Health inspection·March 10, 2023

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure they had developed a baseline care plan for one out of seven sampled residents (Resident 240) within the first 48 hours of admission which should have provided instructions for the provision of effective and person-centered care for Resident 240. This failure could adversely affect the resident's health and safety. Findings: A review of Resident 240's face sheet (demographics) indicated Resident 240 was [AGE] years old, admitted to the facility on [DATE]. Her diagnoses included Esophageal Obstruction (a deformity in which the esophagus, a hollow, muscular tube that passes food and liquid from your throat to your stomach, was partially or completely blocked), Cachexia (Loss of body weight and muscle mass, and weakness that may occur in patients with chronic diseases) and Hypertension (high or raised blood pressure, a condition in which the blood vessels have persistently raised pressure). Resident 240 received her nutrition via a Percutaneous Endoscopic Gastrostomy tube (PEG, a tube inserted through the wall of the abdomen directly into the stomach. It allows air and fluid to leave the stomach and can be used to give drugs and liquids, including liquid food, to the patient). Her Minimum Data Sheet assessment (MDS, a standardized assessment tool that measures health status in nursing home residents) dated 3/10/23, Brief Interview of Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long term care facility) had a score of 14 which indicated intact cognition. Her MDS also indicated she needed extensive assistance of 1 to 2 staff when performing her Activities of Daily Living tasks (ADL's, activities related to personal care such as bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). During a care plan record review on 3/8/23 at 9:32 a.m., Resident 240 did not have a baseline care plan (a document created to promote continuity of care and communication among nursing home staff, increase resident safety, safeguard against adverse events that are most likely to occur right after admission) initiated within 48 hours. It was also noted there was no baseline care plan for PEG tube feeding and care created within 48 hours of her admission to the facility on 3/3/23. During a concurrent interview and care plan record review on 3/8/23 at 9:50 a.m., the Minimum data Set (MDS) coordinator, verified Resident 240 did not have a baseline care plan created for Resident 240 within 48 hours of admission. During an interview on 3/8/23 at 9:53 a.m., the Director of Nursing (DON) verified Resident 240 did not have a baseline care plan for PEG tube. The DON stated Resident 240 should have had a baseline Page 1 of 28 555727 555727 03/10/2023 Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533

F 0655 care plan for PEG tube within 48 hours of admission Level of Harm - Minimal harm or potential for actual harm During an interview on 3/8/23 at 10:06 a.m., the MDS coordinator stated if the baseline care plan was not done, the resident would not have any input on his/her care and staff would not know what person-centered care approach to provide for the resident. Residents Affected - Few During an interview on 3/8/23 at 10:08 a.m., the DON verified there was no baseline care plan created for Resident 240 within 48 hours of her admission to the facility. The DON stated the facility expected the staff to complete this baseline care plan within 24 to 48 hours of admission. During a concurrent interview and care plan record review on 3/8/23 at 4:03 p.m., the MDS coordinator stated she added the PEG tube care plan after we discussed the missing PEG tube care plan this morning. The MDS coordinator stated care plan was important because it directs resident care. The MDS coordinator verified the baseline care plan was not completed within 48 hours of admission and was just completed today. The MDS coordinator stated that the baseline care plan was important because it directed staff how to achieve resident goals and how to care for residents based on their needs. The MDS coordinator stated if the baseline CP was not done timely it could lead to unmet resident needs and expectations. The MDS coordinator stated this could lead to improper care. During an interview on 3/10/23 at 10:53 a.m., the Director of Staff Development stated she was not aware of what were the completion time frames for the baseline care plan. During a review of facility's policy and procedure (P&P) titled Care Plans- Baseline, revised 3/2022, the P&P indicated a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission. 555727 Page 2 of 28 555727 03/10/2023 Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that three of 12 sampled residents (Residents 23, 25, 141) had interdisciplinary (interventions from all departments) and comprehensive person-centered care plans that addressed their preferences (choices), goals (measurable expected outcomes) and interventions (care and services necessary to achieve those goals) when: 1) Resident 23 was on a Regular diet (one that does not include any dietary restrictions). A care plan for food preferences of broth, cheese & crackers, and pineapple to treat weight loss recommended by Registered Dietician (RD) was not developed, implemented and no interventions. 2) Resident 23 was taking Remeron (antidepressant) for depression (A mental health disorder characterized by persistently low mood or loss of interest in activities). A care plan was not developed which included the specific medications being used, the specific target behaviors for each medication, the expected goals to be achieved from using each medication, potential unwanted adverse side effects or specific target interventions that included approaches from all disciplines and described the care and services necessary, including non-pharmacological (non-medication) interventions for Resident 23 to achieve her goals. 3) Resident 25 was taking Trazadone (antidepressant) for depression. A care plan was not developed which included the specific medications being used, the specific target behaviors for each medication, the expected goals to be achieved from using each medication, potential unwanted adverse side effects or specific target interventions that included approaches from all disciplines and described the care and services necessary, including non-pharmacological (non-medication) intervention for Resident 25 to achieve her goals. 4) Resident 141 had a doctor's order for continuous oxygen. A care plan for Oxygen administration was not developed and no specific goals and amount of oxygen to deliver (how much oxygen to give) to achieve and nursing and other IDT intervention for respiratory care. These failures had the potential to result in worsening symptoms for these residents to have not receive the care they needed to treat their medical and mental conditions. Findings: (1) Resident 23 Regular Diet A record review titled Detailed Summary dated 11/14/22 for Resident 23, revealed she was admitted on [DATE] with diagnosis of Sepsis (Severe Infection) due to bacterial infection and on Palliative 555727 Page 3 of 28 555727 03/10/2023 Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533

F 0656 Level of Harm - Minimal harm or potential for actual harm (specialized medical care for people living with a serious illness) Care. A Depression illness was not listed as her diagnosis. A record review titled Physician's Orders dated 11/14/22, the Primary Medical Doctor (PMD) ordered Regular diet for Resident 23. Residents Affected - Some During a concurrent observation and record review on 3/6/23 at 12:15 p.m., in the Resident 23's room, Unlicensed Staff T brought in Resident 23's lunch tray and placed it on top of a bedside table. Resident 23 was laying in her bed, and responded to questions with the sound of a moan, then closed her eyes. This Surveyor checked the contents of the lunch tray and compared with the corresponding meal ticket. Resident 23 had a regular diet with turkey loaf on the lunch tray. The meal ticket revealed no food preference of broth, cheese & crackers and pineapple listed. Unlicensed Staff T assisted Resident 23 with her meal but Resident 23 did not eat. Unlicensed Staff T did not offer an alternate meal or the recommended food preferences. A review of record titled IDT (Interdisciplinary Team) Notes, under RD (Registered Dietitian), dated 2/23/23, revealed Regular diet, prefers broth, cheese and crackers, pineapple, dislikes Ensure/health shakes. A review of Resident 23's Care Plan dated 1/13/23 revealed, under Nutrition, [Resident 23] has a potential risk for altered nutritional status and/or weight loss. Under Approach Offer house supplement per recommendation. The care plan did not reflect, under approach or interventions, the preferences recommended by the RD. (2) Resident 23 Remeron A Review of Physician's Orders for Resident 23 dated 11/18/22 revealed start date 11/20/22, to give Remeron 7.5 mg (milligrams) tablet once daily at nighttime for depression. A Review of Resident 23's Medication Administration Record (MAR) dated 1/23, 2/23, 3/23, revealed under Behavior Monitoring, Monitor for statements of 'I would better off dead.' All shifts for 1/23, 2/23, 3/23 documented 0, which indicated zero episodes of statements, I would be better off dead. During an interview on 03/10/23 at 2:38 p.m., Licensed Staff U stated nurses usually write observed behaviors in the Behavior Monitoring portion of the electronic chart in the MAR. A review of Resident 23's Care Plan revealed, no Depression diagnosis. Under Problems, there was no behavioral monitoring pertaining to depression noted, no medication Remeron was noted or monitoring for any side effect from taking Remeron. (3) Resident 25 Trazadone A record review titled Detailed Summary dated 1/14/23 for Resident 25, revealed she was admitted on [DATE] with diagnosis of Diabetes (increase sugar in the blood) with kidney disease, a heart condition which required a pacemaker (a small device that's placed implanted in the chest to help control the heartbeat), and hemiplegia (one sided weakness of the body). Depression was not listed as her diagnosis. A record review titled Physician's Orders dated 1/20/23 revealed, give Trazadone 50 mg tablet by 555727 Page 4 of 28 555727 03/10/2023 Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533

