Health inspection·June 30, 2022

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 accurate accountability and effective storage of controlled medications (those with high potential for abuse or addiction) when random controlled medication use audits two out of 4 residents (Residents 13 and 128) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Record (MAR) to indicate they were given to the residents. This failure resulted in the facility not having accurate accountability of controlled medications and potential for abuse or misuse of these medications. Findings: The controlled medication CDR for four random residents receiving as-needed controlled medications were requested for review during the survey. During an interview on 6/28/22, at 1:20 p.m., with the Director of Nursing (DON), DON confirmed the expectation was that anytime a nurse needed to administer a controlled medication, they were expected to sign it out of the CDR and document on the MAR. 1. Resident 13 had a physician's order for oxycodone 5 milligram (mg) (a pain medication), 1 tablet every 4 hours as needed for moderate pain and take 2 tablets every 6 hours as needed for severe pain, dated 10/13/21. During a concurrent interview and record review on 6/28/22, at 1:10 p.m., with Medical Records (MR), a review of Resident 13's CDR for oxycodone and 3/2022 MAR indicated the nursing staff removed the following from the medication cart without their administration on the MAR: 1 tablet on 3/24/22 at 5 a.m. and 3/26/22 at 4 a.m. MR verified this finding and confirmed they should have been documented in the MAR. During a concurrent interview and record review on 6/29/22, at 9:08 a.m., with Licensed Vocational Nurse 1 (LVN 1), a review of Resident 13's CDR for oxycodone and 3/2022 MAR indicated, the nursing staff removed the above indicated doses and were not accounted for in the MAR. LVN 1 acknowledged and confirmed the doses should have been documented in the MAR. She stated that the expectation was that when a dose of a controlled medication was removed from the medication cart it was to be documented in the CDR as well as the MAR. During a concurrent interview and record review on 6/29/22 at 12:06 p.m. with DON, a review of Resident 13's CDR for oxycodone and 3/2022 MAR confirmed the 2 oxycodone tablets were not accounted for Page 1 of 17 555735 555735 06/30/2022 Richmond Post Acute Care 955 23rd Street Richmond, CA 94804

F 0755 Level of Harm - Minimal harm or potential for actual harm in the MAR. DON confirmed that each time the oxycodone was administered, it should have been documented in the MAR. 2. Resident 128 had a physician's order for Percocet 5/325 mg (a pain medication), 1 tablet every 6 hours as needed for pain, dated 6/20/22. Residents Affected - Some During a concurrent interview and record review on 6/28/22, at 1:10 p.m., with MR, a review of Resident 128's CDR for Percocet and 6/2022 MAR reflected the nursing staff removed 1 tablet on 6/27/22 at 1 p.m. from the medication cart and documented on the CDR without documenting the respective administration on the MAR. MR verified this finding and stated that the tablet removed from the medication cart should have been documented in the MAR. During a concurrent interview and record review on 6/29/22, at 9:08 a.m., with LVN 1, a review of Resident 128's CDR for Percocet and 6/2022 MAR indicated the nursing staff removed the above indicated dose and it was not accounted for in the MAR. LVN 1 agreed and confirmed the dose should have been documented in the MAR. During a concurrent interview and record review on 6/29/22, at 12:06 p.m., with the DON, a review of Resident 128's CDR for Percocet and 6/2022 MAR confirmed the 1 tablet removed from the medication cart on 6/27/22 at 1 p.m. was documented on the CDR and not on the MAR. DON confirmed the Percocet tablet removed on 6/27/22 at 1 p.m. from the medication cart should have been documented in the MAR and verified that it was unaccounted for. A review of the facility policy titled Medication Administration, dated (undated), indicated, After the resident has taken the medication, immediately initial its square in the MAR. Never delay this action. 555735 Page 2 of 17 555735 06/30/2022 Richmond Post Acute Care 955 23rd Street Richmond, CA 94804

