Health inspection·December 8, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to treat two of 14 sampled residents (Resident 16 and 10) with respect and dignity when: 1. Certified nurse assistant D (CNA D) was standing while feeding Resident 16 in the social dining area; and 2. Resident 10's urinary drainage bag was not covered with a privacy bag. These failures had the potential to negatively affect resident's emotional and psychosocial well-being. Findings: Review of Resident 16's clinical record titled, admission Record, indicated resident was admitted to the facility with diagnoses including hemiplegia (paralysis of one side of the body/a severe or complete loss of strength in the arm, leg, and sometimes face on one side of the body) and hemiparesis (a relatively mild loss of strength in the arm, leg, and sometimes face on one side of the body) following cerebral infarction (also called stroke) affecting left non-dominant side, dysarthria (difficulty speaking) following cerebral infarction and vascular dementia (a condition caused by a stroke affecting thinking and social abilities interfering with daily functioning). During a dining observation on 12/4/2023 at 12:32 p.m., Resident 16 was sitting on a wheelchair. CNA D was observed standing while feeding Resident 16. During an interview with CNA D on 12/4/2023 at 12:43 p.m., CNA D confirmed she was standing while feeding Resident 16. CNA D stated she should sit on a chair when assisting resident with meals. During an interview with the director of staff development (DSD) on 12/5/2023 at 1:01 p.m., the DSD stated staff should sit beside the resident when feeding or assisting them with meals to show respect and to treat them with dignity. During a review of the facility's policy and procedure titled, Promoting/Maintaining Resident Dignity, dated 03/02/2022, it indicated, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity .as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Page 1 of 30 555712 555712 12/08/2023 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. During a review of Resident 10's clinical record, indicated he was admitted to the facility on [DATE] with clinical diagnosis of neuromuscular dysfunction of bladder (a condition wherein a person lacks bladder control due to brain, spinal cord, or nerve condition). Resident 10 had a physician order, dated 9/27/23, for a Foley catheter (a sterile tube inserted into the bladder to drain urine). During a concurrent observation and interview on 12/7/23 at 11:09 a.m., Licensed Vocational Nurse (LVN ) I confirmed that the urinary drainage bag was found on the floor without the dignity bag. LVN I stated the urinary drainage bag should be off the floor and covered with privacy bag. During an interview on 12/7/23 at 3:53 p.m. with Infection Preventionist (IP), IP stated the urinary drainage bag should always be off the floor with a privacy bag. During a review of the facility's policy and procedure titled, Catheter Care, dated 3/1/23, indicated, .residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use; Privacy bags will be available and catheter drainage bags will be covered at all times while in use. 555712 Page 2 of 30 555712 12/08/2023 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure resident's care needs were accommodated for two of 14 sampled residents (Resident 47 and 40) when Resident 47 and Resident 40's call light buttons were not within reach to use. Residents Affected - Few These failures had the potential to affect residents' physical and psychosocial well-being. Findings: 1) Review of Resident 47's clinical record titled, admission Record, indicated Resident 47 was admitted to the facility with diagnoses including paraplegia (a paralysis that occurs in the lower half of the body. It can be a result of an accident or a chronic condition), osteomyelitis (infection of the bone) and pressure ulcer (PU-damage to the skin caused by prolonged pressure) of sacral region (part of the body located in between the bilateral buttocks), stage 4 (PU stage with full-thickness skin loss and possible involvement of the muscle, bone, tendon or joint). During an observation and concurrent interview on 12/4/2023 at 9:30 a.m., Resident 47 was lying in bed with head of bed (HOB) elevated. Resident 47's call light button (a red button used to request assistance) was located below the left bed rail. Resident 47 tried to reach for his call light button but he couldn't reach it. 2) Review of Resident 40's clinical record titled, admission Record, indicated Resident 40 was admitted to the facility with diagnoses including chronic (persisting for a long time or constantly recurring) atrial fibrillation (an irregular and often very rapid heart rhythm), anxiety disorder (a mental illness that causes constant fear) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). During an observation and concurrent interview on 12/6/2023 at 1:15 p.m., Resident 40 was sitting in his wheelchair at the end of the bed, with the overbed table in front of her facing the bedroom's door. Resident 40 was observed still eating lunch. Resident 40 requested the evaluator nurse to press the call light button located at the right bed rail. Resident 40 complained of unable to reach her call light button. Resident 40 stated, I need help. I want to go to bed. During an interview on 12/6/2023 at 1:28 p.m., certified nursing assistant E (CNA E) confirmed Resident 40 was located far from the call light button. CNA E apologized and stated, call light button should be placed within Resident 40's reach. During an interview with the director of nursing (DON) on 12/7/2023 at 1:35 p.m.,the DON stated she did her morning rounds every day whenever she was in the facility. DON further stated residents' call light button should always be within residents' reach. A review of the facility's policy and procedure titled, Call Lights: Accessibility Policy dated 3/1/2023, indicated, .4. Staff will ensure the call light is within reach of resident and secured .5) The call light system will be accessible to the residents while in their bed . 555712 Page 3 of 30 555712 12/08/2023 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to protect a resident's rights to confidentiality of protected health information (PHI, any information in the medical record that can be used to identify an individual and that was created, used, or disclosed in the course of providing a health care service such as diagnosis or treatment) when licensed nurse left the computer screen open and unattended on top of the medication cart. This failure had the potential to compromise the resident's privacy and confidentiality. Residents Affected - Few Findings: During an observation on 12/5/23 at 10:05 a.m., a computer with a resident's medical record information was left opened and unattended on a medication cart in the hallway with two residents nearby potentially seeing the information. During an observation and concurrent interview with the Director of Staff Development (DSD) on 12/5/23 at 10:08 a.m., the DSD walked by the nurses' station and noticed the computer screen on top of the medication cart open. The DSD stated the Medication Administration Record (MAR, a record of medications given) ) of one of the residents was open and it was a HIPPA (Health Insurance Portability and Accountability Act, a federal law to protect privacy and security of health information) violation and locked the screen. The DSD stated no chart has to be exposed specially in the hallway where anyone can see. During an interview on 12/6/23 at 8:20 a.m., with the Director of Nursing (DON), the DON stated she was informed of the incident of an electronic health record that was left open and unattended in the hallway. The DON also stated information must be kept private and staff should make sure to close the screen or lock the computer before leaving the medication cart. The DON acknowledged staff had violated the privacy of the resident. During a review of the facility's Safeguarding of Resident Identifiable Information policy, dated 3/1/23, indicated Implement reasonable and appropriate measures to protect and maintain the safety and confidentiality of the resident's identifiable information and to safeguard against destruction or unauthorized release of information and records; Medical records shall not be left in open areas where unauthorized persons could access identifiable resident information. 555712 Page 4 of 30 555712 12/08/2023 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