F 0656 mouth at bedtime for depression. Level of Harm - Minimal harm or potential for actual harm A record review titled Care Plan for Resident 25 revealed, under Problems, Depression diagnosis was not noted. The intention for the use of Trazadone medication was not noted nor the monitoring of Resident 25's behavior, side effects of Trazadone or goals for treatment. Residents Affected - Some (4) Resident 141 Oxygen A record review titled Detailed Summary for Resident 141 revealed she was admitted on [DATE] with diagnosis of heart disease with heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), pleural effusion (A buildup of fluid between the tissues that line the lungs and the chest), chronic respiratory failure, with hypoxia (oxygen deficiency) and hypercapnia (abnormally elevated carbon dioxide (CO2) levels in the blood.) Respiratory failure results from acute (severe or intense degree) or chronic (long term) impairment of gas (air) exchange between the lungs and the blood causing hypoxia, low oxygen in the blood with or without hypercapnia - the failure of the lung to properly remove carbon dioxide (CO2). During an observation on 03/07/23 at 10:13 a.m., Resident 141 received oxygen via nasal cannula (nc - a plastic tube attached to nose) which delivered 3 Liters of oxygen (amount of oxygen). A record review titled Physician's Orders dated 2/22/23 revealed, Oxygen via Nasal Cannula Continuous for Pleural Effusions. A record review titled Care Plan start date 2/22/2023 revealed, [Resident 141] at risk or falls related to Pleural effusion, Hypertensive Heart Disease with Heart Failure Goal: Minimize risk or falls and injuries. Under Approach: there was no oxygen amount (liters) of oxygen to deliver in the Care Plan, Goals for Oxygen therapy, or any Monitoring for adverse reactions. A record review titled Care Plan start date 3/9/2023, revealed [Resident 141] requires continuous oxygen related to pleural effusions, Goal date 6/7/23 [Resident 141] will be able to taper off supplemental oxygen need through next review. Under Approach: Administer oxygen as ordered start date 3/9/23. This care plan did not discuss the amount of oxygen to deliver. During an interview on 3/9/23 at 2:59 p.m. DON stated Resident 141's [lung] Problem must be in the Care Plan. DON stated oxygen administration must be in Care Plan such as the amount of oxygen to deliver to a resident. DON stated, if there was no indication of the amount of oxygen to deliver, a resident may suffer from severe respiratory distress if there was too much or too little oxygen administered. A review of Facility's Policy & Procedure titled Care plans, Comprehensive Person-Centered revised on 3/2022 revealed, A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Under interpretation and implementation, #2, The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status) and no more than 21 days after admissions. #4 (f, g) Participate in determining the type, amount, frequency, and duration of care. Receive the services and/or items included in the plan of care. 555727 Page 5 of 28 555727 03/10/2023 Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on observation, interview, and record review, the facility failed to ensure six Licensed Staff, which included one Physical Therapist had the appropriate skills and competencies (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles) in providing care included but not limited to assessing, evaluating, planning, and implementing resident care plans and responding to resident's needs when: 1) A care plan was not developed and implemented for Resident 23, 25, 141 for special diet recommended by Registered Dietician (RD) and medications Remeron & Trazadone and oxygen administration. 2) A Licensed nurse did not clarify order with the Medical Doctor (MD) for medications called Remeron and Trazadone for Depression. Residents 23 & 25 did not have a Depression diagnosis documented. 3) A Doctor's order for oxygen was not clarified before administering Oxygen. The MD ordered continuous Oxygen, however, it did not have the amount of Oxygen to administer (for example, the number of liters of Oxygen). 4) A Physical Therapist (PT) performed oxygen titration (to keep within the target oxygen saturation-oxygen in blood - range) without a Doctor's order. 5) Licensed Nurses did not routinely sign the temperature refrigerator logbook to indicate that the refrigerator's temperature was checked, to note the actual temperature of the refrigerator, the date and time noted, sign the Treatment Administrator Record (TAR) to indicate the oxygen tubes were changed. 6) The Licensed Nurses did not fill out the Refrigerator Temperature Log dated 3/23. This failure had the potential to result in worsening respiratory symptoms for Resident 141, illness related to depression medication and side effects for Resident 23 & 25, and all refrigerated medication's potency (the concentration or amount of the drug required to produce a defined effect) due to refrigerator temperature log was not monitored. All these failures may lead to severe illnesses and may lead to death. Findings: 555727 Page 6 of 28 555727 03/10/2023 Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533

F 0726 (1) Level of Harm - Minimal harm or potential for actual harm A record review titled Care Plan for Resident 23, 25, & 141 revealed, Registered Dietician (RD) special dietary recommendations dated 2/23/23, were not developed and implemented. Medications Remeron, Trazadone and oxygen administration were not developed and implemented. Residents Affected - Some During an interview on 03/08/23 at 10:49 a.m. the Dietary Manager (DM) stated, RD came to the facility once a week, either Thursday or Friday for any dietary recommendations. DM stated when RD made recommendations, it would be given to a Licensed Nurse or nurse supervisor and DM received recommendations written in the summary (intra-department report), then Licensed Nurses sent recommendations to the MD. Once an MD's order was received, Licensed Nurses would add the new order to the Physician's Orders list, then DM received the communication slip from nursing department of the new dietary ordered by the MD and then the DM would update the diet order and the meal tickets. A record review titled Physician's Orders dated 11/14/22 revealed, the MD ordered, Regular diet for Resident 23. The Physician's Order list dated 3/8/23 did not have any added special diet recommendations from the RD. During an interview on 03/09/23 at 2:59 p.m. Director of Nursing (DON) stated oxygen administration must be in [Resident 141's] Care Plan such as the amount of oxygen to deliver to a resident. DON stated, if no indication of the amount of oxygen to deliver is ordered then the resident may suffer from severe respiratory distress if there's too much or too little oxygen administered. (2) During a concurrent interview and record review on 3/10/23, The Physician's Orders revealed, Remeron was ordered for Resident 23 and Trazadone for Resident 25 for depression. The Detailed Summary (a facility demographic of resident information) dated 10/28/22 for Residents 23, and Detailed Summary dated 1/14/23 for Resident 25, did not have a diagnosis of depression listed. DON stated a Licensed Nurse needed to clarify an order for Remeron and Trazodone. (3) During a concurrent observation and interview on 3/9/2023 at 11:25 a.m., Resident 141 was on continuous oxygen at 1 liter (unit of measurement) via Nasal Cannula (NC - a clear plastic tube connected to oxygen and placed in nostrils). Licensed Staff A was asked, how she knew the amount of oxygen to deliver/administer to Resident 141 if the MD did not specify. Licensed Staff A stated 2 liters was the standard. When asked, what needed to be done when the doctor's order was not clear, Licensed Staff A stated that a Licensed Nurse needed to call the MD to clarify the order. A record review titled Physician's Orders dated 2/22/23, revealed oxygen via Nasal Cannula (NC) continuous for Pleural Effusions (A buildup of fluid between the tissues that line the lungs and the chest). The Physician's order did not state the amount (liters) of oxygen to deliver. During a concurrent interview and record review on 03/09/23 at 2:59 p.m. DON stated, the doctor's order was not clear because it did not provide the amount of oxygen to deliver. DON stated a Licensed nurse should have called the doctor to clarify the oxygen order. DON stated when a nurse administered oxygen without a doctor's order it was like administering medication without a doctor's order. DON stated, without an order of the amount of oxygen, Resident 141 may receive too much or too little 555727 Page 7 of 28 555727 03/10/2023 Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533