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure: - Seven bottles of methadone (a controlled substance; medication with a high potential for abuse or addiction) were labeled properly with a pharmacy label identifying the contents inside the bottles so they could be verified prior to administration; - Nine bottles of methadone were securely stored; - Eight opened inhalers and biologicals were dated with an open and discard date, to make sure they were not used beyond the discard date; - Nine expired medications were not available for resident use; and - A manufacturer's blister pack of tablets and a vial of insulin (medication used to lower blood sugar level) were labeled properly with a pharmacy label to ensure it was used for the right resident This failure had the potential for diversion (transfer of a medication from a legal to an illegal use from the individual for whom it was prescribed, to another person for illicit use) of controlled medications, and the potential for residents to receive medications with unsafe and reduced potency from being used past their discard date. Findings: 1. On 6/28/22 at 10:32 a.m., an inspection of the Medication Storage Room refrigerator with Licensed Vocational Nurse 1 (LVN 1) identified two unlocked storage boxes. The first storage box contained two bottles of pink liquid methadone. The second storage box contained seven identical plastic bottles containing the same pink liquid medication and the key to the box. The bottles in the second storage box had a patient label on them that did not identify the medication contained inside. LVN 1 confirmed the bottles contained liquid methadone. During an interview on 6/28/22, at 10:42 a.m., with LVN 1, LVN 1 confirmed the refrigerator did not have a lock to secure the methadone inside. She stated that the storage boxes inside the refrigerator were normally kept unlocked. When asked if the storage boxes should have been locked in order to securely store the controlled substances inside, LVN 1 stated, I guess it's supposed to be locked. LVN 1 confirmed and agreed the storage boxes should be kept locked. During an interview on 6/28/22, at 11:11 a.m., with LVN 3, LVN 3 verified that the methadone in the Medication Storage Room refrigerator should have been stored locked inside the storage boxes. She confirmed the storage boxes should not have been kept unlocked. During an interview on 6/28/22, at 1:22 p.m., with Director of Nursing (DON), DON stated, the storage boxes containing methadone should have been locked at all times unless removing a dose. He 555735 Page 3 of 17 555735 06/30/2022 Richmond Post Acute Care 955 23rd Street Richmond, CA 94804

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some confirmed that seven bottles of liquid methadone were missing the name of the drug on the patient label, which was necessary for the nurse to verify the medication prior to administration. DON confirmed the bottles should have been labeled with the name of the drug contained inside of them. During an interview on 6/30/22, at 12:02 p.m., with Pharmacist 1, when asked if it was appropriate for bottles of methadone to be stored in unlocked storage boxes, Pharmacist 1 stated, I believe the regulation says narcotics should be double locked. He agreed that the boxes should have been stored locked. During a review of the facility's policy and procedure titled, Medication Storage, dated (undated), policy indicated, Narcotics must always be stored under a double locking system: They must be kept in the locked box in the unit's locked medication room . During a review of the facility's policy and procedure titled, Storage and Expiration of Medications, Biologicals, Syringes and Needles, dated 12/1/07, policy indicated, Facility should destroy and reorder medications and biologicals with . incomplete . labels. 2. On 6/28/22 at 11:19 a.m., a concurrent interview and inspection of Medication Cart 2 with LVN 1 identified and confirmed the following opened and undated biologicals and inhalers used to treat asthma and chronic obstructive pulmonary disease: - 2 Breo Ellipta 200/25 microgram/microgram (mcg/mcg) inhalers - 3 Breo Ellipta 100/25 mcg/mcg inhalers - 1 Combivent Respimat inhaler - 1 Symbicort 160/4.5 mcg inhaler - Assure Platinum blood glucose test strips (test strips used to test blood sugar levels) During an interview on 6/28/22, at 11:25 a.m., with LVN 1, LVN 1 acknowledged and agreed that the inhalers should have been labeled with an open date and without it, it was not possible to know when they expire once in use. LVN 1 verified the Assure Platinum blood glucose test strips should have been dated once opened and confirmed they expire 3 months after opened. During an interview on 6/30/22, at 12 p.m., with Pharmacist 1, when asked about inhalers and test strips with shortened expiration dates after first use, [NAME] stated, The recommendation is to date when opened so that you know when it expires or calculate it [the date] out to whenever it expires and put it on [the medication]. During a review of the facility's policy and procedure titled, Storage and Expiration of Medications, Biologicals, Syringes and Needles, dated 12/1/07, policy indicated indicated, Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. A review of the manufacturer's labeling for Breo Ellipta, labeling indicated, Discard 6 weeks after opening the foil tray or after the labeled number of inhalations have been used, whichever comes 555735 Page 4 of 17 555735 06/30/2022 Richmond Post Acute Care 955 23rd Street Richmond, CA 94804

