Health inspection·June 14, 2019

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to accommodate personal privacy for one of 10 sampled residents (Resident 4) when: Resident 4's privacy curtain was not drawn around his bed while he rested and exposed his undressed body below the waist line. Residents Affected - Few This failure violated Resident 4's right to be treated with dignity and respect. Findings: During an observation on 6/13/19, at 7:54 a.m., in Resident 4's room, Resident 4 laid in bed while asleep, he was undressed from the waist down and was uncovered. Resident 4's brief, naked legs and feet were visible to those who passed by his room. Resident 4's privacy curtain was not drawn around Resident 4 to provide him with privacy. During a concurrent observation and interview with Certified Nursing Assistant (CNA) 1, on 6/13/19, at 8:05 a.m., CNA 1 stated Resident 4 was uncovered and was not provided with privacy. CNA 1 stated anyone who passed by Resident 4's room could see his brief and undressed lower body. CNA 1 stated Resident 4's privacy curtain was not drawn around his bed to provide him with privacy and should have been drawn around his bed to provide him with privacy. During an interview with the Director of Nursing (DON), on 6/13/19, at 3:45 p.m., the DON stated staff should have made sure all residents were covered and provided with privacy in order to not violate their dignity. The facility policy and procedure titled, Resident Rights . undated, indicated As a resident of this nursing facility, you have the right to a dignified existence . You have the right to be treated with respect and dignity. Page 1 of 9 555749 555749 06/14/2019 Covenant Village Care Center 2125 North Olive Avenue Turlock, CA 95382

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 facility medication error rate did not exceed five percent or greater when: there were 82 medication pass opportunities for error and 10 errors resulted in a medication error rate of 12.2 percent. Residents Affected - Few This failure resulted in the significant medication error for Resident 15. Findings: During an observation and concurrent interview with Licensed Vocational Nurse (LVN) 3, on 6/12/19, at 11:39 a.m., during a morning medication pass, LVN 3 prepared medications for Resident 15. LVN 3 prepared and administered the following medications: amitriptline hydrochloride (hcl) (medication used to treat major depression) (mood disorder) 50 milligram (mg) (dry unit of measurement), carbidopa-levodopa (used to treat Parkinson) (disease of the brain causes involuntary body movements) 25-100 mg, duloxetine hcl (medication to treat depression) (mood disorder ) 30 mg capsule, isosorbide mononitrate 10 mg (mediction used to prevent chest pain), losartan potassium 50 mg tablets (medication to lowers blood pressure), metoprolol succinate 50 mg 1 tablet (high blood pressure medication), ferrous sulfate 325 mg (iron supplement) 1 tablet, vitamin D (supplement) 1 tablet, dabigatran etexilate 150 mg (medication to prevent blood clots), fluticasone propionate (allergy relief medication) 50 microgram (MCG) (unit of measurement) 2 sprays in each nostril, fexofenadine180 mg (allergy medication) 1 tab daily. LVN 3 stated she would not administer glipizide 5 mg tablet (anti-diabetic medication) because the medication indicated an expiration date of 5/2019. LVN 3 stated the medications administered at 11:39 a.m., were all due at 9 a.m., and were considered late. LVN 3 stated Resident 15 was asleep and she did not want to wake him up at 9 a.m. During a review of the clinical record for Resident 15's Nurses notes dated 6/12/19, at 12:46 p.m., LVN 3 not given because the resident was sleeping. During an interview with Resident 15, on 6/13/19, at 2:34 p.m., he stated it was not a problem for him to wake up the morning. Resident 15 stated he wanted to take his medication and he did not mind being woken up by the nurses. Resident 15 stated he would never refuse to take his medications. During a Review of the Minimum Data Set (MDS) assessment (an evaluation of a residents cognitive, physical abilities and needs) dated 3/28/19, indicated Resident 15 had no cognitive impairment with a BIMS (Brief interview for mental status) score of 13 of 15. During a medication reconciliation of the Medication Administration record (MAR), on 6/13/19, at 8:15 a.m., Resident 15's morning medications which included amitriptline hcl 50 mg, carbidopa-levodopa 25-100 mg, duloxetine hcl 30 mg, isosorbide mononitrate 10 mg, losartan potassium 50 mg, metoprolol succinate 50 mg, ferrous sulfate 325 mg 1 tablet, vitamin D 1 tablet, dabigatran etexilate 150 mg, fluticasone propionate, 50 microgram 2 sprays in each nostril, fexofenadine180 mg 1 tab daily and glipizide 5 mg tablet were ordered to be administered at 9 a.m. Resident 15's, MAR indicated medications were initialed as administered by LVN 3 at 9 a.m., and not 11:39 a.m. LVN 3 initialed glipizide 5 mg as being administered on 6/12/19 at 9 a.m. During an interview with the Director of Nursing (DON), on 6/13/19, at 2:54 p.m., she stated LVN 3 should have woken Resident 15 to administer his medication. 555749 Page 2 of 9 555749 06/14/2019 Covenant Village Care Center 2125 North Olive Avenue Turlock, CA 95382