F 0726 oxygen. DON stated Resident 141 may develop respiratory distress. Level of Harm - Minimal harm or potential for actual harm (4) Residents Affected - Some During a concurrent interview and record review on 3/9/2023 at 11:25 a.m., Licensed Staff A stated, PTA V (Physical Therapist Assistant) titrated the amount of oxygen for Resident 141 to keep within a targeted oxygen saturation (a measurement of oxygenated blood). Licensed Staff A stated, Resident 141's oxygen saturation (the amount of oxygenated blood) was 94%. Normal range of oxygen is typically 94% - 100%. During a concurrent interview and record review on 3/10/23 at 10:30 a.m., the Director of Rehabilitation (DR PTA) stated the process of titration depends on the doctor's orders. DR PTA stated usually it was to keep the oxygen saturation above 90%. When asked to review the Physician's Order's (for Resident 141) for titration of oxygen, DR PTA stated there was no doctor's order for oxygen titration. During a telephone interview on 3/10/23 at 12:15 p.m., PTA V, stated that she performed oxygen titration for Resident 141. PTA V stated, she did not verify the Physician's Order for titrating the oxygen for Resident 141. PTA V stated that it was their practice to verify orders before performing any evaluation. When asked what a possible outcome could be performing procedures without a doctor's order, PTA V stated, Resident 141's oxygen saturation may go below normal value and may have developed respiratory distress. (5) During a concurrent observation and record review on 3/7/2023, in Resident 141's room, the NC (nasal cannula) had a sticker dated 3/7/2023 to indicate the oxygen tubing was changed. Treatment administration record (TAR) revealed, no Licensed Nurse initialed to indicate the oxygen tubing was changed. (6) A record review titled Refrigeration Temperature Log dated 3/23, revealed Licensed Nurses did not complete the necessary information such as date and time of [medication] refrigerator temperature logs by initialing on dates of 3/2/23, 3/3/23, 3/4/23 and 3/5/23 in the morning and in the evening. The Facility did not provide a Policy & Procedure for Competency of Licensed Nurses. A review of the regulations §483.70(e), the facilities are required to address the staff competencies that are necessary to provide the level and types of care needed for the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population. 555727 Page 8 of 28 555727 03/10/2023 Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533

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 implement pharmaceutical policies and procedures when Expired E-Kits (Emergency-Kit, storage box containing emergency supplies of medication) medications were not removed and replaced according to facility policy, with the potential for administration of expired and ineffective emergency medications or having medication errors. Findings: During a concurrent observation of medication room's refrigerator (station 2) and interview with Licensed Staff Q (LS Q) on 3/6/23 at 10:45 a.m., three medication E-Kits were found in the refrigerator which expired on 7/31/21, 7/31/21, and 1/4/23. LS Q confirmed all E-kits in the refrigerator were expired and needed to be replaced by the pharmacy. During an interview with the Director of Nursing (DON) on 3/9/23 at 9:05 a.m., the DON acknowledged that expired E-Kits should have been removed by the staff. The DON further stated that E-kits were also discontinued. The DON confirmed that having discontinued and expired medications available to staff could increase the risk of medication error or administering expired and ineffective medications to residents. A review of the facility policy Emergency Pharmacy Service and Emergency Kits, revised 12/17, indicated The kits are monitored/inventoried by the [consultant pharmacist/provider pharmacy] at least [every thirty (30) days] for completeness and expiration dating of the contents. A review of the facility policy Storage of Medications, revised 5/19, indicated Outdated, contaminated or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal. 555727 Page 9 of 28 555727 03/10/2023 Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533

F 0756 Level of Harm - Minimal harm or potential for actual harm 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 interviews, and records review, the facility failed to: Residents Affected - Few 1. act on the facility's Consultant Pharmacist's (CP) recommendation for one of three residents (Resident 15) when the physician, the Director of Nursing (DON), and new CP did not follow-through the recommendation to gradually reduce the dose of escitalopram (medication for depression - a mood disorder that causes a persistent feeling of sadness and loss of interest affecting how you feel, think and behave and can lead to a variety of emotional and physical problems) with the addition of buspirone (medication for anxiety - a mental disorder in which a person is often worried or anxious about many things and finds it hard to control this anxiety). This failure had the potential to increase the risk of a rare but serious condition characterized by confusion, hallucination (hearing, seeing, feeling, smelling, or even tasting things that seem real, but they're not), seizure, extreme changes in blood pressure, increased heart rate, fever, excessive sweating, shivering or shaking, blurred vision, muscle spasm or stiffness, tremor (a neurological disorder that causes shaking movements in one or more parts of the body, most often in your hands caused by unintentional (involuntary) muscle contractions), incoordination, stomach cramp, nausea, vomiting, and diarrhea. Severe cases may result in coma and even death. 2. ensure two of three residents (Resident 23 and Resident 25) were free of unnecessary medication when the facility pharmacy consultant did not identify the indication for use of Remeron (or Mirtazapine, a medication used to treat depression) for Resident 23, and Trazodone (medication used to treat depression and anxiety) for Resident 25. These failures had the potential to result in confusion or unusual drowsiness and age-related liver, kidney, or heart problems, for Resident 23. Unintended intake of trazodone may result in adverse health consequences such as somnolence/sedation, dizziness, constipation, and blurred vision increasing the risk for falls for Resident 25. Findings: 1. During a review of records, Resident 15's electronic medical information indicated, she was admitted to the facility on [DATE]. Resident 15's quarterly Minimum Data Set (MDS - a federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems) dated 12/29/22, indicated, she was reported feeling down, depressed, hopeless, feeling bad about herself, and thought of better off dead almost every day. Active diagnosis included non-Alzheimer's dementia (medical condition caused by progressive damage to the cells of the front and temporal part of the brain manifested by progressive deficits in behavior, executive function, or language), anxiety disorder, major depressive disorder, and insomnia. Residents 15's medications included an antianxiety, and antidepressant. A review of the Physician Orders indicated Resident 15 was receiving escitalopram 20 mg (milligram - unit of measure) once daily for depression since 7/31/21. Further review of the facility's pharmacy consultant's Medication Regimen Review (MRR) dated 6/1/22, and the Interdisciplinary Team notes (IDT) dated 6/9/22, indicated the physician ordered to decrease the dose of escitalopram per the CP's recommendation, but Resident 15's designated DPOA (or durable medical POA - also called a healthcare POA - someone given the authority to make decisions about your medical care if you become incapacitated. These decisions could be about treatment options, medication, surgery, end-of-life care, and 555727 Page 10 of 28 555727 03/10/2023 Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533