F 0761 first. Level of Harm - Minimal harm or potential for actual harm A review of the labeling from the manufacturer for Combivent Respimat, labeling indicated, Discard 3 months after first actuation (inhalation) or after labeled number of actuations has been reached and locking mechanism is engaged, whichever comes first. Residents Affected - Some A review of the manufacturer's labeling for Symbicort, labeling indicated, Discard inhaler after the labeled number of inhalations have been used (the dose counter will read 0) or within 3 months after removal from foil pouch. A review of the manufacturer's labeling for Assure Platinum blood glucose test strips, labeling indicated, When you first open the vial, write the date on the vial label. Use the test strips within 3 months of first opening the vial. 3. On 6/28/22 at 10:32 a.m., a concurrent interview and inspection of the Medication Storage Room with LVN 1 identified the following expired medications: - Ceftriaxone IV (intravenous) 2 gm (an antibiotic), expired 6/23/22 - Levemir FlexTouch insulin pen (a long-acting insulin), opened 3/27/22 - Firvanq 50mg/ml (an antibiotic), expired 5/14/22 - 6 tubes Insta-Glucose (used to rapidly raise low blood sugar), expired 4/2022 During an interview on 6/28/22, at 10:59 a.m., with LVN 1, LVN 1 confirmed expiration of the above items and confirmed that they should have been removed from stock and disposed of. A review of the manufacturer's labeling for Levemir FlexTouch insulin pen, labeling indicated, Cartridges and prefilled pens that have been punctured (in use) should be . used within 42 days. During a review of the facility's policy and procedure titled, Disposal/Destruction of Expired or Discontinued Medications, dated 12/1/07, policy indicated, Facility should place all discontinued medications or outdated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to destruction. 4. On 6/28/22 at 11:19 a.m., a concurrent interview and inspection of Medication Cart 2 with LVN 1, LVN 1 identified 1 vial Humulin R (a short-acting insulin) was unlabeled with a patient label. LVN 1 acknowledged and agreed that the vial should have had a label on it to identify which resident it was for. On 6/28/22 at 12:06 p.m., an inspection of Medication Cart 1 alongside LVN 3 identified one manufacturer's blister pack of Verzenio (medication used to treat breast cancer) without a patient label. LVN 3 confirmed and agreed the medication should have had a label on it but did not. During a review of the facility's policy and procedure titled, Medication Administration, dated (undated), policy indicated, Check the label of the medication against the order on the resident's MAR, making sure everything matches including the: 555735 Page 5 of 17 555735 06/30/2022 Richmond Post Acute Care 955 23rd Street Richmond, CA 94804

F 0761 a. Name of the medication Level of Harm - Minimal harm or potential for actual harm b. Dose c. Route Residents Affected - Some d. Times to be given. During a review of the facility's policy and procedure titled, Storage and Expiration of Medications, Biologicals, Syringes and Needles, dated 12/1/07, policy indicated, Facility should destroy and reorder medications and biologicals with . missing labels. 555735 Page 6 of 17 555735 06/30/2022 Richmond Post Acute Care 955 23rd Street Richmond, CA 94804