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. Based on observation, interview, and record review the facility failed to provide a clean, safe, comfortable, and homelike environment for five of 14 sampled residents (Residents 6, 47, 40, 44 and 41) when: Residents Affected - Some 1. Resident 6's privacy curtain was not properly hooked to the rod; 2. Resident 47's privacy curtain had a dark red stain; 3. Resident 40's privacy curtain had a white stain; 4. Resident 44's room was cold; 5. Resident 41's room was cold; and 6. Facility hallways, lobby, and dining room temperatures were not maintained within the range of 71 to 81 degrees Fahrenheit (a scale for measuring temperature). These failures had the potential to result for residents decreased sense of well-being, and exposed to an uncomfortable environment. Findings: 1. During an observation on 12/4/2023 at 10:15 a.m., Resident 6's privacy curtain was not properly hooked at the ceiling rod. Four holes in the privacy curtain were not in a hook and was just hanging. During another observation on 12/5/2023 at 9:32 a.m., Resident 6's privacy curtain was not properly hooked to the ceiling rod. During an interview with the licensed vocational nurse H (LVN H) on 12/5/2023 at 9:46 a.m., LVN H stated the maintenance director (MD) was in charge of checking the residents' privacy curtains. During a follow up interview at 11:00 a.m., LVN H stated the MD did room rounds every day. LVN H further stated, staff would call MD if something were needed to be fixed. During a concurrent environmental tour and interview with MD on 12/5/2023 at 12:18 p.m., MD confirmed Resident 6's privacy curtain was not properly hooked at the ceiling rod and had to be fixed. 2 During an observation on 12/5/2023 at 9:00 a.m., Resident 47's privacy curtain had a dark red stain. During an interview on 12/5/2023 at 12:15 p.m., the MD stated housekeepers did the laundry of the privacy curtains as part of resident room's deep cleaning. The MD further stated the infection preventionist (IP) nurse would schedule each resident room's deep cleaning. During a concurrent environmental tour and interview with MD on 12/5/2023 at 12:18 p.m., the MD confirmed Resident 47's privacy curtain had dark red stain. The MD agreed Resident 47's privacy curtain 555712 Page 5 of 30 555712 12/08/2023 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0584 needed to be cleaned. Level of Harm - Minimal harm or potential for actual harm During a concurrent environmental tour and interview with IP nurse on 12/5/2023 at 12:22 p.m., the IP nurse confirmed the housekeepers complete resident room's deep cleaning monthly that included the privacy curtains. The IP nurse stated she also did her daily room rounds. She checked Resident 47's privacy curtain and confirmed that the dark red stain on it was dried blood, and stated Resident 47's privacy curtain should be laundered. Residents Affected - Some 3. During a concurrent observation and interview with Resident 40 on 12/5/2023 at 10:56 a.m., Resident 40's privacy curtain had a white stain. Resident 40 stated, Their curtains here are dirty and ugly. During a concurrent environmental tour and interview with the MD on 12/5/2023 at 12:18 p.m., the MD agreed Resident 40's privacy curtain need to be laundered. During a review of the facility's policy and procedure titled, Routine Cleaning and Disinfection, dated 7/1/2023, indicated, .14. Privacy curtains in resident rooms will be changed when visibly dirty by laundering or cleaning with an EPA [Environmental Protection Agency - a government agency responsible for protecting human health and the environment] registered disinfectant per the curtain and disinfectant manufacturer's instructions. 4. During an observation on 12/4/23 at 9:02 a.m., Resident 44 was sleeping with fleece blanket cover. During a concurrent observation and interview on 12/4/23 at 10:59 a.m., in Resident 44's room, Resident 44 stated she informed the staff that her room was cold all the time, and cold air was blowing through the air vent. The air vent was located on the ceiling over Resident 44's bed. Resident 44 stated the staff offered blankets when it was cold. During a concurrent environmental tour and interview with the Maintenance Director (MD), on 12/6/23 at 11:07 a.m., the MD measured Resident 44's room temperature using the infrared thermometer (a device used to measure the temperature from a distance) and it indicated 68.4 degrees Fahrenheit (F - a scale of temperature). 5. During an interview on 12/4/23 at 11:06 a.m., Resident 41 stated her room gets cold at night and the staff would provide extra blankets. During a concurrent environmental tour and interview with MD on 12/6/23 at 11:07 a.m.,the MD measured the temperature of Resident 41's room using the infrared thermometer which indicated 70.2 degrees F. 6. During a concurrent environmental tour and interview with MD, on 12/6/23 at 11:07 a.m.,the MD measured the temperature the following rooms using the infrared thermometer:: Room A = 68.4 F; Room B= 70.2 F; Hallway A = 70.7 F; Hallway B = 70.3 F; lobby = 70.9 F; and dining area = 69.6 degrees Fahrenheit. The MD was unable to state the temperature range to maintain a comfortable environment. During an interview with the Director of Nursing (DON) on 12/7/23 at 9:29 a.m., DON stated the maintenance staff monitored the temperature of the residents' rooms. The DON was not able to state the temperature range to maintain a comfortable environment. 555712 Page 6 of 30 555712 12/08/2023 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0584 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's Temperature and Homelike Environment policy, dated 3/1/23, indicated Will maintain comfortable and safe temperature levels, Common resident areas between 71 and 81 degrees Fahrenheit. Residents Affected - Some 555712 Page 7 of 30 555712 12/08/2023 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 50's clinical records indicated Resident 50 was transferred out to the hospital on [DATE] due to a low blood pressure (BP - the pressure of blood pushing against the walls of the arteries). During an interview with the SSD on [DATE] at 10:43 a.m., SSD stated she notified the State LTCO within 24 hours of resident's discharge either to home, hospital or even when the resident expired at the facility. During a concurrent interview and record review on [DATE] at 3:34 p.m., SSD reviewed Resident 50's Notice of Transfer/Discharge. The SSD stated Resident 50 was transferred to the hospital and Resident 50's daughter was notified. SSD confirmed the notice did not indicate a copy was faxed or sent to the State LTCO. During a review of the facility's policy and procedure titled, Transfer and Discharge (including AMA [against medical advice]), dated [DATE], indicated, The Social Services Director, or designee, will provide copies of notices for emergency transfers to the Ombudsman .; .the notice must be provided to the resident, resident's representative if appropriate, and LTC ombudsman . 