F 0756 more) and IDT agreed during discussion to keep the current dose. Level of Harm - Minimal harm or potential for actual harm In an electronic correspondence dated 3/9/23 at 9:07 PM, the CP confirmed Resident 15's DPOA preferred to keep her on escitalopram 20 mg in June 2022, after a gradual dose reduction (GDR) was requested. Residents Affected - Few On continued review of records, an IDT notes dated 1/31/23 indicated a discussion between facility CP and nurse supervisor of Resident 15's increased aggressiveness and angry outburst. The Plan of Care was to add buspirone (anti-anxiety) 7.5 mg twice daily while gradually decreasing the dose of escitalopram. A review of a fax message received by the facility on 2/1/23 indicated the response of Resident 15's physician to the request to add buspirone to Resident 1's medication while gradually decreasing escitalopram was, okay to add buspirone 15mg, 1/2-tablet twice a day, check urine analysis and culture and sensitivity, then will consider the lexapro dose. During an interview on 3/09/23, at 3 P.M., the DON when asked how the facility pharmacy consultant's MRR was processed by the facility, the DON stated Nursing conducted reviews of behavior for psychotropic medication (any drug capable of affecting the mind, emotions, and behavior) at least quarterly but did it every month with the same CP who did the monthly MRR. Nursing follows-through with the recommendations if any, by communicating the recommendations with the physician and obtaining an order or a response to the recommendation. When asked what action was taken on the recommendation dated 1/31/23 to start buspirone and gradually reduce escitalopram, the DON stated buspirone was started. When asked what action was taken to gradually reduce the dose of escitalopram, the DON stated she did not see documentation of any action. During a concurrent review of records and interview on 3/10/23, at 2:27 PM, the DON showed the IDT notes dated 2/4/23 indicating Resident 1 did not have a urinary tract infection. When asked what action was taken on the Pharmacist's recommendation to gradually reduce escitalopram, the DON stated there was none. The DON acknowledged nursing should have followed through with the recommendation. A review of the facility policy titled, Medication Regimen Review, revised 8/17, indicated CP's recommendations are acted upon and documented by the facility staff and/or the prescriber. The prescriber accepts and acts upon the suggestion or rejects and provides an explanation for disagreeing. If there is a potential for serious harm to the resident, this process must be completed in a manner to ensure no actual harm occurs. 2. A record review titled Detailed Summary (a facility demographic) dated 11/14/22 for Resident 23 revealed she was admitted on [DATE] with diagnosis of Sepsis (Severe Infection) due to bacterial infection and on Palliative (specialized medical care for people living with a serious illness) care. Depression was not listed as one of her diagnoses. A record review titled Physician's Orders for Resident 23 dated 11/18/22 revealed start date 11/20/22, to give Remeron 7.5 mg tablet once daily at nighttime for Depression. A review of MRR (Medication Regimen Review a comprehensive review of each resident's medication regimen) dated 1/31/23 revealed, Remeron (Mirtazapine) for depression. Under Plan of Correction (POC) No changes at this time. A record review titled Detailed Summary for Resident 25 revealed she was admitted on [DATE] with diagnosis of Diabetes (increase sugar in the blood) with kidney disease, a heart condition which 555727 Page 11 of 28 555727 03/10/2023 Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few required heart pacemaker (a small device that's placed (implanted) in the chest to help control the heartbeat), and Hemiplegia (one sided weakness of the body). Depression illness was not listed as one of her diagnoses. A record review titled Physician's Orders dated 1/20/23 revealed, give Trazadone 50 mg tablet by mouth at bedtime for Depression. During a concurrent telephone interview and record review on 3/9/23 at 3:26 p.m., the CP stated that he conduct's monthly MRR in the facility. When asked CP if there's a diagnosis of depression for Resident 23 & 25, CP stated he reviewed he medical records for Resident 23 & 25 and found no diagnosis for Depression. CP stated, when he conducts monthly MRR he normally doesn't review and compare the diagnosis according to medical records. A review of MRR dated 1/24/23 revealed, Current Orders for Resident 25 Trazodone 50 for depression. Under Recommendation: Monitor target behavior and side effects for the medications for Trazodone. A review of the facility's policy titled Medication regimen review revised 8/17, indicated consultant pharmacist's recommendations are acted upon and documented by the facility staff and/or the prescriber. The prescriber accepts and acts upon the suggestion or rejects and provides an explanation for disagreeing. If there is a potential for serious harm to the resident, this process must be completed in a manner to ensure no actual harm occurs. 2. A review of facility document titled, Provider pharmacy requirements revised 8/14, indicated the provider pharmacy screens each new medication order for an appropriate indication or diagnosis. If the diagnosis or indication is not available, notify the nursing staff of the need to obtain the information from the prescriber prior to administration of the drug. A review of the facility document titled Medication regimen review revised 8/14 indicated the consultant pharmacist identifies irregularities by reviewing and evaluating a written diagnosis, indication, or documented objective findings to support each medication order. A review of the Facility's Policy & Procedure titled Medication and Treatment Orders revised 7/2016 revealed, Orders for medications and treatments will be consistent with principles of safe and effective order writing #9 (e) revealed, Orders for medications must include. (e) Clinical condition or symptoms for which the medication is prescribed. 555727 Page 12 of 28 555727 03/10/2023 Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533

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 failed to ensure the medication error rate did not exceed 5% (percent) for three sampled residents (Resident 142, Resident 190, and Resident 8) when: Residents Affected - Few 1. For Resident 142, a licensed staff did not administer Resident's oxybutin (a medication for overactive bladder), as ordered by the physician. 2. For Resident 190, a licensed staff did not administer Resident's fish oil (a medication for heart health), as ordered by the physician. 3a. For Resident 8, a licensed staff did not administer Resident 8's fish oil as ordered by the physician. 3b. For Resident 3, a licensed staff did not administer Resident 8's glucosamine (a medication for joint health) as ordered by the physician. These failures resulted in four errors identified out of 34 opportunities during the observation of medication administration; the facility medication error rate was 11.76 %. Findings: 1. During an observation of medication administration on 3/6/23 at 10:45 a.m., Licensed Staff Q (LS Q) prepared and administered Resident 142's medications which did not include oxybutin. During an interview on 3/6/23 at 10:55 a.m. with LS Q, LS Q stated that a dose of oxybutin could not be given to Resident 142 since the facility was still waiting to receive Resident 142's oxybutin. LS Q stated that two other doses were missed on Saturday (3/4/23) and Sunday (3/5/23) making the Monday dose (3/6/23) the third missed dose. LS Q also stated that this could negatively affect the resident's quality of care. Reconciliation of the observation of medication administration with Resident 142's current Physician Orders indicated an order for oxybutin . ER [Extended Release] 5 mg [milligram, unit of measure] .by mouth once daily for overactive bladder ordered on 3/2/23 with the start date of 3/4/23. A review of Resident 142's March 2023 Medication Administration Record (MAR) for oxybutin indicated three doses were not given on 3/4/23, 3/5/23, and 3/6/23. During an interview on 3/9/23 at 9:30 a.m. with the Director of Nursing (DON), the DON acknowledged that the prescribed oxybutin medication needed to be given to Resident 142 on time as ordered by the physician. A review of facility policy titled, Medication Administration - General Guidelines, revised 12/17, indicated Medications are administered as prescribed .If a medication with a current active order cannot be located in the medication cart/drawer .the pharmacy is contacted or the medication removed from the night box/emergency kit .Medications are administered in accordance with written orders of prescriber. 555727 Page 13 of 28 555727 03/10/2023 Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. During an observation of medication administration on 3/7/23 at 8:55 a.m., LS Q prepared and administered Resident 190's medications which included one capsule of fish oil, 500 mg, for Resident 190's fish oil order. Reconciliation of the observation of medication administration with Resident 190's current Physician Orders indicated an order dated 3/4/23 for Fish Oil 1,000 mg 1 CAP [capsule] by mouth once daily. During an interview on 3/7/23 at 12:05 p.m., LS Q stated only one 500 mg capsule of fish oil was given to Resident 192. During an interview on 3/9/23 at 9:30 a.m. with the DON, the DON acknowledged that the prescribed fish oil dose was not given to Resident 192. A review of facility policy titled, Medication Administration - General Guidelines, revised 12/17, indicated Medications are administered in accordance with written orders of prescriber .The medication administration record (MAR) should contain supplemental information to help assure accurate dosing. Examples of supplemental information that can be added without requiring a prescriber's order include numbers of tablets or capsules required for the dose (1/2 tablet, 2 capsules, 4 tablets, etc.) . 3a. During an observation of medication administration on 3/7/23 at 12:13 p.m., LS S prepared and administered Resident 8's medications which included one capsule of fish oil, 700 mg, for Resident 8's fish oil order. Reconciliation of the observation of medication administration with Resident 8's current Physician Orders indicated an order dated 1/5/23 for Fish Oil 1400 mg 1 softgel [a type of capsule] by mouth once daily for supplement. During an interview on 3/7/23 at 2:45 p.m., LS S stated only one 700 mg capsule of fish oil was given to Resident 8. LS S also stated that per medication bottle, the serving size to give 1400 mg of fish oil was 2 softgels; therefore, only 700 mg of fish oil was administered during the afternoon medication pass. 3b. During an observation of medication administration on 3/7/23 at 12:13 p.m., LS S prepared and administered Resident 8's medications which included one capsule of glucosamine 800 mg, for Resident 8's glucosamine order. Reconciliation of the observation of medication administration with Resident 8's current Physician Orders indicated an order dated 1/5/23 for glucosamine 500 mg 1 tab [tablet] by mouth once daily for supplement. During an interview on 3/7/23 at 2:45 p.m., LS S stated one 800 mg tablet of glucosamine was given to Resident 8. LS S also stated that per medication bottle, the serving size for 3 tablets equaled to 2400 mg of glucosamine; therefore, one table, 800 mg, was more than the prescribed amount of 500 mg. During an interview on 3/9/23 at 9:30 a.m. with the DON, the DON acknowledged that the prescribed doses of fish oil and glucosamine were not given to Resident 8. 555727 Page 14 of 28 555727 03/10/2023 Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533