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation, interview, and facility document review, the facility failed to ensure the competency of the Certified Dietary Manager (CDM) when pureed food was prepared to a consistency too thin to hold it's shape. This failure had the potential for one resident who received a pureed diet, out of 28 residents who ate food by mouth, to aspirate (to breath fluid or food into the lungs) when eating the pureed food and/or to eat less due to an undesirable consistency of food. Findings: During a review of the Diet Manual for long Term Care and Residential Facilities dated 2020, showed Nectar Thick consistency flows off a spoon but pours slower than thin drinks. The description for a Pureed Diet showed it was for residents who had difficulty chewing and/or swallowing. The texture of the food should be able to hold its shape. During a review of the Policy and Procedure titled Self Feeding Devices dated 2018, policy indicated, a self-feeding device such as a divided plate, was used by a resident to maintain or improve their ability to eat or drink. A physical therapist, occupational therapist, or speech therapist and/or designated person would evaluate the resident for the need of a self-feeding device. In addition, tray cards would indicate if a device was needed. During an observation on 6/27/22 at 11:35 a.m., showed [NAME] 1 pureeing food in a food processor for the lunch meal. [NAME] 1 placed cooked Salisbury steak patties into the food processor and added gravy, then pureed the food. When [NAME] 1 transferred the pureed meat into a container to serve on trayline, the meat was thin enough so it was pourable. [NAME] 1 then added cooked diced, fried potatoes into the food processor and added milk. [NAME] 1 did not measure the milk added. She blended the mixture and poured the pureed potato into a container for trayline. Then [NAME] 1 added cooked corn kernels and gravy to the food processor. She blended the ingredients and poured the mixture into a container for trayline. During an observation and interview with CDM on 6/27/22 at 12 p.m., showed [NAME] 1 plated food for the lunch trayline. An observation of Resident 4's tray ticket showed the resident was on a Pureed diet and did not indicate a divided plate. When [NAME] 1 plated the pureed food for Resident 4 she used a divided plate (a plate that is divided into sections and has high sides which keeps food separated and can make it easier to place food on an eating utensil using the sides of the plate to push food onto the utensil) to plate the pureed food. CDM confirmed a divided plate was not indicated on Resident 4's tray card and stated the divided plate was used so the pureed food did not run together. She stated the consistency of the pureed food should be nectar thick. She said it was okay if the food did not hold it's shape. She said she did not think pureed meat should be as thick as pudding. During an interview on 6/28/22 at 12 p.m., with the Physical Therapist (PT), PT stated, there was no record that resident 4 was seen by a therapist to be evaluated for the need of an assistive device for eating such as a divided plate. 555735 Page 7 of 17 555735 06/30/2022 Richmond Post Acute Care 955 23rd Street Richmond, CA 94804

F 0802 Level of Harm - Minimal harm or potential for actual harm Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview and record review, the facility failed to ensure dietary staff competency when: Residents Affected - Some 1. There was not enough Salisbury Steak to be served for lunch on 6/27/22 for three residents. 2. [NAME] 1 did not prepare a pureed vegetable salad to be served. These deficient practices had the potential for four residents out of 30 to not get the type and amount of food as indicated on the planned menu which could compromise their nutritional status. Findings: 1. Review of the cook spreadsheet menu titled Summer Menu dated 6/27/22, showed all diets served received Salisbury Steak for lunch on 6/27/22. During a concurrent observation and interview on 6/27/22, with [NAME] 1, at 12:00 p.m., in the kitchen, during trayline, observed that there were still 3 food trays with regular diet orders that needed to be made but there were no Salisbury Steak in the holding tray. [NAME] 1 stated, they are missing 3 Salisbury Steak and need to cook a substitute for it. During a concurrent interview on 6/28/22, at 9:32 a.m., with [NAME] 1and [NAME] 2, [NAME] 1 and [NAME] 2 stated, they followed the Salisbury Steak recipe to make enough for 32 residents. She said she combining the recipe that serves 8 which called for 2 pounds of meat and recipe that serves 24 which called for 6 pounds of meat, so she used 8 pounds of meat total. During an interview on 6/28/27 at 9:57 a.m., with the Dietary Manager (CDM), CDM stated, the [NAME] should have used 9 pounds of meat to have at least 4 extra servings in case there's a new admit or extra is needed for some reason. 2. During a review of the cook spreadsheet titled Summer Menus dated 6/27/22, the menu indicated, a pureed diet receive a pureed fresh green salad. During an observation on 6/27/22, at 11:40 a.m., in the kitchen, during trayline, the tray ticket for Resident 4 indicated, resident was on a Pureed diet. [NAME] 2 did not put a pureed fresh green salad on Resident 4's tray. The tray was then delivered to the resident without the pureed salad. During an interview on 6/27/22, at 1:51 p.m., with [NAME] 2, [NAME] 2 stated, she did not put a pureed fresh green salad on Resident 4's tray because the blender was being used and the food cart needed to be sent out already. [NAME] 2 stated, Resident 4 should have the pureed fresh green salad on the tray. During an interview on 6/28/22, at 11:35 a.m., with CDM, CDM stated, the cook should have made the pureed fresh green salad and delivered it to the resident separately after the lunch tray was served. 555735 Page 8 of 17 555735 06/30/2022 Richmond Post Acute Care 955 23rd Street Richmond, CA 94804