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The facility policy and procedure titled, Administering Medications dated 12/12, indicated, Medications shall be administered in a safe and timely manner, and as prescribed .4. Medications must be administered with one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). 6. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving a medication . 555749 Page 3 of 9 555749 06/14/2019 Covenant Village Care Center 2125 North Olive Avenue Turlock, CA 95382

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure Resident 15 was free of a significant medication error when Licensed Vocational Nurse (LVN) 3 did not administer a morning dose of glipizide (medication used to treat high blood sugar). Residents Affected - Few This failure placed Resident 15 at risk for complications from elevated blood sugar. Findings: During an observation and concurrent interview with Licensed Vocational Nurse (LVN) 3, on 6/12/19, at 11:39 a.m., during a morning medication pass, LVN 3 prepared medications for Resident 15. LVN 3 prepared all 9 a.m., medications ordered except for glipizide 5 mg tablet. LVN 3 stated she was not going to administer Resident 15's glipizide because the medication indicated an expiration date of 5/2019. During a concurrent observation and interview with LVN 3, on 6/12/19, at 11:45 a.m., LVN 3 checked Resident 15's blood sugar. Resident 15's blood sugar was 187 and required 2 units of novolin insulin (medication used to help control blood sugar) injection based on a sliding scale (ordered amount of insulin given according to the blood sugar reading) ordered by the physician. LVN 3 drew up and administered 2 units of insulin to Resident 15. During a telephone interview with the Pharmacy Supervisor (PS), on 6/13/19, at 2:33 p.m., the PS stated the expiration date for glipizide was 5/2019. The PS stated the glipizide was an intermediate acting dose that would act similar to insulin by lowering the blood sugar. The PS stated Resident 15 might not have required the regular insulin administration if glipizide was administered in the morning. During an interview with the Director of Nursing (DON), on 6/13/19, at 2:54 p.m., she stated there was a possibility Resident 15 might not have required his insulin injection if he had received the glipizide in the morning. The facility policy and procedure titled, Administering Medications dated 12/12, indicated, Medications shall be administered in a safe and timely manner, and as prescribed .4. Medications must be administered with one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). 6. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving a medication . 555749 Page 4 of 9 555749 06/14/2019 Covenant Village Care Center 2125 North Olive Avenue Turlock, CA 95382