F 0759 Level of Harm - Minimal harm or potential for actual harm A review of facility policy titled, Medication Administration - General Guidelines, revised 12/17, indicated Medications are administered in accordance with written orders of prescriber .The medication administration record (MAR) should contain supplemental information to help assure accurate dosing. Examples of supplemental information that can be added without requiring a prescriber's order include numbers of tablets or capsules required for the dose (1/2 tablet, 2 capsules, 4 tablets, etc.) . Residents Affected - Few 555727 Page 15 of 28 555727 03/10/2023 Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533

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 implement their medication storage policy when: 1. A medication storage room was left unlocked and unattended, with the potential for access by unlicensed staff or facility residents. 2. Expired medications were not removed and destroyed according to facility policy, with the potential for administration of expired and ineffective medications. 3. Medications requiring storage in the refrigerator were kept at a temperature higher than the recommended temperature range, with the potential for negative impact on effectiveness of the medications stored in the refrigerator. 4. Medications requiring storage at room temperature were kept in a medication room without monitoring the room temperature, a thermometer, or a temperature log with the potential for negative impact on potency of the stored medications. 5. A used inhaler and a bottle of sugar test strips were found in the medication cart without having the date opened and the new expiration date, with the potential for administration of expired medications or pharmaceutical products. Findings: 1. During a medication room inspection on 3/6/23 at 10:32 a.m., medication room (station 2) was observed to be unlocked and unattended. During an interview with Licensed Staff Q (LS Q) on 3/6/23 at 10:35 a.m., LS Q acknowledged the medication room (station 2) was unlocked and unattended. LS Q also confirmed that the unlocked medication room increased the risk of drug diversion and accidental medication use by the residents or staff. During an interview with the Director of Nursing (DON) on 3/9/23 at 9 a.m., the DON acknowledged that leaving the medication room unlocked and unattended was an issue that made pharmaceutical products accessible to other residents and unlicensed personnel. The DON stated there was an issue with the doorknob that was not allowing the door to be locked. A review of the facility policy Storage of Medications, revised 5/19, indicated Medications and biologicals are stored safely, securely, and properly .Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. 2. During a concurrent inspection of medication room (station 2) and interview with LS Q on 3/6/23 at 10:55 a.m., an expired bottle of vitamin D3 (a nutrient that body needs for building and maintaining healthy bones) 10 mcg (microgram, unit of measure) was found in the medication room with an expiration date of 5/2022. LS Q acknowledged that the medication was expired and should have been 555727 Page 16 of 28 555727 03/10/2023 Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533

F 0761 removed from the medication shelf. Level of Harm - Minimal harm or potential for actual harm During a concurrent inspection of treatment cart (station 1) and interview with LS R on 3/7/23 at 10 a.m., an expired tube of clotrimazole and betamethasone cream (combination of two medications used to treat skin infection and inflammation)1%/0.05% (percentage, unit of measure) and two expired tubes of lidocaine (a medication used for pain) 2% were found in the treatment cart. LS R acknowledged that the three tubes had the expiration dates of 8/2022, 9/2022, and 9/2022 and should have been removed per facility's policy. Residents Affected - Some During an interview with the DON on 3/9/23 at 9:225 a.m., the DON acknowledged that the expired medications with the potential of being ineffective should have been removed from the treatment cart. A review of the facility policy Storage of Medications, revised 5/19, indicated Outdated, contaminated or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal. 3. During a concurrent inspection of station 1's medication refrigerator and interview with LS R on 3/7/23 at 9:40 a.m., the temperature of the refrigerator, in which vaccines were stored, was observed to be at 50 degrees F (Fahrenheit, unit of measure for temperature). LS R acknowledged that the temperature in the refrigerator was out of range (36-46 F). LS R also confirmed that the temperature log was not being completed by the facility and the log was not completed for at least 4 consecutive days in March (3/2/23, 3/3/23, 3/4/23, 3/5/23) in the morning and in the evening. During a concurrent inspection of station 1's medication refrigerator and interview with LS A on 3/8/23 at 11:30 a.m., the temperature of the refrigerator was observed to be at 50 degrees F a day after the first observation. LS A confirmed that the temperature was still out of range. During an interview with the DON on 3/9/23 at 9:10 a.m., the DON acknowledged that the facility had to replace station 1's medication refrigerator since the facility was unable to bring the temperature down and keep it within the required temperature range. The DON confirmed that having temperatures warmer than the required temperature range could negatively affect the quality of pharmaceutical products in the refrigerator. A review of the facility policy Storage of Medications, revised 5/19, indicated Medications requiring refrigeration are kept in a refrigerator at temperatures between 36 [degree] F and 46 [degree] F with a thermometer to allow temperature monitoring .The facility should maintain a temperature log in the storage area to record temperatures .The facility should check the refrigerator or freezer in which vaccines are stored, at least two times a day . 4. During a concurrent inspection of station 1's medication room and interview with LS R on 3/7/23 at 9:40 a.m., the LS R was unable to check the medication room's temperature, find a thermometer in the medication room, or provide a temperature log for the medication room. The LS R acknowledged that the facility never checked the medication room's temperature which was being used for storage of pharmaceutical products. During a concurrent inspection of station 1's medication room and interview with LS A on 3/8/23 at 11:30 a.m., the LS A was unable to check the medication room's temperature, find a thermometer in the medication room, or provide a temperature log for the medication room. The LS R also acknowledged 555727 Page 17 of 28 555727 03/10/2023 Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533

F 0761 that the facility never checked the medication room's temperature. Level of Harm - Minimal harm or potential for actual harm During an interview with the DON on 3/9/23 at 9:15 a.m., the DON acknowledged that the facility needed to monitor station 1's medication room's temperature. The DON stated that a new thermometer and a new temperature log were placed in the medication room to monitor the medication room's temperature. The DON confirmed that having out of range temperatures in the medication could affect the quality of pharmaceutical products in the medication room. Residents Affected - Some A review of the facility policy Storage of Medications, revised 5/19, indicated Medications requiring storage at room temperature are kept at temperatures ranging from 59 [degree] F to 77 [degree] F .The facility should maintain a temperature log in the storage area to record temperatures at least one a day. 5. During a concurrent inspection of station 2's medication cart and interview with LS Q on 3/7/23 at 9:15 a.m., an opened unit of umeclidinium and vilanterol inhalation powder, combination of two medications to help with breathing problems, was observed without an open date. LS Q acknowledged that the unit was previously used without documenting the open date on the inhaler or the box. LS Q stated that the nurse who opened the inhaler for the first time must have forgotten to write the open date on the medication. She acknowledged and confirmed per manufacture's recommendation the inhaler needed to be discard 6 weeks after opening the foil tray. During a concurrent inspection of station 1's medication cart and interview with LS R on 3/7/23 at 9:45 a.m., an opened bottle of blood glucose test strips (test strips collect blood sample to measure blood sugar level) was observed without an open date. LS R acknowledged that more than half of the test strips were used, but the bottle still did not have an open date. LS R also confirmed that the blood glucose test strips bottle needed to have an open date label to determine the product's expiration date which had to be used within three months of first opening per manufactures recommendation. During an interview with the DON on 3/9/23 at 9:20 a.m., the DON acknowledged that the open date labels should have been documented on the inhaler and blood glucose test strips to determine the expiration dates and reduce the risk of using expired medications or pharmaceutical supplies. A review of the facility policy Storage of Medications, revised 5/19, indicated Drugs dispensed in the manufacture's original container will carry the manufacture's expiration date. Once opened, there will be good to use until the manufacture's expiration date is reached unless the medication is .an item for which the manufacture has specified a usable life after opening .When the original seal of a manufacture's container or vial is initially broken, it is recommended that a nurse write the date opened on the medication container or vial .The nurse will check the expiration date of each medication before administering it .Certain medications or package types, such as .blood sugar testing solutions and strips, once opened, require an expiration date shorter than the manufacture's expiration date to insure medication purity and potency. 555727 Page 18 of 28 555727 03/10/2023 Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533