F 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review, the facility failed to ensure that the physician ordered diets were followed when: Residents Affected - Some 1. Incorrect portion sizes for the diced fried potatoes were served for 11 residents with CCHO (Consistent Carbohydrate Diet for Diabetes) diet orders. 2. Incorrect portion size of corn with green peppers was served for four residents with small portion diet orders. 3. Butter/Margarine was not served for 2 out of 5 fortified diet orders These deficient practices had the potential for residents not receive the nutrients calculated for the menu and potentially lead to nutrition related health issues for 17 residents out of a facility census of 30. Findings: 1. During a concurrent observation and interview on 6/27/22, at 12:00 p.m., in the kitchen, with CDM, observed #8 (1/2 cup) scoop was used to serve the diced fried potatoes on all the trays with CCHO diet orders during trayline. CDM stated, CCHO diet orders should have received #16 (1/4 cup) scoop for the diced fried potatoes. During a review of the meal tickets for lunch on 6/27/22, meal tickets indicated that 11 out of the 30 meal tickets had a CCHO diet order. During a review of the facility's Summer Menu Cook's Spreadsheet for Week 4 Monday (6/27/22, 7/25/22, 8/22/22), Cook's Spreadsheet indicated, the serving for diced fried potatoes for CCHO diet is #16 (1/4 cup.) During a review of the facility's Diet Manual for Long Term Care (LTC) and Residential Facilities, dated 2020, the diet manual indicated, CCHO diet: Instead of counting calories; the carbohydrates are evenly, systematically and consistently distributed through three meals and H.S. (Bedtime) snack in an effort to maintain a stable blood sugar level throughout the day. The diet manual also indicated, The carbohydrates are controlled through portion control 2. During a concurrent observation, interview and record review on 6/27/22, at 12:00 p.m., in the kitchen, with CDM, observed that the #8 (1/2 cup) scoop was used to serve corn with green peppers on all the trays during trayline. CMD stated, the small portion orders should have received the #16 (1/4 cup) scoop. During a review of the Summer Menu Cook's Spreadsheet for Week 4, the cook's spreadsheet indicated, corn with green peppers serving size is ¼ cup for a regular small portion diet. 3. During an observation on 6/27/22, at 11:40 a.m., in the kitchen, observed 2 trays had a fortified diet on the meal ticket and no butter on the tray. 555735 Page 9 of 17 555735 06/30/2022 Richmond Post Acute Care 955 23rd Street Richmond, CA 94804

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 6/27/22, at 1:48 p.m., with [NAME] 1, [NAME] 1 stated, fortifying a meal would mean adding 1 tablespoon of melted butter on the meat and the vegetable in a meal tray. [NAME] 1 stated, she did 3 fortified meal trays today. During a review of the meal tickets for lunch, meal tickets indicated that five out of 30 meal tickets had fortified diet order. During a review of the facility's Diet Manual for Long Term Care (LTC) and Residential Facilities, dated 2020, the diet manual indicated, The fortified diet is designed for residents who cannot consume adequate amounts of calories and/or protein to maintain their weight or nutritional status. The diet manual also indicated, Examples of adding calories may include: Extra margarine or butter to food items such as vegetable, potatoes, hot cereal, bread, toast, pancakes, waffles, rice, pasta, etc. 555735 Page 10 of 17 555735 06/30/2022 Richmond Post Acute Care 955 23rd Street Richmond, CA 94804