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review, the facility failed to follow the recipe portion size for five of five sampled residents (Resident 21, Resident 37, Resident 18, Resident 193, Resident 22) when: the Dietary [NAME] (DC) served 2.2 ounces (dry unit of measurement) of braised Swiss steak instead of serving four ounces for one lunch meal. This failure placed Resident 21, Resident 37, Resident 18, Resident 193 and Resident 31 at risk for nutritional inadequacy. Findings: During a concurrent observation and interview with the DC, on 6/12/19, at 11:50 a.m., in the kitchen, the DC served the residents with the lunch of the day. The DC served braised Swiss steak, cheese tortellini with pesto sauce, sliced apples and a cucumber salad with ginger vinaigrette to Resident 18, Resident 21, Resident 22, Resident 37, and Resident 193. The DC did not measure the braised Swiss steak prior to serving. The DC stated the braised Swiss steak weighed four ounces prior to cooking. The DC stated she would weigh the braised Swiss steak and should have weighed the braised Swiss steak prior to serving. The DC calibrated the weighing scale, then took a slice of braised Swiss steak and weighed the braised Swiss steak on the scale. The braised Swiss steak weighed 2.2 ounces. DC stated, I should have served two slices of meat to make it 4 ounces. The DC stated she did not serve four ounces of braised Swiss steak to the five residents which could have lead to a protein inadequacy and weight loss. During a concurrent observation and interview with the Kitchen Director (KD), on 6/12/19, at 12:15 p.m., in the kitchen, the KD adjusted the weighing scale and re-weighed the braised Swiss steak for the second time. The KD validated the braised Swiss steak per slice weighed 2.2 ounces. The KD stated she should have instructed the staff to weigh the meat after cooking before serving to residents. The KD stated the residents should have been served 4 ounces of braised Swiss steak as indicated in the diet spreadsheet to prevent the risk of weight loss. During a concurrent interview and record review with the Registered Dietitian (RD), on 6/12/19, at 12:15 p.m., the RD reviewed the facility document titled Diet Spreadsheets dated 6/12/19, indicated .Regular .Braised Swiss Steak .Portions .4 [ounces] oz .'' The RD stated residents did not meet the posted amount of 4 ounces of meat that should have been provided to residents who were on a regular diet. The RD stated if less than 4 ounces of Swiss steak was served to residents there was not enough protein served and that could be a reduced nutritional supplement which could lead to weight loss and impaired wound healing. The facility policy and procedure titled, Menu Planning guidelines dated 5/22/17, indicated Policy .Procedure .2. Menu content is planned to be nutritionally adequate to meet most resident populations on regular diets. Modified diets are restricted to their specific guidelines and may or may not meet dietary guidelines RDA/DRI [Recommended Dietary Allowances/Dietary Reference Intakes] .7. Dietitian is responsible for ensuring menu meet nutritional adequacy,signs and dates the menu spreadsheet or individual diet plan . 555749 Page 5 of 9 555749 06/14/2019 Covenant Village Care Center 2125 North Olive Avenue Turlock, CA 95382

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure food was stored, prepared and served in accordance with professional standards for food service safety when: undated, opened bags of spices, hot dog buns, waffles, sugar, mayonnaise, chunk light tuna, chopped onions and an expired 1/4 milk gallon container were stored and available for use in the walk-in freezer, refrigerator and dry food storage areas. These failures to ensure effective dietetic service operations placed residents that received meal from the kitchen at risk for food borne illness and the growth of microorganisms. Findings: During a concurrent observation and interview with the Kitchen Director (KD), on 6/11/19, at 9:07 a.m., in the dry storage area, an undated and unlabeled 40 ounce opened bag of parsley flakes, an opened undated and unlabeled bag of basil leaves, an opened undated and unlabeled 8 ounce bag of white sugar with an expiration date of 5/1/19 were stored and available for use. The KD stated the items should have been dated with open date and used by date by the kitchen staff. During a concurrent observation and interview with the KD, on 6/11/19, at 9:35 a.m., in the kitchen's walk in freezer, four undated opened unlabeled bags of hotdog buns, two undated opened unlabeled plastic bags of cooked waffles were stored and ready for use in the walk in freezer. The KD confirmed the bags were not dated. The KD stated the items in the kitchen needed to have opened and used by date on the package label. During a concurrent observation and interview with KD, in the kitchen's freezer, on 6/11/19, at 9:55 a.m., an expired 1/4 fat free milk gallon with an opened date of 6/9/19 and used by 6/10/19 was available for use. An undated opened jar of mayonnaise was available for use. An undated opened plastic bag of chunk light tuna (prepared by kitchen staff on 5/23/19) and an undated bag of chopped onions were stored and ready for use. The KD reviewed the items and was unable to locate open or used by dates for the mayonnaise, chunk light tune and chopped onions. The KD confirmed the milk should have been discarded on 6/10/19 and the packed chunk tuna should have been labeled with use by date. The KD stated expired food items could cause food borne illness and elderly residents were susceptible to illness. The facility policy and procedure titled .Food and Nutrition Services, section 11: Sanitation and Infection control Labeling and Dating dated 1/2016, indicated Policy: All foods will be appropriately wrapped, labeled and dated based on food storage guidelines .Procedures: All foods are labeled, dated, and securely covered and use by dates are monitored and followed . All products are rotated using the first in, first out (FIFO) inventory method . The facility policy and procedure titled Food products Shelf Life Guidelines dated 1/12/17, indicated Purpose of the food Product shelf life guidelines To provide .general guideline for the shelf -life for food products .Product Description .spices, ground .dry storage .6-12 months .sugar confectioners or powdered 18 months .breads and rolls .Freezer .2 months . Pancakes and waffles .Freezer .1 month .Milk: whole, Reduced and low fat and fat free .Refrigerator . 7 days . Mayonnaise, commercial, refrigerate after opening . Refrigerator . 1 year unopened, 2 months opened .Deli meat/ Salads . store-prepared (or homemade) eggs, chicken, ham, tuna .Refrigerator . 3-5 days . 555749 Page 6 of 9 555749 06/14/2019 Covenant Village Care Center 2125 North Olive Avenue Turlock, CA 95382

