 3 of 8 555684 10/14/2022 Legacy Post Acute Care 1790 Muir Road Martinez, CA 94553

F 0761 shortened expiration date once opened. Level of Harm - Minimal harm or potential for actual harm 2. During a concurrent observation of medication room in Station 1 and interview with Licensed Vocational Nurse (LVN 6), on [DATE], at 9:57 a.m., one opened Purified Protein Derivative vial (PPD is a test used for skin test to identify a lung infection) had no open date label, found inside the refrigerator in the medication room. LVN 6 acknowledged PPD vial should be labeled of date when opened. Residents Affected - Some During a review of the facility policy titled, Storage and Expiration Dating of Medications, Biologicals . dated 4/2022, indicated, Once any medication or biological package is opened, facility should follow manufacturer/ supplier guidelines with respect to expiration dates for open medications. Facility staff should record the date opened on the medication container . 3.During a concurrent observation of the medication storage room and interview with the Minimum Data Set Coordinator (MDSC), on [DATE], at 10:11 a.m., the central supply room was observed to have no temperature log. MDSC stated the thermometer in medication storage room was broken and acknowledged there was no record to monitor the temperature of the central supply room. During a review of the facility policy titled, Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, dated 04/2022, indicated, . Facility should ensure that medications and biologicals are stored at their appropriate temperatures . guidelines for temperature ranges . Room Temperature: 59 to 77 degrees Fahrenheit (a scale for measuring temperature) . 4. During a concurrent inspection of Med Cart 3 and interview with LVN 5 on [DATE], at 10:41 a.m., 6 whole and 3 broken loose pills were found in the Med Cart 3 drawer. LVN 5 verified 6 whole and 3 broken loose pills were found in Med Cart 3 drawer. During a review of facility policy Storage of Medications, dated [DATE], indicated, .The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner . Drugs should be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medication shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. 5. During a concurrent inspection of Medication Cart 3 and interview with LVN 5, on [DATE], at 10:41 a.m., found 2 undated opened blood glucose test strips (strips used to test blood sugar). LVN 5 verified the blood glucose test strips had no open date labels. LVN 5 read and acknowledged the manufacturer recommendation in the test strip bottles indicated blood glucose test strips expiration in 6 months once bottle is opened. During a review of the facility policy titled, Storage and Expiration Dating of Medications, Biologicals . dated 4/2022, indicated, Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for open medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. 6. During a concurrent inspection of Med Cart 3 and interview with LVN 5, on [DATE], at 10:41 a.m., four opened unlabeled and undated 10 ml. vials of Regular, Novolog, Lantus and Levemir insulins (medications to lower blood sugar), were found in the medication cart drawer. LVN 5 stated, insulin vials should have been labeled with residents' names and open dates. 555684 Page 4 of 8 555684 10/14/2022 Legacy Post Acute Care 1790 Muir Road Martinez, CA 94553

F 0761 Level of Harm - Minimal harm or potential for actual harm During a review of the facility policy titled, Storage and Expiration Dating of Medications, Biologicals . dated 4/2022, indicated, Once any medication or biological package is opened, facility should follow manufacturer/ supplier guidelines with respect to expiration dates for open medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. Residents Affected - Some During a review of the facility policy titled, Interim, Stat, Emergency Supplies of Medications, dated 4/2022, indicated, .To avoid waste, facility staff should place a sticker or label with the resident's name and room number on the multi dose container to assure the medication is identified as belonging to the specific resident. Facility may also place a sticker on the medication container to refer to the directions for use on the physician's order and/or the current medication administration record. Record date opened if applicable. 7. During a concurrent inspection of Med Cart 3 and interview with LVN 5, on [DATE], at 10:41 a.m., Resident 21's opened Humalog Insulin 3 ml. Kwik Pen (an injection insulin pen used to treat high blood sugar) was found in the medication drawer had no open date label. LVN stated, insulin pen should have had an open date label. During a review of the facility policy titled, administering medications dated 12/2012, indicated, . When opening a multi dose container, the date opened shall be recorded on the container . Insulin pens will be clearly labeled with the resident's name or other identifying information . 555684 Page 5 of 8 555684 10/14/2022 Legacy Post Acute Care 1790 Muir Road Martinez, CA 94553