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 observations, interviews, and records review, the facility failed to implement measures to reduce the risk of disease and infection transmission, when: Residents Affected - Some 1. The Certified Nursing Assistants (CNA) did not perform proper hand hygiene before and after assisting residents with meals and before and after passing individual food trays, for 12 out of 12 residents (Residents 2, 3, 5, 10, 11, 12, 14, 15, 22, 29, 34 and 38). This failure had the potential to result in spread of infections and/or transmission of diseases to the staff and vulnerable residents. 2. The facility failed to ensure staff were not wearing gloves while feeding a resident (Resident 11). This failure had the potential for an issue with resident dignity and/or increased infection transmission. 3. The facility failed to ensure the Freestyle Libre 2 reader (a continuous glucose monitoring reader) for Resident 14 was adequately sanitized when staff used a sanitizing wipe that was not recommended by the manufacturer. These failures had the potential to result in contamination, infections and faulty glucose readings. Findings: 1. During an observation at the communal dining room on 3/6/23 at 12:00 p.m., there was no hand hygiene offered to Residents 11, 5, 22, 14, 3 and 10. During an observation on 3/6/23 at 12:08 p.m., Resident 34 was eating his lunch while his wife assisted him. The staff did not offer hand hygiene prior to Resident 36 eating his lunch. During an observation on 3/6/23 at 12:12 p.m., Unlicensed Staff N assisted multiple residents with no hand hygiene performed in between helping residents. Unlicensed Staff N was also observed touching the IPAD (a touchscreen computer tablet) located in the dining room then proceeded to assist Resident 3 with no hand hygiene prior to assisting her. During an observation on 3/6/23 at 12:27 p.m., Unlicensed Staff N took the drinking glass from Resident 14 to get her some water and then proceeded to assist Resident 11, Resident 3 and Resident 14 with no hand hygiene in between. During an observation on 3/6/23 at 12:42 p.m., there was no hand hygiene offered to Resident 11 after eating her lunch. Unlicensed Staff L assisted Resident 11 out of the dining room and no hand hygiene was offered to the resident before bringing Resident 11 back to her room. During an observation on 3/6/23 at 12:43 p.m., Resident 22 was not offered hand hygiene after eating her lunch. During an observation on 3/6/23 at 12:45 p.m., Resident 34 was not offered a hand hygiene after eating lunch. During an observation on 3/6/23 at 12:47 p.m., staff did not offer Resident 14 hand hygiene after 555727 Page 19 of 28 555727 03/10/2023 Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533

F 0880 eating her lunch. Level of Harm - Minimal harm or potential for actual harm During an observation on 3/6/23 at 12:49 p.m., staff did not offer Resident 5 hand hygiene after eating her lunch. Residents Affected - Some During an observation on 3/6/23 at 12:50 p.m., staff did not offer Resident 10 hand hygiene after eating her lunch. During an interview on 3/6/23 at 12:52 p.m., Unlicensed Staff N verified Resident 14 was using her hands while she was eating lunch. Unlicensed Staff N verified staff did not offer Resident 14 hand hygiene after eating her lunch. During an interview on 3/7/23 at 10:12 a.m., Resident 36 stated it was seldom staff would offer hand hygiene to her prior to and after meals. Resident 36 stated she was not offered hand hygiene before and after her breakfast this morning. During an observation on 3/7/23 at 11:36 a.m., Resident 14 was observed using a spoon to take off dirt from her nails. During an observation 3/7/23 at 11:36 a.m., Resident 34 was eating food brought in by his family. Staff did not offer hand hygiene prior to Resident 34 eating his lunch. During an observation on 3/7/23 at 11:39 a.m., Staff did not offer hand hygiene to Residents 14, 10, and 15 prior to serving their soup. During an observation on 3/7/23 at 11:57 a.m., staff did not offer Resident 34 hand hygiene prior to leaving the dining room. During an observation 3/7/23 12:01 p.m., Unlicensed Staff D did not perform hand hygiene first when she took Resident 14's food tray in the food cart. Resident 14 started eating her lunch but there was no hand hygiene offered by staff first. During an observation on 3/7/23 at 12:03 p.m., Resident 10 was served her lunch, but staff did not offer hand hygiene first. During an observation on 3/7/23 at 12:04 p.m., Unlicensed Staff D served the food trays for Resident 10, 15 and 11 with no hand hygiene performed between tasks. There was no hand hygiene offered by staff to Residents 10, 15 and 11 before consuming their lunch. During an observation on 3/7/23 at 12:05 p.m., Unlicensed Staff N did not offer hand hygiene to Resident 22 when he served her lunch. During an observation on 3/7/23 at 12:08 p.m., Unlicensed Staff D did not perform hand hygiene prior to feeding Resident 11. During an observation on 3/7/23 at 12:10 p.m., Unlicensed Staff N delivered Resident 16's lunch in her room at room [ROOM NUMBER]. Unlicensed Staff N did not offer hand hygiene to Resident 16 prior to her eating her lunch. 555727 Page 20 of 28 555727 03/10/2023 Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During consecutive observations on 3/7/23 at 12:11 p.m. and 12:13 p.m., Unlicensed Staff E brought lunch trays to Resident 38's room and Resident 29's room. Unlicensed Staff F did not offer to wash these residents' hands nor offer wet wipes or wet hand towels. During an interview on 3/7/23 at 12:16 p.m., Resident 34 stated, sometimes staff would ask to clean [Resident 34's] hands before and after meals, sometimes they don't, it was mixed. Resident 34 verified staff did not offer to clean his hands before and after lunch today. During an observation on 3/7/23 at 12:20 p.m., Unlicensed Staff F brought Resident 2's lunch tray to his/her room. Unlicensed Staff F did not offer to wash or wipe the resident's hand prior to setting up the lunch tray. During an interview on 3/7/23 at 12:22 p.m., when Unlicensed Staff F was informed she was not observed to offer to wash or wipe the resident's hands before serving lunch, Unlicensed Staff F stated she had not practiced the hand hygiene before although she can use hot towels if the residents wanted. During an interview on 3/7/23 at 12:23 p.m., when asked why she did not offer hand hygiene to residents prior to serving lunch trays, Unlicensed Staff E stated she offered to wipe the residents' hand with wet wipes prior to serving trays. Unlicensed Staff E however admitted she did not do that with Resident 29. During an interview on 3/7/23 at 3:45 p.m., the Infection Preventionist (IP) stated hand hygiene should be performed prior to resident going into the DR (dining room). IP verified staff should ensure hand hygiene was done for the residents before and after meals. IP stated hand hygiene was very important. IP stated hand hygiene was done before and after meals, and staff should perform hand hygiene whenever they're changing task or helping in between residents. IP verified staff should be performing hand hygiene every time they take out trays from the food cart. IP stated if hand hygiene was not being done by staff and the residents, it could lead to spread of infection and gastrointestinal disease (GI, any health problem that occurs in the digestive tract, from mouth to anus). During an interview on 3/8/23 at 4:26 p.m., the Director of Staff Development (DSD) stated staff should perform hand hygiene on residents before and after meals. The DSD stated staff should be performing hand hygiene to resident prior to leaving the resident rooms for meals and then again, perform hand hygiene after meals, which should be done in the dining room. When asked how the facility ensured hand hygiene was performed prior to residents leaving their rooms for meals, DSD was silent. When asked, how the facility ensured residents who were already in the dining room, after attending the activity of the day, had hand hygiene prior to eating their meals, DSD was silent. DSD stated the current policy of staff performing hand hygiene to resident before they leave their room was ineffective. The DSD stated not performing hand hygiene before and after meals indicated staff were not following the facility policy. DSD stated not performing hand hygiene before and after meals could result to resident getting sick and acquiring infection. During an interview on 3/9/23 at 9:56 a.m., the DON stated staff were expected to perform hand hygiene between task and between residents. The DON stated staff was expected to perform hand hygiene every single time they hand out residents' food trays and whenever they change task, before touching trays and before and after helping residents in between. The DON stated if hand hygiene were not done for these tasks, the facility was not in compliance and this could lead to infection, residents getting sick, and staff passing on disease or infection to other staff and the residents. The DON also stated resident were expected to perform hand hygiene before and after meals. The DON stated staff 555727 Page 21 of 28 555727 03/10/2023 Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some performs hand hygiene before bringing the resident to the DR. The DON stated staff need to perform hand hygiene on residents before and after meals. When asked what would happen when residents were already in the dining room, because they had attended activities prior to lunch, the DON stated there were hand sanitizers across the dining room and expecedt staff to perform hand hygiene on these residents before they started eating their meal. The DON stated if the staff were not performing hand hygiene on residents before and after meals, it could result in [spreading] infection and GI (gastrointestinal) issues. During an interview on 3/9/23 at 2:31 p.m., Licensed Staff A stated staff should be providing hand hygiene to the residents before and after meals. Licensed Staff A stated if hand hygiene was not done, it could result in contamination and illness. Licensed Staff A stated hand hygiene should be performed when helping in between resident and in between task. Licensed Staff A stated hand hygiene should be performed every time staff touches a food tray. During an interview on 3/10/23 at 11:00 a.m. the Wellness Assistant verified that on 3/6/23, Residents 3, 11, 5, 22, 10 and 14 had attended the activities in the dining room and did not go back to their rooms before lunch. The Wellness Assistant Verified that on 3/7/23 Residents 14, 10, 15 and 11 attended the activities in the dining room and did not go back to their rooms before lunch. During a review of facility's policy and procedure (P&P) titled Handwashing/Hand Hygiene revised 8/2019, the P&P indicated all personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors .use an alcohol based hand run containing at least 62% alcohol or alternatively soap and water, before and after direct contact with residents, after contact with resident skin, before and after eating or handling food, before and after assisting residents with meals. 2. A review of Resident 11 face sheet (demographics) indicated Resident 11 was [AGE] years old with diagnoses which included Hypertension (high or raised blood pressure, a condition in which the blood vessels have persistently raised pressure), Alzheimer's Disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment) and Depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act). Resident 11's Minimum Data Set assessment (MDS, a standardized assessment tool that measures health status in nursing home residents) dated 1/16/23, Brief Interview of Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long term care facility) indicated she had both short term and long term memory impairment. Her MDS also indicated she required extensive assistance of one to two staff when performing her Activities of Daily Living tasks (ADL's, activities related to personal care such as bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). During an observation on 3/6/23 at 12:14 p.m., Unlicensed Staff L was wearing gloves while feeding Resident 11. During an interview on 3/8/23 at 3:45 p.m., the Infection Preventionist (IP) stated staff should not be wearing gloves when feeding a resident, per facility policy. IP stated staff wearing gloves while feeding a resident was a dignity issue and could lead to residents or visitors thinking they have infection. IP stated wearing gloves could lead to infections because it provides staff a false sense of security. The IP stated staff should not be wearing gloves when feeding the residents as this was an infection control issue. The IP stated if staff was wearing gloves while feeding a resident 555727 Page 22 of 28 555727 03/10/2023 Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533