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to establish and maintain an effective infection prevention and control program to prevent cross contamination (the transfer of germs from one surface to another) when: Residents Affected - Some 1. A used nebulizer mask (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) laid on top of Resident 9's nebulizer machine. The mask was unmarked. 2. An out dated nasal cannula (device used to deliver supplemental oxygen or increased airflow to a patient) laid on top of a concentrator (a medical device used to deliver oxygen which purifies the surrounding air) dated 6/2/19. These failures had the potential for bacteria to grow. 3. Resident 20's indwelling catheter (a flexible plastic tube inserted into the bladder to provide continuous urinary drainage) was kinked at the lower end of the catheter line and catheter urinary bag. This failure had the potential to place the resident at risk for discomfort and could lead to urinary tract infection. 4. Soiled briefs were found on top of a trash can in Resident 20 and Resident 4's restroom. These failures had the potential to place the residents at risk for cross contamination and exposure to infectious organisms. 5. Two dietary staff had hair exposed during meal preparation. These failures placed residents at risk for food borne illness. Findings: 1. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 2, on 6/11/19, at 10 a.m., Resident 9's uncovered and unmarked nebulizer mask laid on top of the nebulizer. LVN 2 stated she did not change Resident 9's nebulizer mask because it was changed by the night shift nurse. LVN 2 stated the night shift were supposed to change the masks on Sunday nights and label them after being changed. 2. During a concurrent observation and interview with Resident 1, on 6/11/19, at 11:21 a.m., in Resident's 1 room, a nasal cannula used by Resident 1 was inside a plastic bag dated 6/2/19. Resident 1 stated he used the nasal cannula every night. During an interview with LVN 2, on 6/11/19, at 11:26 a.m., LVN 2 stated the oxygen tubing was changed every week on Sunday night by the night nurse. LVN 2 stated Resident 1's tubing was out dated, the date on the bag was 6/2/19. LVN 2 stated Resident 1 used his oxygen on a as needed basis. LVN 2 stated the tubing should have been changed on 6/9/19 by the night nurse. LVN 2 stated it was an 555749 Page 7 of 9 555749 06/14/2019 Covenant Village Care Center 2125 North Olive Avenue Turlock, CA 95382