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, and facility document review, the facility failed to prepare food to meet the needs of residents when the texture of corn served to residents receiving a mechanical soft diet was not the texture indicated on the menu, recipe, and the diet manual. This failure had the potential for two residents who received a mechanical soft diet to choke out of 30 residents who received food from the kitchen. Findings: Review of the menu cooks spreadsheet titled Summer Menus dated 6/27/22, the menu indicated, regular textured diets received corn with green peppers and mechanical soft diets received creamed corn. Review of the recipe titled Corn with [NAME] Peppers dated Week 4 Monday the recipe indicated, one of the ingredients was frozen corn. The recipe also indicated, for mechanical soft diets to substitute creamed corned for regular corn and to add cooked green peppers. Review of the Diet Manual for long Term Care and Residential Facilities dated 2020, the diet manual indicated, the Mechanical Soft diet was designed for residents who experienced chewing or swallowing limitations. For cooked vegetables, the diet manual indicated corn was to be creamed corn or could be whole if in mixed vegetables or soups. An observation and interview with the CDM and [NAME] 1 on 6/27/22, [NAME] 1 placed a scoop of regular corn on the trays that indicated a Mechanical Soft diet. When the surveyor asked the CDM if the corn served was the appropriate texture according to the menu, she stated, the corn should be creamed corned. When the CDM instructed [NAME] 1 to make creamed corn, [NAME] 1 asked the CDM how to make creamed corn. CDM told [NAME] 1 to blend the corn with milk. A recipe for creamed corn was not available. 555735 Page 11 of 17 555735 06/30/2022 Richmond Post Acute Care 955 23rd Street Richmond, CA 94804

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and facility document review, the facility failed to store, prepare, and distribute food safely when: 1. [NAME] 1 was placing lids on cups touching the drinking surface of the cups with no gloves. 2. The can opener had residue and paper from the can label sticking on the blade and the holder. 3. The 3-compartent dishwashing sink had no airgap (a gap of air between the floor a drainpipe.) 4. The refrigerator that stored food for the residents that are brought in by the family did not have a thermometer and was not clean. These deficient practices placed the residents at risk for contamination of food and equipment resulting in food borne illnesses for 28 residents who received food from the kitchen out of a facility census of 30. Findings: 1. During a concurrent observation and interview on 6/28/22, at 9:11 a.m., with Certified Dietary Manager (CDM) in the kitchen, [NAME] 1 was observed to be placing lids on drinking cups that had milk and juice to serve for resident lunches, touching the drinking surface of the cup with no gloves. CDM stated, that gloves need to be worn when placing lids on drinking cups because the hand would be touching the top of the cup where the residents' drinks from. During an interview on 6/28/22, at 12:45 p.m., with CDM, CDM stated, there was no policy and procedure for handling cups, but it was their policy not to touch the top of the cups with no gloves. According to the 2017 Federal Food Code, tableware which includes cups are to be handled so that contamination of [NAME]-and lip-contact surfaces are prevented. 2. During a concurrent observation and interview on 6/27/22, at 10:22 a.m., with [NAME] 1, observed that the industrial can opener was stored in a holder attached to the steam table. The can opener blade had black and brown residue and paper from the can label sticking on its blade. The can opener holder attached to the table also had brown and black residue and label paper stuck to the surface. [NAME] 1 stated, the can opener was last used in the earlier in the morning. [NAME] 1 stated,the can opener and the base are dirty, and it should be cleaned after each use. During an interview on 6/27/22, at 11:30 a.m., with CDM, CDM stated, can opener should be cleaned after each use. During a review of the policy and procedure titled Can Opener and Base dated 2018, the policy indicated can opener must be cleaned after each shift and more frequently when necessary. During a review of the facility's policy and procedure (P&P) titled, Cleaning and Sanitizing Dishes, Utensils, Pots and Pans, (undated), the P&P indicated, everything in the operation was to be kept 555735 Page 12 of 17 555735 06/30/2022 Richmond Post Acute Care 955 23rd Street Richmond, CA 94804