3. During an off site preparation phone interview with the facility's State LTCO on [DATE] at 9:30 a.m., State LTCO stated they were not getting any notification about the facility's discharges from August to early weeks of November. State LTCO further stated, The facility should notify us with discharges. During an interview with SSD on [DATE] at 10:43 a.m., SSD stated all discharges should be reported to the State LTCO. SSD further stated she faxed the Transfer/Discharge Notification form with resident's name, the date of discharge and the destination to the State LTCO. During a concurrent interview and record review with SSD on [DATE] at 3:34 p.m., SSD reviewed the Notice of Transfer/Discharge forms for the month of September, October and Novermber 2023. The notification form indicated a box that should be checked when the form was faxed to the State LTCO with the date. SSD confirmed the boxes in the forms of 26 more residents were not checked and not dated. During a concurrent interview and record review with the State LTCO on [DATE] at 3:44 p.m., State LTCO reviewed the Notice of Transfer/Discharge forms for the month of September, October and [DATE]. State LTCO confirmed she did not received all the discharge notifications. Based on interview and record review, the facility failed to provide written notification to the Office of the State Long-Term Care Ombudsman (LTCO - person who routinely visits the facility and advocates for the residents in the nursing homes) for 28 out of 31 discharged residents reviewed when: 1. Resident 49 went for dialysis and was transferred to the hospital; 2. Resident 50 was transferred to the hospital; and 3. Social service director (SSD) failed to notify the State LTCO for 26 more resident discharges in a period of 3 months (September-[DATE]). 555712 Page 8 of 30 555712 12/08/2023 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0623 This failure had the potential to compromise the resident's admission, transfer, and discharge rights. Level of Harm - Minimal harm or potential for actual harm Findings: Residents Affected - Few 1. Review of Resident 49's clinical record indicated she was admitted to the facility on [DATE] with a diagnoses of hypertensive heart disease with heart failure (heart problems that occur because of high blood pressure that is present over a long time), unspecified sequelae of cerebral infarction (a result of disrupted blood flow to the brain), chronic atrial fibrillation (irregular heartbeat). The resident was discharged from the facility on [DATE]. During a concurrent interview and record review with SSD on [DATE] at 2:17 p.m., SSD stated Resident 49 was admitted on [DATE] and went for dialysis on [DATE] and was transferred to acute hospital after experiencing shortness of breath. The SSD stated the Ombudsman was notified of the discharge but does not keep a copy of the fax receipt confirmation of the Transfer/Discharge Notification form. The SSD stated, I throw them away. The SSD stated that she does not document in the progress notes when the Ombudsman was notified. During a review of the facility's Transfer and Discharge (including AMA) policy , dated [DATE], indicated The Social Services Director, or designee, will provide copies of notices for emergency transfer to the Ombudsman ; must also send a copy of the discharge notice to a representative of the Office of the State Long-Term Care Ombudsman. 555712 Page 9 of 30 555712 12/08/2023 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to encode and transmit in a timely manner the Minimum Data Set (MDS- a tool used for resident assessment) for two of 14 sampled residents (Resident 29 and 14) when: Residents Affected - Few 1. The MDS nurse (MDSN) used a wrong assessment reference date (ARD - date of the MDS assessment) for Resident 29's Skilled Nursing Facility Part A Prospective Payment System Discharge Assessment (SNF Part A PPS DC - a required assessment to determine resident's last day of skilled services and resident's current status); and 2. Resident 14's two MDS Entry Tracking's were transmitted to the Center for Medicare and Medicaid System (CMS) late. These failures resulted in wrong ARD MDS assessment submitted to CMS and Entry Tracking's not received by CMS within the time requirement. Findings: 1. Review of Resident 29's clinical record titled admission Record, indicated, Resident 29 was readmitted to the facility on [DATE] with diagnoses including ataxia (no coordination due to lose muscle control in arms and legs), lack of coordination, paroxysmal atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart), and peripheral vascular disease (a slow and progressive circulation disorder). Review of Resident 29's Notice of Medicare Non-Coverage (NOMNC - a notice that indicates the end of resident's skilled services) letter indicated, Resident 29's last covered skilled day was 10/25/2023. During a concurrent interview and record review on 12/7/2023 at 10:52 a.m., MDSN reviewed Resident 29's NOMNC letter and the MDS Part A PPS DC assessment she completed. MDSN stated she did the Part A PPS DC assessment because Resident 29 stayed in the facility. MDSN confirmed the ARD she used for Part A PPS DC assessment was 10/26/2023. During a follow up interview with the MDSN on 12/7/2023 at 11:22 a.m., MDSN confirmed she made a mistake in using the date 10/26/2023 for Resident 29's assessment. MDSN stated the ARD for Resident 29's assessment should have been 10/25/2023. Review of the Centers for Medicare and Medicaid Services' Long Term Care Facility Resident Assessment Instrument (CMS RAI - guide for facility staff to existing coding and transmission) 3.0 User's Manual, dated October 2023, indicated, .The ARD for standalone Part A PPS Discharge assessment is always equal to the End Date of the most Recent Medicare Stay . 2. Review of the facility's document titled, CMS Submission Report, MDS 3.0 NH (Nursing Home) Final Validation Report, dated 1/28/2023, it indicated a warning in Resident 14's Entry tracking dated 1/10/2023. The report indicated, Record Submitted Late: The submission date is more than 14 days . Another review of the facility's document titled, CMS Submission Report, MDS 3.0 NH Final 555712 Page 10 of 30 555712 12/08/2023 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0640 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Validation Report, dated 4/25/2023, it indicated another warning in Resident 14's Entry tracking dated 4/10/2023. The report indicated, Record Submitted Late: The submission date is more than 14 days . During a concurrent interview and record review with the MDS nurse consultant (MDSNC) on 12/7/2023 at 1:44 p.m., MDSNC reviewed Resident 14's MDS submitted in the CMS Submission Report. MDSNC confirmed Resident 14 was admitted to the facility on [DATE] and was transferred out to the hospital on 4/6/2023. MDSNC stated Resident 14 returned to the facility on 4/10/2023. MDSNC further confirmed Resident 14's two Entry trackings were submitted more than 14 days after the entry. MDSNC stated both Entry trackings should have been submitted to CMS within 14 days of entry. Review of the Centers for Medicare and Medicaid Services' Long Term Care Facility Resident Assessment Instrument (CMS RAI - guide for facility staff to existing coding and transmission) 3.0 User's Manual, dated October 2023, indicated, .Tracking Information Transmission: For Entry .tracking records, information must be transmitted within 14 days of the Event Date (Date of Entry) . 