F 0880 infection control issue and the resident could get sick from germs on the tubing. Level of Harm - Minimal harm or potential for actual harm During an interview with the Director of Nursing (DON), on 6/12/19, at 10:00 a.m., the DON stated there was no bag to store Resident 9's nebulizer mask. The DON stated Resident 1's oxygen cannula tubing was out date and should have been changed on Sunday night [6/9/19] by the night nurse. The DON stated it was an infection control issue and the residents could get sick from having germs on the out dated nasal cannula and the unbagged mask. Residents Affected - Some The Facility policy and procedure titled Respiratory Therapy - Prevention of Infection dated 11/2011, indicated Purpose The purpose to this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, 4. Change the oxygen cannula and tubing every seven (7) days, or as needed. 5. Keep the oxygen cannula and tubing used PRN in a plastic bag when not in use. 3. During an observation on 6/11/19, at 2:45 p.m., in Resident 20's room, Resident 20 laid in bed, awake,with a kinked indwelling urinary catheter. Resident 20's catheter tubing was kinked where the tube connected to the catheter bag and did not allow urine to drain into the collection bag. During a concurrent observation and interview with LVN 1, on 6/11/19, at 3:37 p.m., LVN 1 stated Resident 20's catheter bag was kinked and did not drain urine into the bag. LVN 1 stated urine needed to flow freely without any kinks in the tubing. LVN stated there could be urine retained in the bladder that could lead to a urinary tract infection if the line was kinked. During an interview with Certified Nursing Assistant (CNA) 1, on 6/12/19, at 9:18 a.m., CNA 1 stated she cared for Resident 20 on 6/11/19 during the morning shift. CNA 1 stated she should have checked Resident 20's catheter tubing and verified that it was free of kinks and did not do so. CNA 1 stated a kink in the catheter could back up to the bladder and cause infection to Resident 20. During an interview with Director of Staff Development (DSD), on 6/12/19, at 9:25 a.m., DSD stated staff should have checked the patency (unlinked tubing) of the catheter during the catheter care. DSD stated the kinks in the catheter could cause urinary tract infection and discomfort to Resident 20. During an interview with Director of Nursing (DON), on 6/13/19, at 3:45 p.m., the DON stated staff should make sure that catheter lines were patent (open) so that urine flow will run freely to prevent urine backflow that could lead to discomfort and urinary tract infection The facility policy and procedure titled, Catheter Care, Urinary dated 7/2014, indicated, The purpose of this procedure is to prevent catheter-associated urinary tract infection . Maintaining Unobstructed urine Flow 1. Check the resident frequently to be sure he or she is lying on the catheter and to keep the catheter and tubing free of kinks . 4. During a concurrent interview and observation with LVN 1, on 6/11/19, at 3:37 p.m., in Resident 20 and Resident 4's restroom, LVN 1 found soiled briefs, one unbagged and the other brief was on top of the trash can in Resident 20 and Resident 4's room. LVN 1 stated, I do not know who forgot to toss it in the trash can. LVN 1 stated soiled briefs left on top of trash was an unsanitary practice. During an interview with the DSD, on 6/12/19, at 9:25 a.m., the DSD stated staff should have checked the restroom during their rounds with residents and before their shift ended. The DSD stated the soiled briefs on top of the garbage could cause cross contamination to residents who used the 555749 Page 8 of 9 555749 06/14/2019 Covenant Village Care Center 2125 North Olive Avenue Turlock, CA 95382

F 0880 restroom left with soiled briefs. Level of Harm - Minimal harm or potential for actual harm The facility policy and procedure titled Infection Control and Prevention dated 11/1/16, indicated, Policy: It is the policy of Covenant Retirement Communities to maintain an infection control and prevention program within the facility as well as an Antibiotic Stewardship Program. The facility will provide a safe, sanitary, and comfortable environment designed to prevent as possible and improve control of transmittable pathogens [germs], disease and infection . Residents Affected - Some 5. During a concurrent observation and interview with Dietary [NAME] (DC) and Dietary Staff (DS), on 6/12/19, at 11:29 p.m., in the kitchen during the trayline meal preparation, DC and DS partially covered their hair and exposed hair from their forehead. DC stated all of their hairs should have been covered with the hair net. DC stated it was important to cover all of their hair to prevent hair from falling into the food being prepared. During an observation on 6/12/19, at 11:29 in the kitchen. DC was working in the preparation meal table with exposed hair from her forehead not covered by the hairnet. During a concurrent observation and interview with DC, on 6/13/19, at 6:53 a.m., in the kitchen. DC had uncovered and exposed hair from her forehead while she prepared breakfast. DC stated, My hair is too thick and heavy its always pulling down. I should have .checked my hair if it was all covered before going into the kitchen. The DC stated covering her hair would prevent her hair from falling into the food. During an interview with Registered Dietitian (RD) on 6/13/19, at 4:25 p.m., RD stated staff needed to make sure to cover all of their hair during food preparation. RD stated uncovered hair was a potential risk for food contamination to residents. The facility policy and procedure titled Hair Restraint Policy dated 1/4/19, indicated, Policy: Hair restraints must be worn in the kitchen at all times to ensure food safety. Procedure: 1. Hair restraints (hairnets, hats, or caps) must cover hair sufficiently to effectively keep hair from contacting exposed food, clean equipment, utensils, linens, and unwrapped single- service and single- use articles as well as to minimize hand contact with hair . The facility policy and procedure titled, Infection Control and Prevention dated 11/1/16, indicated, Policy: It is the policy of [facility] to maintain an infection control and prevention program within the facility . The facility will provide a safe, sanitary and comfortable environment . 555749 Page 9 of 9