F 0812 clean. Any surface that comes into contact with food must be washed, rinsed and sanitized after each use . Level of Harm - Minimal harm or potential for actual harm According to the 2017 Federal Food Code, food-contact surfaces and utensils are to be clean to sight and tough Also nonfood-contact surfaces of equipment are to be kept free of an accumulation of food residue and other debris. Residents Affected - Many 3. During a concurrent observation and interview on 6/28/22, at 9:16 a.m., with DM, in the kitchen, observed there was a 3-compartment warewashing sink that was directly plumbed into the wall with no airgap. DM confirmed that there was no airgap for the 3-compartment sink. During an interview on 6/29/22, at 10:30 a.m., with Administrator (ADM), ADM stated, the 3-compartment sink was installed about 2 and a half years ago after the county inspection required the installation of it upon the change of ownership. During a review of the facility's P&P titled, Accident Prevention-Safety Precaution, , dated 2018, the P&P indicated, An air gap is the most reliable backflow prevention device. It is the physical separation of the potable and non-potable water supply systems by an air space. All steam tables, ice machines and bins, food preparation sinks, display cases, soda fountains, espresso machines and other equipment that discharge liquid waste or condensate shall be drained thorough an air gap into an open floor sink. According to the 2017 Federal Food Code, a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed. 4. During an interview on 6/29/22, at 10:45 a.m., with Director of Nursing (DON), DON stated, food brought in by visitors for the residents are stored in the refrigerator in the employee's lounge. During a concurrent observation and interview on 6/29/22, at 10:53 a.m., with Maintenance Director (MD), , there was one refrigerator/freezer located in the staff lounge. MD stated, resident food was stored in the freezer/refrigerator with the staff food if food was brought into residents by family or visitors. Observed the freezer had brown and yellow dried matter on its inside surface. Also, the refrigerator did not have a thermometer inside. MD confirmed that there was no thermometer in the refrigerator and stated the freezer was dirty. During a review of the facility's P&P titled, Procedure for Refrigerated Storage, dated 2018, the P&P indicated, Two thermometers, placed to be easily visible for checking, should be inside all walk-in, reach in-refrigerators. The P&P also indicated, Refrigeration equipment should be routinely cleaned. According to the 2017 Federal Food Code, food-contact surfaces of equipment are to be clean to sight and touch. In addition, nonfood-contact surfaces of equipment are to be kept free of an accumulation of food residue and other debris. 555735 Page 13 of 17 555735 06/30/2022 Richmond Post Acute Care 955 23rd Street Richmond, CA 94804

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and facility document review, the facility failed to ensure staff followed the policy and procedure for food brought into residents by family and other visitors. This failure had the potential for decreased consumption of food preferred by 28 residents who ate food by mouth out of a facility census of 30. Residents Affected - Many Findings: A review of the policy and procedure titled Food for Residents from Outside Sources dated 2018, policy indicated, food brought into the facility from outside sources would be monitored in order to measure the effectiveness of this intervention in residents with low food intake. Nursing and/or Admissions would provide the family of new admits with the information sheet Bringing in food for our residents. The procedures for this policy included Prepared food brought in for the resident must be consumed within (1) hour of receiving it in an effort to prevent food borne illness. Unused food will be disposed of immediately thereafter. The procedures also included Prepared foods, beverages, or perishable food that requires refrigeration, can be stored for the resident in the facility kitchen, nursing station's refrigerator or in the residents' personal refrigerator. In the food service department, the policy on food storage will apply. Otherwise, if unopened, refrigerator or frozen items will be disposed of by the expiration date on the container. If opened, the food must be sealed, dated to the date opened and disposed of in 2 days after opening. Frozen items, such as ice cream, will be disposed of in 30 days. A review of the document titled Bringing in Food for a Resident dated 2018, document indicated, Foods or beverages that are past the manufacturer's expiration date will be thrown away. Foods in unmarked or unlabeled containers will be marked with the current date and the resident's name . Prepared foods, beverages, or perishable foods that require refrigeration will be marked with the date food was opened and resident's name. Refrigeration can occur in a personal room refrigerator, nurses station food refrigerator, or food and nutrition services refrigerator. Unused food will be discarded within 2 days and if kept frozen, 30 days. During an interview on 6/29/22 at 10:20 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated, food brought in by family or visitors was not allowed to be stored. She said they can eat food brought in, but it was never stored for them. She also stated unopened packaged food such as bottled drinks could not be stored for the residents. During an interview on 6/29/22 at 10:45 a.m., with the Director of Nursing (DON), DON stated, food brought in by family or visitors could be stored in the refrigerator for residents located in the staff lounge. He stated there were two refrigerators, 1 for staff, and 1 for residents. He said the food for the residents had to be labeled and dated and how long it could be stored depended on the type of food. When the DON reviewed the policy, he stated it was contradictory when it read perishable food brought it had to be discarded if the resident did not eat it and that perishable food could be stored for 2 days in the refrigerator. During an observation and interview with the Assistant Administrator (AADM) on 6/29/22, AADM showed 1 refrigerator in the staff lounge. The AADM stated, food brought into residents by family and visitors could be stored in the staff refrigerator for up to 24 hours. During an interview on 6/29/22 at 11:15 a.m., with the CDM, CDM stated, resident food could be 555735 Page 14 of 17 555735 06/30/2022 Richmond Post Acute Care 955 23rd Street Richmond, CA 94804