555712 Page 11 of 30 555712 12/08/2023 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure residents at risk for pressure injuries (an area of skin that breaks down when something keeps rubbing or pressing against the skin) received care, consistent with professional standards of practice to prevent pressure injuries for one of three residents (Resident 40) at risk for pressure injuries when licensed nurses did not follow Resident 40's doctor's order to prevent pressure injuries and did not update Resident 40's care plan. Residents Affected - Few These failures had the potential to result in Resident 40's development of pressure injuries. Findings: Review of Resident 40's clinical record titled, admission Record indicated Resident 40 was admitted to the facility with diagnoses including disorder of the autonomic nervous system (a dysfunction of the nerves that regulate nonvoluntary functions, such as heart rate, blood pressure, and sweating), chronic (persisting for a long time or constantly recurring) atrial fibrillation (an irregular and often very rapid heart rhythm), anxiety disorder (a mental illness that causes constant fear) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident 40's Quarterly Braden Scale (a tool developed to predict patient at risk for forming pressure injuries) dated 11/7/2023, indicated Resident 40 had a moderate risk of developing pressure injuries. Review of Resident 40's Quarterly Minimum Data Set (MDS-a tool used for resident assessment) dated 11/7/2023, it indicated Resident 40 had moderate difficulty (speaker had to increase volume and speak distinctly) in hearing and moderate impairment in cognition (process of thinking) without signs and symptoms of delirium (a serious change in mental abilities). Review of Resident 40's Order Summary Report, with order dated 2/2/2022, indicated, Elevate bilateral heels with pillow as tolerated every shift for blanchable (skin turns white when pressed) redness until resolved. Further review of Resident 40's Order Summary Report, with order dated 10/31/2023, indicated, Apply Bilat. (bilateral - both) Heel Protectors (a pair of boots used to keep off pressure to heels) Qshift (every shift) for skin protection. During a concurrent observation and interview with Resident 40 on 12/5/2023 at 10:56 a.m., Resident 40's bilateral legs were on top of a flat pillow. Resident 40's bilateral heels were observed touching the bed and not offloaded. Resident 40 was aware about the order for heel protectors. Resident 40 stated, Oh, I don't have it yet. During a concurrent interview and record review on 12/5/2023 at 11:08 a.m., licensed vocational nurse A (LVN A) reviewed Resident 40's Order Summary Report. LVN A confirmed there was an order for bilateral heel protectors since 10/31/2023. LVN A stated, Oh, I didn't check that today. I will go and check it. LVN A confirmed another order to elevate bilateral heels with pillow. During a follow up observation and interview with LVN A on 12/5/2023 at 11:10 a.m., LVN A confirmed Resident 40's bilateral heels were touching the bed. LVN A stated, this pillow should be placed behind the legs to elevate the heels. LVN A checked Resident 40's bilateral heels and confirmed Resident 40's heels had blanchable redness. LVN A looked for Resident 40's heel protectors inside the room 555712 Page 12 of 30 555712 12/08/2023 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0686 and in each of Resident 40's drawers. LVN A confirmed he couldn't find them. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview with certified nursing assistant E (CNA E) on 12/6/2023 at 1:28 p.m., Resident 40 was sitting on a wheelchair and one heel protector was on top of her bed. CNA E confirmed there was a new order of heel protector just for Resident 40's left heel. Residents Affected - Few During a concurrent interview and record review on 12/7/2023 at 1:26 p.m., director of nursing (DON) reviewed Resident 40's order summary report and list of care plans. DON confirmed about the bilateral heel protector ordered since 10/31/2023, and stated she was not aware about it. The DON further confirmed the bilateral heel protector order was discontinued on 12/5/2023. The order summary report indicated, Monitor resident's Heel Protector to left heel as prophylaxis every shift for skin protection. DON stated she was not sure why the order was changed. DON confirmed there was no care plan about the use of heel protector. DON further stated there should be a care plan about it and the nurse who received the order should have initiated or revised Resident 40's care plan. During a review of the facility's policy and procedure titled, Pressure Injury Prevention and Management, dated 3/1/2023, indicated, This facility is committed to the prevention of avoidable pressure injuries .Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk .Interventions will be documented in the care plan and communicated to all relevant staff . 555712 Page 13 of 30 555712 12/08/2023 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to ensure adequate safety monitoring for four of 14 sampled residents (Resident 16, 31, 37, and 38) when the wanderguard device was not checked for proper functioning. This failure had the potential for the alarm system to not work and increase the risk for elopement (leave a facility without staff knowledge). Findings: During an observation on 12/4/23 at 10:07 a.m., Resident 31 was dressed in street clothes and lying on top of his bed sleeping. There was a Wanderguard (a device that activates an alarm when a resident attempts to leave a safe area) on his right wrist. Review of Resident 31's physician order dated 1/2/22 indicated: Wanderguard on at all times, check placement to right wrist every shift. Review of Resident 31's quarterly Elopement Risk Assessment, dated 11/30/23, indicated a score of 8 (A score of 6 or more indicates that the resident should be considered High Risk for elopement.) During an observation on 12/4/23 at 10:40 a.m., Resident 38 was sitting on the edge of his bed dressed in street clothes. There was a Wanderguard on his left ankle. Review of Resident 38's physician order dated 3/21/23 indicated Wander guard to be worn at all times every shift. Device located on left ankle. Review of Resident 38's Wandering Risk Assessment, dated 3/4/23, indicated a score of 13 (A score of 6 or more indicates that the resident should be considered High Risk for elopement.) During an observation on 12/5/23 at 1:37 p.m., Resident 16 was sitting in his wheelchair in his room. There was a Wanderguard on his left ankle. Review of Resident 16's physician order dated 5/15/23 indicated Wander guard to be worn at all times on left ankle, every shift check placement of device. Further review of Resident 16's medication administration record (MAR) indicated licensed nurses were initialing and using a checkmark to monitor for placement of the wanderguard every shift. During an interview and concurrent record review with licensed vocational nurse A (LVN A), he confirmed Resident 16 had a Wanderguard on his left ankle. LVN A stated there is a physician order to check placement of Resident 16's Wanderguard. When asked if there was a physician order to monitor the functioning of the Wanderguard, LVN A stated there was no physician order to monitor Resident 16 Wanderguard's functionality. LVN stated the staff need to check that the Wanderguard is working, and he stated I take the residents to the front door to test and see if the alarm goes off. When asked if he documents his testing of the Wanderguard, he responded I don't write it down anywhere. During an observation on 12/5/23 at 2:09 p.m., Resident 37 was lying in his bed in the room. There was a Wanderguard on his right ankle. Review of Resident 37's clinical record indicated there was no physician order for the use of the 555712 Page 14 of 30 555712 12/08/2023 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0689 wanderguard. Level of Harm - Minimal harm or