F 0880 with no infection, it meant the facility policy was not followed. Level of Harm - Minimal harm or potential for actual harm During an interview on 3/8/23 4:26 p.m., the Director of Staff Development (DSD) verified staff should not be wearing gloves when feeding residents for infection control and for dignity purposes. Residents Affected - Some During an interview on 3/9/23 at 11:03 a.m., Unlicensed Staff L stated staff were not supposed to wear gloves while feeding residents for infection control purposes and for resident's dignity. During an interview on 3/9/23 at 11:03 a.m., Unlicensed Staff P stated staff should not wear gloves while feeding residents for infection control purposes and for resident's dignity. Unlicensed Staff P stated, if staff wore gloves while feeding a resident, then the facility policy was not followed. Policy and Procedure for glove usage while feeding a resident was requested but not provided. 3. A review of Resident 14's face sheet (demographics) indicated Resident 14 was [AGE] years old with diagnoses which included Diabetes Mellitus (DM, a chronic disease associated with abnormally high levels of the sugar glucose in the blood). Alzheimer's Disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), Depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act) and Muscle Weakness. Her Minimum Data Sheet assessment (MDS, a standardized assessment tool that measures health status in nursing home residents) dated 1/16/23, Brief Interview of Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long term care facility) indicated she had both short term and long term memory impairment. Her MDS also indicated she needed an extensive assistance from one staff when performing her ADL's. During a concurrent observation and interview on 3/7/23 at 4:01 p.m., Licensed Staff M verified she had used one sheet of a purple-top sani cloth sanitizing wipe to sanitize Resident 14's continuous glucose monitoring reader (a glucose monitor gives a blood sugar result). Licensed Staff M verified she only sanitized the continuous glucose monitoring sensor after she had checked Resident 14's blood sugar. During an interview on 3/8/23 at 4:00 p.m., the Infection Preventionist stated the continuous glucose monitoring reader should be sanitized before and after use. The IP verified staff were using the purple-top sani wipes to sanitize the reader. During a concurrent interview on 3/9/23 at 9:56 a.m., the DON stated the continuous glucose monitoring reader should be sanitized before and after use, using the manufacturer recommended sanitizing wipes. The DON stated if staff were not using the approved sanitizing wipes it could lead to a sensor malfunction, and could lead to inaccurate blood sugar readings which could result in resident harm. The DON verified the purple-top sanitizing wipes' active ingredient was ammonium chloride. During an interview on 3/9/23 at 10:59 a.m., Licensed Staff I stated she had already checked Resident 14's blood sugar using the continuous glucose monitoring reader this morning. Licensed Staff I verified she had used 1 piece of purple top sanitizing wipe to sanitize the sensor. Licensed Staff I stated she only sanitized the sensor once, after use. During an interview on 3/10/23 at 3:46 p.m., the DON verified the facility did not have policy and procedure in place for sanitizing the continuous glucose monitoring reader. The DON verified the 555727 Page 23 of 28 555727 03/10/2023 Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some current sanitizing wipe the staff were using to sanitize the reader did not contain 0.55% of sodium hypochlorite (bleach solution). The DON verified, based on manufacturer's recommendation, in order to adequately sanitize the continuous glucose monitoring reader, the sanitizing wipe should contain 0.55% sodium hypochlorite. Based on manufacturers recommendation, to clean and disinfect the continuous glucose monitoring reader, a wipe containing 0.55% Sodium Hypochlorite (NaOCl, or bleach) solution should be used as it has been shown to be safe for use with the reader . use a second bleach wipe to wipe all outside surfaces of the Reader until they are wet .the reader should be cleaned and disinfected prior to being handled by any person providing testing assistance to the user. 555727 Page 24 of 28 555727 03/10/2023 Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533