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three of 20 sampled residents (Resident 52, 75 and 233), were notified when the menu changed. This failure had the potential to negatively affect Residents 52, 75 and 233's nutritional intake. Findings: During an interview on 10/10/22, at 2:51 p.m., with Resident 233, Resident 233 stated, the menu was changed 2-3 times a week, since her admission on [DATE]. Resident 233 stated, staff didn't tell her when or why the menu changed. Resident 233 stated, on 10/9/22, dinner was a hamburger and potato salad, when the menu had chicken strips in sweet lemon sauce with garlic ginger noodles. Resident 233 stated, on 10/10/22, lunch was a bowl of bean soup, corn bread and salad, when the menu had pot roast and gravy. Resident 233 stated, she was upset and disappointed when staff changed the menu without telling her. During an interview on 10/10/22, at 3:05 p.m., with Resident 52, Resident 52 stated, the menu was changed 2-3 times a week, since her admission on [DATE]. Resident 52 stated, staff didn't tell her when or why the menu changed. Resident 52 stated, on 10/9/22, dinner was a hamburger and potato salad, when the menu had chicken strips in sweet lemon sauce with garlic ginger noodles. Resident 52 stated, on 10/10/22, lunch was a bowl of bean soup, corn bread and salad, when the menu had pot roast and gravy. Resident 52 stated, she was upset and disappointed when staff changed the menu without telling her. During an interview on 10/11/22, at 9:14 a.m., with Resident 75, Resident 75 stated, the menu was wrong a few times a week. Resident 75 stated, staff didn't tell him when or why the menu changed. Resident 75 stated, last week, he got a ham sandwich when the menu was chicken and noodles. Resident 75 stated, he felt disappointed when staff changed the menu without telling him. During an interview 10/11/22, at 2:16 p.m., with register dietitian (RD), RD stated, they didn't notify each resident when the menu changed. RD stated, menu changes can cause residents to be emotionally dissatisfied. RD stated, it can affect residents clinically and cause residents to eat less, lose weight or not gain weight. During a review of the Menu Item Substitution List, dated 10/10/22, the list indicated on 10/10/22, lunch was changed from pot roast, mashed potatoes, Brussels sprouts and sweet corn salad to beef chili with mixed green salad and cornbread. During a review of the Substitution List, dated 10/7/22 through 10/9/22, the list indicated the menu was changed on 10/7/22 breakfast and lunch, 10/8/22 breakfast and 10/9/22 lunch and dinner. 555684 Page 6 of 8 555684 10/14/2022 Legacy Post Acute Care 1790 Muir Road Martinez, CA 94553

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food was stored and prepared under sanitary conditions when: Residents Affected - Many 1. A kitchen wall and equipment were not clean; 2. Multiple food items were unlabeled, and undated; 3. Staff food was stored in refrigerator #3. This failure had the potential to put residents at risk for cross contamination and food born illnesses. Findings: During a concurrent observation and interview on 10/10/22, at 09:25 AM, with Dietary Director (DD), the wall behind Refrigerator #2 had dust, and black and gray particles. DD stated, the wall was dirty and needed to be cleaned. The can opener had black and brown particles and residue on the blade and on multiple surfaces. The toaster had black and brown particles on the crumb tray, and inner surfaces. In the dry storage, there was 1 dented can of Tuna 4.16 pounds. In the dry storage, there was a container of individually packaged syrups that were not labeled had an open or expiration dates. In the dry storage, there was an opened 10-pound Box of graham crumbs that was not labeled with open or expiration dates. Refrigerator #1 had a half gallon container of milk that was not labeled with an open date. Freezer #2 had 1 package of opened hash and 1 package of frozen dinner rolls that were not labeled with open or expiration dates. DD stated, the dented can and food items that were not labeled with open or use by dates needed to be thrown away. Refrigerator #3 had 60 unpasteurized eggs. DD stated, eggs belonged to staff , and shouldn't have been stored in the resident's refrigerator. During a concurrent observation and interview on 10/10/22, at 2:11 p.m., with DD, the resident refrigerator in the staff break-room had an open box of peanut brittle, had no open or expiration dates. DD stated, it should have a received date label. During an interview on 10/11/22, at 02:16 p.m., with Registered Dietician (RD), RD stated, the kitchen walls should have been cleaned at end of each day and the dirty wall pose a risk for food borne illnesses. RD stated, the can opener should have been cleaned between each RD stated, the toaster should have been cleaned at end of each day. RD stated, dented cans should be put and aside and returned to the distributor. RD stated, food should've been labeled when it was received and opened. RD stated, incorrectly labeled food pose a risk for contamination and food borne illnesses to the residents. RD stated, staff's un-pasteurized eggs shouldn't have been in the resident's refrigerator. During a review of the facility's policy and procedure (P&P) titled, Walls Ceilings, and Light Fixtures, reviewed 9/19/22, the P&P indicated, Walls and ceilings must be washed thoroughly at least twice a year. Heavily soiled surfaces must be cleaned more frequently as necessary. During a review of the facility's policy and procedure (P&P) titled, Can Opener and Base, reviewed 9/19/22, the P&P indicated, The can opener must be thoroughly cleaned each work shift and, when necessary, more frequently. 555684 Page 7 of 8 555684 10/14/2022 Legacy Post Acute Care 1790 Muir Road Martinez, CA 94553

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a review of the facility's policy and procedure (P&P) titled, Electrical Food Machines, reviewed 9/19/22, the P&P indicated, Toasters. 1. Clean daily. 2. Remove crumbs from the crumb tray daily and wipe the toaster case with a soft damp cloth . During a review of the facility's policy and procedure (P&P) titled, Food Storage-Dented Cans, reviewed 9/19/22, the P&P indicated, Food in unlabeled, rusty, leaking, broken containers or cans with side seam dents, rim dents or swells shall not be retained or used by the facility. During a review of the facility's policy and procedure (P&P) titled, Labeling and Dating of Foods, reviewed 9/19/22, the P&P indicated, All food items in the storeroom, refrigerator, and freezer need to be labeled and dated. The P&P indicated, Food delivered to facility needs to be marked with a received date. The P&P indicated, Newly opened food items will need to be closed and labeled with an open date and used by the date . 555684 Page 8 of 8