potential for actual harm During a observation and concurrent interview with the director of nursing (DON) on 12/6/23 at 2:25 p.m., she checked Resident 37 and confirmed he was wearing a Wanderguard on his left ankle. Residents Affected - Some During a follow-up record review and interview with the DON on 12/6/23 at 2:30 p.m., she confirmed that Resident 37 did not have a physician order for the use of a Wanderguard and she stated she did not know when the Wanderguard was applied to Resident 37. She stated that Resident 37 should have a physician order if he is wearing a Wanderguard. The DON was questioned about the staff's responsibility for monitoring those residents in the facility who are wearing wanderguards. The DON stated there should be a physician's order to check the placement and functionality of all Wanderguards worn by any residents in the facility. The DON reviewed the physician orders for Resident 16, 31, 37, and 38 and confirmed there were no physician orders to check the functioning of the Wanderguards for these 4 residents. The DON stated there are physician orders to check placement of the Wanderguards for Residents 16, 31, 37, and 38 but no orders to check functionality of their Wanderguards. The DON stated there should be physician orders in place so that the Wanderguards can be assessed, at least daily, for proper functioning. Review of the facility's policy titled Resident Exit Alarms/Wanderguard Policy, implemented 7/1/23, indicated .7. Monitoring and modification . When alarms are utilized, additional monitoring shall be provided, including but not limited to; . ii. Verifying alarms are working properly. 555712 Page 15 of 30 555712 12/08/2023 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

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 provide respiratory care in accordance with professional standards of practice for one of six residents (Resident 101) on respiratory treatment when: Residents Affected - Some 1. The licensed nurse failed to ensure oxygen was administered as specified in the physician's order; 2. The facility staff failed to monitor Resident 101's shortness of breath as specified in the physician's order for more than two months. These failures had the potential to compromise Resident 101's health and safety. Findings: 1. Review of Resident 101's clinical record indicated he had diagnoses including chronic respiratory failure with hypoxia (inability to keep oxygen and carbon dioxide at normal levels), congestive heart failure (heart works less efficiently and can lead to buildup of fluid in the lungs and shortness of breath), hypertensive heart disease with heart failure (type of high blood pressure that affects the blood vessels of the heart). During an observation on 12/4/23 at 10:08 a.m., Resident 101 was lying in bed receiving oxygen at 4 liters per minute (LPM, rate of oxygen administration) via a nasal cannula (flexible tubing placed into the nostrils and connected to an oxygen source). During a second observation on 12/5/23 at 8:56 a.m., Resident 101 was lying in bed receiving oxygen at 5 LPM via nasal cannula. Review of Resident 101's physician's order, dated 10/13/23, indicated he was to receive oxygen via nasal cannula at 2 liters per minute every shift for chronic hypoxemic respiratory failure. During an observation and concurrent interview with licensed vocational nurse A (LVN A) on 12/5/23 at 9:04 a.m., LVN A looked at Resident 101's oxygen concentrator (machine used to deliver oxygen) and stated it was set at 5 LPM. LVN A checked Resident 101's physician order and stated the oxygen concentrator should have been set at 2 LPM. LVN A confirmed he did not check Resident 101's concentrator to ensure the oxygen was administered at the prescribed rate. 2. Review of Resident 101's physician's order, dated 10/13/23, indicated to monitor for shortness of breath every shift for chronic hypoxemic respiratory failure. The physician's order had further monitoring details indicating: 0=none, 1=SOB (shortness of breath) with activity and/or increased number of pillows to sleep; 2= Increased SOB with activity; 3= Unrelieved SOB, SOB with rest, sits upright in chair to rest. Review of Resident 101's medication administration record (MAR) , for November and December 2023, indicated facility licensed nurses were monitoring Resident 101's SOB by documenting with a single checkmark and initial. Licensed nurses were not using the number codes identified on Resident 101's physician order to monitor for SOB. 555712 Page 16 of 30 555712 12/08/2023 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a record review and concurrent interview with the director of nursing (DON) on 12/5/23 at 10:00 a.m.,the DON reviewed the MAR for November and December 2023 and she confirmed the licensed nurses were monitoring Resident 101's SOB by indicating with a single checkmark. The DON stated the licensed nurses should follow the physician's order and characterize Resident 101's SOB using the number codes identified in the physician's order ( )= none (no SOB) and 1= SOB) rather than putting check marks The DON further stated the documentation on the MAR should indicate the presence or absence of SOB, because the single check mark does not indicate licensed nurse's assessment of Resident 101's presence or absence of SOB. Review of facility's policy Oxygen Administration, implemented 5/1/23, indicated oxygen is administered to residents who need it, consistent with professional standards of practice . 1. Oxygen is administered under orders of a physician . 3. Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy. 555712 Page 17 of 30 555712 12/08/2023 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure adequate communication with the dialysis center for one of two residents on dialysis (Resident 21), when the communication form sections which are to be filled out by the facility and dialysis center was not completed. Residents Affected - Few This failure had the potential to result in Resident 21's negative health outcome. Findings: Review of Resident 21's clinical record titled, admission Record, indicated Resident 21 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (a condition which affects the way the body processes blood sugar) due to underlying condition with foot ulcer (open sores or lesions that will not heal or that return over a long period of time), metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction) , multiple sclerosis (a disease affecting the brain and spinal cord that disrupts the communication of the brain and the rest of the body) and chronic kidney disease with heart failure (A chronic condition in which the heart doesn't pump blood as well as it should) .and stage 1 through stage 4 chronic kidney disease (advance kidney damage). Review of Resident 21's Order Summary Report, it indicated Resident 21 was getting hemodialysis (a process of purifying the blood of a person whose kidneys are not working normally) every Tuesday, Thursday, and Saturday. Review of Resident 21's licensed nurse (LN) progress note dated 11/16/2023 at 7:31 p.m., indicated, .Dialysis clinic did not complete post dialysis assessment, needs f/u (follow-up) in AM. Another review of Resident 21's LN's progress note dated 11/16/2023 at 10:53 p.m., it indicated the resident arrived from dialysis at 4:00 p.m. During a concurrent interview and record review on 12/6/2023 at 3:40 p.m., director of nursing (DON) reviewed Resident 21's hemodialysis communication form and nursing progress notes on 11/16/2023. The hemodialysis communication form was divided into three sections: 1. the top section indicated the Pre-Dialysis Information. The DON confirmed the nurses should document on this section of the form to provide information