F 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many stored in the staff refrigerator for up to 2 days if it was sealed and covered. She said sealed container was one that had a lid that was closed. She said if the food was not covered it would be discarded. She stated resident food brought in from outside never entered the kitchen. She agreed that the current policy was contradictory when it read perishable food brought it had to be discarded if the resident did not eat it and that perishable food could be stored for 2 days in the refrigerator, and that the policy should reflect what the facility was actually allowing. 555735 Page 15 of 17 555735 06/30/2022 Richmond Post Acute Care 955 23rd Street Richmond, CA 94804

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the proper disposal of refuse and garbage when: Residents Affected - Many 1. One of the two trash bins outside the facility was overfilled and did not have the lid closed completely. This deficient practice had the potential to attract rodents and insects resulting in pest related illness for all 30 residents residing in the facility. Findings: During a concurrent observation and interview on 6/28/22, at 11:45 a.m.,with Maintenance Director (MD), outside the facility, observed a trash bin overflowing with black and white trash bags. The trash bin had two lids and one lid was open over 1.5 feet and the other lid was open 1 foot with trashbags that did not allow the lids to close completely. MD confirmed this was the only trash bin for the facility. During an interview on 6/29/30, at 6:35 a.m., with MD, MD stated, they would usually call the garbage disposal company if garbage bins were full, but they did not attempt to call them yesterday. During a review of the facility's policy and procedure (P&P) (untitled and undated), the P&P indicated, The EVS shall call should there be a need for extra garbage pickup. According to the 2017 Federal Food Code, receptacles and waste handling units for refuse with materials containing food residue and used outside are to have tight-fittings lids, doors, or covers. 555735 Page 16 of 17 555735 06/30/2022 Richmond Post Acute Care 955 23rd Street Richmond, CA 94804

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 and interview, the facility had five resident rooms (Rooms 4, 5, 8, 9 and 10) with multiple beds that provided less than 80 square (sq. ft) per resident. This deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents in each room, or for storage of the residents' belongings. Findings: During an interview with the Assistant Administrator (AADM) on 06/29/2022 at 11:18 am, the following rooms and corresponding square footage per bed were identified: 1. room [ROOM NUMBER] had two beds and it measured 154 sq ft, providing 77 sq ft per resident 2. room [ROOM NUMBER] had two beds and it measured 154 sq ft, providing 77 sq ft per resident 3. room [ROOM NUMBER] had three beds and it measured 220 sq ft, providing 73.33 sq ft per resident 4. room [ROOM NUMBER] had three beds and it measured 220 sq ft, providing 73.33 sq ft per resident 5. room [ROOM NUMBER] had three beds and it measured 220 sq ft, providing 73.33 sq ft per resident During random observations of care and services from 06/27/2022 through 06/30/2022, there was sufficient space for the provision of care for the residents in all rooms. There was no heavy equipment kept in the rooms that might interfere with residents care and each resident had adequate personal space and privacy. There were no complaints from the residents regarding insufficient space for their belongings. There were no negative consequences attributed the decreased space and/or safety concerns in the five rooms. 555735 Page 17 of 17