F 0895 Have a Compliance and Ethics Program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to implement their compliance and ethics policy when a medication temperature monitoring log was falsified with a potential to negatively impact the quality of pharmaceutical products being stored in a medication storage room or a medication refrigerator. Residents Affected - Few Findings: During a concurrent inspection of station 1's medication refrigerator and interview with Licensed Staff R (LS R) on 3/7/23 at 9:40 a.m., the temperature of the refrigerator, in which vaccines were stored, was observed to be at 50 degrees F (Fahrenheit, unit of measure for temperature). LS R acknowledged that the temperature in the refrigerator was out of range (36-46 F). LS R also confirmed that the temperature log was not being completed by the facility and the log was not completed for at least 4 consecutive days in March (3/2/23, 3/3/23, 3/4/23, 3/5/23) in the morning and in the evening. During a concurrent inspection of station 1's medication refrigerator and interview with LS A on 3/8/23 at 11:30 a.m., the temperature of the refrigerator was observed to be at 50 degrees F a day after the first observation. LS A confirmed that the temperature was still out of range. During a concurrent record review and interview with Director of Staff and Development (DSD) on 3/8/23 at 2 p.m., the provided copy of the temperature log was filled out completely which did not match with the surveyor's documented records from 3/6/23 and 3/7/23. When asked DSD about the discrepancy among the records, the DSD acknowledged that the staff had completed the form on the day that it was requested. During an interview with the DON on 3/9/23 at 9:10 a.m., the DON acknowledged that the facility had to replace station 1's medication refrigerator since the facility was unable to bring the temperature down and keep it within the required temperature range. The DON confirmed that the room and refrigerator temperatures were not checked and documented by the facility and the log was not completed for at least 4 consecutive days in March (3/2/23, 3/3/23, 3/4/23, 3/5/23) in the morning and in the evening. The DON acknowledged that the provided copy of temperature log to the surveyors was not accurate and it was completed with inaccurate data. A review of the facility policy Compliance and Ethics Program Components, revised 12/20, indicated This facility is committed to integrity, transparency, and accountability, and to promoting a culture of ethical and lawful practices .The program includes the following components .A process for investigations and remedies, including: (1) cooperating with government inquiries and investigations; (2) recordkeeping during investigation . A review of the facility policy Storage of Medications, revised 5/19, indicated Medications requiring refrigeration are kept in a refrigerator at temperatures between 36 [degree] F and 46 [degree] F with a thermometer to allow temperature monitoring .The facility should maintain a temperature log in the storage area to record temperatures .The facility should check the refrigerator or freezer in which vaccines are stored, at least two times a day . 555727 Page 25 of 28 555727 03/10/2023 Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the call light (a device used by a patient to signal his or her need for assistance from staff) for one out of five sampled residents (Resident 36) was working as indicated by the funtioning of the red light above Resident 36's door. This failure could result in residents not being able to call staff for assistance which had the potential to result in late provision of care, care not rendered, or accidents and falls. Residents Affected - Few Findings: A review of Resident 36 face sheet (demographics) indicated Resident 36 was initially admitted to the facility on [DATE]. Resident 36's diagnoses included Bilateral Hearing Loss (hearing loss on both ears), Hypertension (high or raised blood pressure, a condition in which the blood vessels have persistently raised pressure) and Polyneuropathy (when multiple peripheral nerves become damaged, symptoms includes problems with sensation, coordination, or other body functions). Her Minimum Data Sheet assessment (MDS, a standardized assessment tool that measures health status in nursing home residents) dated 1/27/23, Brief Interview of Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long term care facility) score of 14 which indicated intact cognition. Her MDS also indicated she needed an extensive assist from 1 staff when performing her Activities of Daily Living tasks (ADL's, activities related to personal care such as bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). During a concurrent observation and interview on 3/7/23 at 10:12 a.m., Resident 36 was up in bed, reading the morning paper. Resident 36 stated she had been pressing her call light this morning to alert staff she needed help clearing her bedside table. When Resident 36 pressed the call light again it was noted that the red light by the resident's door was not on. During a concurrent observation and interview on 3/7/23 at 10:16 a.m., Unlicensed Staff G verified Resident 36's call light was not working due to a loose [wall] socket. During an observation on 3/7/23 at 10:47 a.m., the call light was pressed but there was no red light visible by Resident 36's door which indicated the call light was still not working. Total time of the call light not working was 35 minutes. During an observation on 3/7/23 at 11:20 a.m., the call light was pressed again but there was no red light visible by Resident 36 door which indicated the call light was still not working. Total time of the call light not working was 1 hour and 8 minutes. During an observation on 03/07/23 at 12:13 p.m., the call light was pressed again but there was no red light visible by Resident 36's door which indicated the call light was still not working. Total time of the call light not working was 2 hours and 1 minute. During a concurrent observation and interview on 03/07/23 at 2:16 p.m., Resident 36's food on the bedside table was untouched. Resident 36 stated she pressed the call light to alert staff she need help repositioning herself in bed, but nobody came so she did not eat. Resident 36 pressed the call light again but there was no red light visible by Resident 36's door indicated the call light was still not working. Total time of the call light not working was 4 hours and 4 mins. 555727 Page 26 of 28 555727 03/10/2023 Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533

F 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 3/7/23 at 3:41 p.m., the call light was pressed but there was no red light visible by Resident 36 door, which indicated the call light was still not working. Total time of the call light not working was 5 hours and 29 minutes. During a concurrent observation and interview on 3/7/23 4:07 p.m., Unlicensed Staff B verified Resident 36's call light was not working initially, however, when she removed the call light from the socket and repositioned it, the call light functioned. Unlicensed Staff B stated the call light's [wall] socket was loose. Unlicensed Staff B stated she would report this to the nurse so she could notify the receptionist to call maintenance to fix Resident 36's call light system. Unlicensed Staff B stated the expectation was for maintenance to get call light issues fixed within an hour. Unlicensed Staff B stated a non-functioning call light could result in late provision of care, accidents, falls and residents feeling anxious. During an interview on 3/8/23 at 11:33 a.m., Unlicensed Staff H stated non-working call light issues would need to be reported to the front desk as they would be the one to enter a work order for maintenance. Unlicensed Staff H stated if a call light was nonfunctioning, it had to be fixed as soon as possible. Unlicensed Staff H stated if the non-working call light was not fixed right away it could lead to falls and accidents. During an interview on 3/8/23 at 11:35 a.m., Licensed Staff I stated if the call light was nonfunctioning it would need to be fixed immediately. Licensed Staff I stated if the call light was not fixed immediately it could put residents at risk for falls and accidents. Licensed Staff I stated that [the process was] staff would report the nonfunctioning call light to front desk who then entered work order for maintenance to review. During an interview on 3/8/23 at 11:38 a.m., Receptionist J verified the facility policy was staff would call front desk to report if there was anything broken for the maintenance to fix and they would log it in the computer for the maintenance staff to review. During a concurrent interview and maintenance log record review on 3/8/23 at 1:22 p.m., Receptionist K reviewed the maintenance log. Receptionist K verified that from 3/7/23 up to 3/8/23, nothing was called to the front desk to fix the call light in Resident 36's room. During an interview on 3/8/23 at 2:15 p.m. Licensed Staff A stated if a socket connecting to the call light was loose and the call light ceased working then it had to be reported to the maintenance as soon as possible. Licensed Staff A stated a non-working call light was dangerous and could lead to residents' accidents or falls. During an interview on 3/8/23 at 3:14 p.m., the Minimum Data Set Coordinator/ Infection Preventionist (MDS/IP) stated if a call light was not working, due to a loose socket, it would need to be reported to maintenance as soon as possible. MDS/IP stated if a call light was nonfunctioning, residents would not be able to call for assistance which could lead to delay in care. MDS/IP stated a nonfunctioning call light could put residents at risk for not receiving care timely or needs not being met at all. MDS /IP stated this could also result to falls and accidents. During an interview on 3/8/23 at 4:26 p.m., the Director of Staff Development (DSD) stated, a non-working call light due to a loose socket needs to be reported so maintenance could get it fixed as soon as possible. The DSD stated a nonfunctioning call light could lead to late provision of care and accidents. 555727 Page 27 of 28 555727 03/10/2023 Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533

F 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 3/9/23 at 9:56 a.m., the Director of Nursing (DON) stated that a loose socket which resulted in a nonfunctional call light needed to be reported to maintenance right away. The DON stated a nonfunctioning call light could lead to resident's needs not being met on time which could lead to a resident feeling frustrated. During a concurrent observation and interview on 3/9/23 at 10:55 a.m., Resident 36 pressed her call light three times and the call light was still not working. Unlicensed Staff L verified Resident 36's call light was not working (no red light went on at Resident 36's door). Unlicensed Staff L stated that Resident 36's nonfunctioning call light had been reported to the maintenance multiple times in the past, however, staff was told that unfortunately, Resident 36's call light could not be fixed since there was an issue with the wiring itself. Unlicensed Staff L stated, if a call light was not working this could lead to residents feeling scared. Unlicensed Staff L stated a nonfunctioning call light could also result to delay in provision care. During an interview on 3/9/23 at 2:17 p.m., Licensed Staff A stated loose socket or faulty wiring for a non-working call light had to be reported to maintenance. Licensed Staff A stated the facility policy was to call the front desk to report a nonfunctioning call light. Licensed Staff A stated the receptionist (at the front desk) put in the work orders for maintenance. Licensed Staff A stated a nonfunctioning call light had to be fixed right away, within hour or at least by the end of the day. Licensed Staff A stated if a call light was not working it could lead to fall, mismanaged care and delayed provision of care. During a concurrent interview and maintenance work log record review on 3/9/23 at 3:15 p.m., the DON verified there was no work order called in for Resident 36's nonfunctioning call light due loose socket and faulty wiring between 3/7/23 and 3/9/23. The DON verified the Work Order Policy she handed me was not the one they follow. The DON verified there was no policy and procedure in place for their new system, where staff would call the front desk receptionist who would then put in the work order request for the maintanence department. A request for Work Order Policy and Procedure was requested, however, was told the facility had no policy and procedure in place for the facility's new work order system. During a concurrent observation and interview on 3/9/23 at 3:20 p.m., Licensed Staff M verified Resident 36's call light was still not working. Licensed Staff M stated this would be reported to maintenance. Licensed Staff M stated if a call light was not working it could lead to residents getting anxious, which could lead to accidents and falls. 555727 Page 28 of 28