to the receiving hemodialysis staff such as resident's name, date of birth , medications administered prior to dialysis, meal/snack sent, vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions), shunt (a dialysis access surgically placed to resident's arm) location/status, any additional information, and the nurse signature; 2. The middle section of the form indicated, Dialysis Center Information. The DON confirmed this section should be filled out by the dialysis nurse. This section should indicate the pre and post dialysis weight, dialysis starts and end time, amount of fluid removed, meal/snack intake, shunt location/status, additional information like change in condition, medications administered, any laboratory (lab) drawn, lab results, any new physician order/recommendations, vital signs, and nurse signature; and 3. the bottom part of the form indicated, Post -Dialysis Information. The DON confirmed the receiving nurse should document on this section of the form. This section should indicate the date/time the resident came back from dialysis, the shunt location/status, bruit and thrill (a thrill or buzz is like a vibration caused by blood flowing through the fistula and can be felt by placing your fingers just above the incision line. present), any bleeding, general condition of resident, vital signs and nurse signature. The DON also verified both middle and bottom section of the forms were left blank on 11/16/2023. The DON 555712 Page 18 of 30 555712 12/08/2023 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few confirmed there was no communication between the receiving nurse and the dialysis nurse about the resident's pre and post hemodialysis weight and other pertinent information. The DON agreed the receiving nurse should have called the dialysis nurse to get a report and verified there was no follow up communication on 11/17/2023, between the facility nurse and dialysis nurse. During a review of the facility's policy and procedure titled, Hemodialysis Policy, dated 7/1/2023, indicated, .The facility will coordinate and collaborate with the dialysis facility to assure that: The resident's needs related to dialysis treatments are met; The provision of the dialysis treatments and care of the resident meets current standards of practice for the safe administration of the dialysis treatments; Documentation requirements are met to assure that treatments are provided as ordered by the nephrologist, attending practitioner and dialysis team .The licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form . 555712 Page 19 of 30 555712 12/08/2023 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the daily staffing information posted was the current date. This failure had the potential to result in nurse staffing misinformation to the residents, family and visitors. Residents Affected - Some Findings: During an initial facility rounds on 12/4/2023 at 10:30 a.m., the Census and Direct Care Service Hours Per Patient Day (DHPPD - contains daily staffing information) form was posted in front of the nurse station, dated 11/30/23. During another facility rounds on 12/5/2023 at 10:00 a.m., the DHPPD form was still posted with the same date, 11/30/23 ( 5 days past). During a concurrent observation and interview with director of nursing (DON) on 12/7/2023 at 1:14 p.m., DON reviewed the DHPPD posting. The DON confirmed the date in the DHPPD form was 12/6/2023. DON stated the posting was always the day before the current date. DON was informed of the date observed on 12/4 and 12/5/2023. The DON stated nobody updated the staffing information on a weekend. During a concurrent observation and interview with the administrator in training (AIT) on 12/8/2023 at 10:05 a.m., the AIT confirmed the date in the DHPPD form was 12/7/2023. During a follow up interview with the chief executive officer (CEO) and the AIT on 12/8/2023 at 10:08 a.m., the CEO agreed that the daily staffing information posted should be the current date, and he stated, this is a good learning experience for us and from now on we will start posting the staffing information indicating the current date and will include in our QAPI (quality assurance and performace improvement). During a document review from the Centers for Medicare and Medicaid Services Compliance Group, titled Posted Nurse Staffing Information, dated 4/30/2021, indicated, The required information that needs to be posted includes: Facility name, current date .The data should be clear, readable, up to date and current. 555712 Page 20 of 30 555712 12/08/2023 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to ensure controlled substance medications (those with high potential for abuse and addiction) were accurately accounted for on the Medication Administration Record (MAR) and the Controlled Drug Record (CDR) for one of three randomly selected residents (Resident 44). This failure resulted in the facility not having accurate accountability of controlled medications and potential for abuse or misuse of this medication. Findings: A review of Resident 44's clinical record indicated she had a physician's order, dated 11/8/23, for Norco (hydrocodone-acetaminophen, a controlled medication for pain) 5-325 milligrams (mg, a unit of measurement), one tablet by mouth every four hours as needed for pain. During a concurrent interview and record review on 12/7/23 at 9:29 a.m., with the Director of Nursing (DON), a review of Resident 44's CDR for Norco and the 10/2023 MAR reflected the nursing staff removed one tablet of Norco on 10/20/23 at 6 p.m., and on 10/24/23 at 9 p.m., without documenting in the MAR that they were administered. The DON stated I agree, it's not there, and she verified that a total of two tablets were signed out of the CDR but were not documented on the MAR to account for the medication taken. During a review of the facility's Medication Administration policy, dated 3/1/23, indicated Medications are administered .in accordance with professional standards of practice; sign MAR after administered. 555712 Page 21 of 30 555712 12/08/2023 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the pharmacist's medication regime review (MMR) recommendations for one of 14 sampled residents (Resident 16) were acted upon. This failure had the potential to negatively affect the residents' health and well-being. Findings: 1. Review of Resident 16's medical record indicated he was admitted on [DATE] with diagnoses including major depressive disorder (a mood disorder that causes persistent feelings of sadness or loss of interest) and vascular dementia (decline in thinking skills caused by blocked or reduced blood flow to the brain). Review of Resident 16's document titled Note To Attending Physician/Prescriber, written by the consultant pharmacist (CP) and dated 4/19/23, indicated: This resident has been taking the antidepressant Zoloft 150 mg. (milligrams, unitof measurement) for depression since 12/21, please evaluate the current dose and consider a dose reduction. Review of a physician telephone order, dated 4/26/23, indicated Resident 16's primary care physician response to the CPs note: Please have the patient take the same dose of Zoloft as it has been prescribed by his specialist (psychiatric). Please call psychiatry for a follow-up appointment since he was last seen in 2021. During a record review and concurrent interview with the director of nursing (DON) on 12/8/23 at 12:58 p.m., she confirmed Resident 16's physician had requested a follow-up appointment for a psychiatric visit for Resident 16. The DON stated she could find no evidence in Resident 16's record to indicate that resident had been seen by psychiatry per MD's telephone order on 4/26/23. The DON stated it was the social services department who would be responsible for making an appointment for Resident 16's psychiatric services. During a record review and concurrent interview with the social services director (SSD) on 12/8/23 at 2:04 p.m., she confirmed Resident 16's physician had requested a follow-up appointment for a psychiatric visit. The SSD stated she was not employed as the SSD on 4/26/23 when the telephone order was received from Resident 16's physician. The SSD could find no evidence that an appointment was made for Resident 16's to be seen by psychiatry for a follow-up visit. The SSD confirmed an appointment should have been made. Review of the facility's policy titled Pharmacy and Addressing Medication Regime Review, implemented 7/1/23 indicated, It is the policy of this facility to provide a Medication Regime Review (MMR) for each resident in order to identify irregularities and respond to those irregularities in a timely manner .The medication regime of each resident must be reviewed by a licensed pharmacist at least once a month .The attending physician will review the identified irregularities and what, if any, action has been taken to address it. 555712 Page 22 of 30 555712 12/08/2023 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

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, prepared, distributed, and served in accordance with professional standards for food safety when: Residents Affected - Many 1. There were opened and undated food items in the reach-in refrigerator; 2. There was a dented can on the food preparation table; 3. The kitchen staff were not following their policy for checking dishwasher temperature and sanitizing frequency. These failures had the potential to cause food contamination and food-borne illness to 45 of 45 residents who received their food from the kitchen. Findings: 1. During an initial kitchen tour on 12/4/23 at 8:15 a.m., accompanied by the dietary aide B (DA B), in the reach-in refrigerator there was an opened undated 46 fluid ounce container of prune juice and an opened undated 32 fluid ounce container of soy milk. DA B confirmed the 2 items were opened and not dated, and stated all items should be dated when opened. DA B stated the prune juice and the soy milk must be discarded. Review of the facility's undated policy and procedure manual titled Recommended Storage Practices, indicated . C. Refrigerated . Label all cooked and opened items with open and use by dates. 2. During a kitchen observation on 12/4/23 at 8:30 a.m., DA B was observed putting sweet potatoes from a can into a large metal pan on the preparation table. There were 3 cans on the preparation table, one of the cans was dented. When the DA B opened the dented can, she was asked if she should be using the sweet potatoes from the dented can. The DA B confirmed the can was dented and stated it was not good to use. The DA B said the dented can of sweet potatoes must be discarded. Review of the facility's undated policy and procedure manual titled Recommended Storage Practices, indicated . Leaking, dented, or rusty cans should be disposed of promptly to prevent contamination. 3. During a record review and concurrent interview on 12/6/23 at 9:30 a.m., with the dietary supervisor (DS), he was asked how frequently the kitchen staff checked the temperature and the sanitizing solution of the dishwasher. The DS stated the dishwasher was a low temperature machine and the staff checked the temperature during the wash and rinse cycles every morning. The DS also stated the chlorine sanitizer check was also done at the same time every morning. The DS produced the kitchen logs that indicated these functions were performed once every day. The policy and procedure manual was reviewed with the DS, which indicated the dishwashing temperature and sanitizer level are to be checked three times a day. The DS stated he was unaware of this requirement and stated has always directed his staff to only check it once a day in the morning. Review of the facility's undated policy and procedure manual titled Guidelines for the Food and Nutrition Service Department, indicated . C. Dishwashing Temperatures - Required Records .The temperature of the dish machines will be recorded three times a day . Temperatures will be recorded for each 555712 Page 23 of 30 555712 12/08/2023 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0812 meal's dish washing . The sanitizer will also be checked and recorded. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 555712 Page 24 of 30 555712 12/08/2023 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0836 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. Based on observation, interview and document review, the facility failed to comply with Federal and State laws, and regulations when the approval letter for staffing waiver was not posted where visitors, family and residents could easily read. This failure had the potential to result in nurse staffing misinformation about residents' care. Findings: During an observation on 12/4/2023 at 1:30 p.m., the facility's postings in a locked glass frame located at the hallway entrance included the facility's license posted but no staffing waiver letter of approval posted. During another observation of the facility's postings in a locked glass frame on 12/5/2023 at 4:05 p.m., the staffing waiver letter of approval was not posted. During a concurrent observation and interview with the facility's administrator in training (AIT) on 12/7/20023 at 2:03 p.m., the AIT reviewed all the postings in a locked glass frame located at the hallway entrance. The AIT confirmed she couldn't find the staffing waiver letter of approval. AIT stated the staffing waiver letter of approval should have been posted. During a follow up concurrent observation and interview with the AIT on 12/7/2023 at 2:17 p.m., she stated. It's my fault, it should be posted here, while pointing where the facility's license was posted. The AIT showed this nurse surveyor a copy of the staffing waiver letter of approval which was posted behind a door at the nurse station. The AIT stated, Yes, it's not supposed to be there. Sorry, it's my fault. The AIT further stated it should be posted near the facility's license. Review of one of the facility's survey documents titled, Approval of Workforce Staffing Waiver, dated 6/28/2023, indicated, Your request is approved and valid from July 1, 2023, to June 30, 2024, under the following conditions: 1. This approval letter shall be posted immediately adjacent to the facility's license . 555712 Page 25 of 30 555712 12/08/2023 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

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 implement infection control practices when: Residents Affected - Some 1. Certified nursing assistant D (CNA D) did not perform hand hygiene when assisting two residents (Residents 16 and 24) with meals; 2. Licensed vocational nurse A (LVN A) did not perform hand hygiene in between glove changes during Resident 47's wound treatment; 3. Certified nursing assistant G (CNA G) practiced double gloving (wearing of inner and outer gloves) during Resident 47's incontinent care; and 4. Resident 10's urinary drainage bag was found lying on the floor. These failures had the potential to compromise resident's health and safety in the facility. Findings: 1. During dining observation on 12/4/2023 at 12:39 p.m., inside the dining room, Resident 24 was eating lunch using her fork. CNA D held Resident 24's fork and knife to help slice the meat on her plate. After assisting Resident 24, CNA continued feeding Resident 16 using his spoon. CNA D did not perform hand hygiene after assisting Resident 24. During an interview with CNA D on 12/4/2023 at 12:45 p.m., CNA D confirmed she forgot to perform hand hygiene after helping Resident 24 in slicing the meat on her plate. CNA D stated she should have performed hand hygiene before she assisted Resident 16. During an interview with infection preventionist (IP) nurse on 12/7/2023 at 3:59 p.m., IP agreed CNA D should have performed hand hygiene in between resident's meal assistance. During a review of the facility's policy and procedure titled, Hand Hygiene, dated 7/1/2023, indicated, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, resident, and visitors. Review of the Centers for Disease Control and Prevention's (CDC) Hand Hygiene in Healthcare Settings, it indicated, Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient .after touching a patient or patient's immediate environment. 2. During wound treatment observation on 12/7/2023 at 9:05 a.m., LVN A showed both sacrum ((part of the body located in between the bilateral buttocks) and right ischial (lower part of the buttocks) wounds of Resident 47. LVN A removed his dirty pair of gloves and donned (put on) a new pair without performing hand hygiene. LVN A cleansed the sacrum wound, touched a box of gloves, and doffed (removed) his dirty gloves. LVN A donned a new pair of gloves without hand hygiene. LVN A touched the box of gloves again and moved it closer to him, then doffed his gloves and donned a new one without performing hand hygiene. LVN A applied an ointment to remove damaged tissue to sacrum wound, packed it with wet gauze, then applied a dry gauze. LVN A removed his dirty gloves and donned a new one 555712 Page 26 of 30 555712 12/08/2023 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some without hand hygiene. LVN A was about to apply wet gauze to the right ischium wound, but he touched Resident 47's overbed table and pulled towards him, took a pair of bandage scissors, and cut a piece of gauze. LVN A doffed his dirty gloves and donned a new one without hand hygiene. LVN A continued covering the right ischium wound with dry dressing. During a follow up interview with LVN A on 12/7/2023 at 9:35 a.m., LVN A confirmed he did not perform hand hygiene after doffing and before donning of gloves. During an interview with the infection preventionist (IP) nurse on 12/7/2023 at 3:53 p.m., IP nurse stated nurses should perform hand hygiene before donning a new pair of gloves and after removal of dirty gloves. During a review of the facility's policy and procedure titled, Hand Hygiene, dated 7/1/2023, indicated, .If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. 3. During a wound treatment observation on 12/7/2023 at 9:05 a.m., CNA G was present to help Resident 47 maintained a left side lying position while LVN A was performing wound treatment. Resident 47 had a small soft bowel movement while getting a wound treatment. CNA G wiped it out with the used of wet wipes and continued to hold Resident 47's right hip with same dirty gloves. At 9:31 a.m., CNA G removed the pair of dirty gloves and observed she still had a remaining pair of gloves on. LVN A instructed CNA G to remove the second pair of gloves, but CNA G refused to follow LVN A's instruction. CNA G stated. Okay, it's me. CNA G donned a new pair of gloves on top of the second layered gloves and continued cleaning Resident 47. During an interview with CNA G on 12/7/2023 at 9:50 a.m., CNA G confirmed she wore double gloves. CNA G stated she preferred to wear double gloves and she further stated, I feel protected. CNA G confirmed she refused to follow the CDC guidelines in hand hygiene and proper use of gloves. CNA G stated she would always wear double gloves. During an interview with the IP on 12/7/2023 at 3:53 p.m., the IP nurse stated used of double gloves was not allowed in the facility. During a review of the facility's policy and procedure titled, Hand Hygiene, dated 7/1/2023, indicated, The use of gloves does not replace hand hygiene. 4. Review of Resident 10's clinical record indicated, he was admitted to the facility on [DATE] with clinical diagnosis of neuromuscular dysfunction of bladder (a condition wherein a person lacks bladder control due to brain, spinal cord, or nerve condition). Resident 10 had a physician order, dated 9/27/23, for a Foley catheter (a sterile tube inserted into the bladder to drain urine). During a concurrent observation and interview on 12/7/23 at 11:09 a.m., Licensed Vocational Nurse(LVN) I confirmed that the urinary drainage bag was found on the floor. LVN I stated the urinary drainage bag should be off the floor. During an interview on 12/7/23 at 3:53 p.m. with IP nurse, the IP nurse stated the urinary drainage bag should always be off the floor. During a review of the facility's policy and procedure titled, Catheter Care, dated 3/1/23, 555712 Page 27 of 30 555712 12/08/2023 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0880 Level of Harm - Minimal harm or potential for actual harm indicated, It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care . ; Ensure drainage bag is located below the level of the bladder to discourage backflow of urine. Residents Affected - Some 555712 Page 28 of 30 555712 12/08/2023 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure multiple rooms had at least 80 square feet per resident. Having less than 80 square feet per resident had the potential to compromise the care and services the residents receive. Findings: During the initial pool observation on 12/4/2023 at 9:16 a.m., the following was observed: Room Beds Sq.ft./Room Sq.Ft./Resident 1 3 224.28 74.76 2 3 194.67 64.89 3 3 194.67 64.89 6 3 194.67 64.89 7 3 194.67 64.89 12 3 189.03 63.01 14 2 140.52 70.26 15 2 146.46 73.23 During an interview with the administrator in training (AIT) on 12/7/2023 at 2:17 p.m., the AIT confirmed rooms [ROOM NUMBERS] were additional room waiver request. The AIT stated these additional rooms are not going to change their total licensed beds. The AIT further stated the additional rooms would allow them to accommodate resident's needs. During multiple observations and staff and resident interview during survey, there were no care issues identified regarding the size of the rooms. Recommended continuance of room waiver and approval of the two additional rooms. 555712 Page 29 of 30 555712 12/08/2023 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0924 Put firmly secured handrails on each side of hallways. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to ensure that part of a handrail in the hallway was firmly affixed and secured to the wall. This failure had the potential to cause injuries to residents, staff, and visitors. Residents Affected - Few Findings: During a concurrent observation and interview on 12/6/23 at 9:23 a.m., with Certified Nursing Assistant (CNA) F and CNA G, CNA F confirmed that the handrail in the hallway going to the dining area was loose and wiggly. CNA F stated the residents used the handrail to grab on for support. CNA G stated, it's loose and it should be fixed. During a concurrent observation and interview on 12/7/23 at 9:17 a.m., with the Maintenance Director (MD), the MD confirmed that the handrail was loose and stated it was missing a screw. MD stated he was not aware of the issue. During a concurrent observation and interview on 12/7/23 at 9:29 a.m., with the Director of Nursing (DON), DON confirmed that the handrail was loose. During a review of the facility's Handrails policy, dated 3/1/23, indicated The facility will equip corridors with a handrail on each side of the hall; All handrails will be firmly secured; Secured handrail means handrails that are firmly affixed to the wall; Handrails that are loose or incorrect in any way can be reported by visitors, residents, staff, etc. to any staff member; Staff members will report all handrail issues to the maintenance department. 555712 Page 30 of 30