Health inspection·August 2, 2019

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 Based on interview and record review, the facility failed to develop baseline care plans within the first 48 hours of admission which provided instructions for the provision of effective and person-centered care for four of 22 sampled residents (Residents 231, 77, 73 and 7) when: a. For Residents 231 and 77, there were no baseline care plans to address their pacemakers (devices to help control abnormal heart rhythms) htat included specific information about the pacemaker. For Residents 231 and 77, this deficient practice had the potential to result in unrecognized abnormal pacemaker function (include fainting, dizziness, palpitations, and slow or fast heart rate) and the delay of care. b. For Resident 73, there was no baseline care plan to address the administration of Lovenox (a medicine that thins the blood). For Resident 73, this deficient practice had the potential to result in unrecognized adverse effects of Lovenox (medication used to prevent and treat blood clots. Adverse effects include unusual bleeding or bleeding that will not stop) and the delay of care in a bleeding emergency. c. For Resident 7, there was no baseline care plan to address the diagnosis of chronic obstructive pulmonary disease (COPD - a condition involving constriction of the airways and difficulty or discomfort in breathing). For Resident 7, this deficient had the potential to result in unrecognized complications of COPD (difficulty breathing, respiratory infection, respiratory failure) and the delay of care. Findings: a. Review of Resident 231's Detailed Summary, dated 7/18/19, indicated Resident 231 was admitted to the facility with multiple diagnoses that included a pacemaker. During a concurrent interview and record review with the Minimum Data Set Coordinator (MDSC 2) on 8/01/19, at 9:31 a.m., MDSC 2 stated Resident 231's Face Sheet, dated 7/18/19, indicated he had a pacemaker. MDSC 2 stated the night shift nurses developed baseline care plans on new admissions. MDSC 2 was not able to show documentation, in Resident 231's clinical record, that a pacemaker baseline care plan had been developed. MDSC 2 stated Resident 231 needed a baseline care plan to address his pacemaker. Review of Resident 77's Detailed Summary, dated 7/31/19, indicated Resident 77 was admitted to the facility on with multiple diagnoses that included a pacemaker. Page 1 of 7 555843 555843 08/02/2019 Masonic Home 34400 Mission Blvd Union City, CA 94587

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with MDSC 2 on 8/02/19, at 9:41 a.m., MDSC 2 stated she did not develop a baseline care plan for Resident 77's pacemaker. During a concurrent interview and record review with the Director of Nursing (DON) on 8/02/19, at 10:06 a.m., DON stated Resident 77 needed a baseline care plan to address her pacemaker. DON stated the pacemaker care plan needed to include Resident 77's cardiologist's (a doctor who specializes in the treatment of heart diseases) name, and information about the pacemaker's make and model. DON was not able to show documentation, in Resident 77's clinical record, that a pacemaker baseline care plan had been developed. b. Review of Resident 73's Detailed Summary, dated 7/23/19, indicated Resident 73 was admitted to the facility with multiple diagnoses that included a fracture (a crack or break of a bone) of the left femur (thigh bone). Review of Resident 73's physician's orders, dated 7/31/19, indicated Resident 73 had an order to receive 40 milligrams of Lovenox subcutaneously (an injection that goes under the skin) daily. During an interview with MDSC 2 on 7/31/19, at 9:05 a.m., MDSC 2 stated Resident 73 did not have a baseline care plan to address her receiving Lovenox, but stated Resident 73 needed one. c. Review of Resident 7's Detailed Summary, not dated, indicated Resident 7 was admitted to the facility with multiples diagnoses that included COPD. During a concurrent interview and record review with MDSC 2 on 8/01/19, at 10:24 a.m., MDSC 2 stated Resident 7 needed a baseline care plan for COPD, but MDSC 2 was not able to show documentation in Resident 7's clinical record that a baseline care plan for COPD had been developed. Review of the facility's policy and procedure titled SNF-Chapter 10-Resident Assessment & Care Planning 004 Care Plans-Baseline, revised 11/2/17, indicated .1. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission 555843 Page 2 of 7 555843 08/02/2019 Masonic Home 34400 Mission Blvd Union City, CA 94587

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review, the facility failed to develop and implement a comprehensive care plan for one of 22 (Resident 40) sampled residents when Resident 40 did not have a care plan to address him receiving Eliquis (a medication that thins the blood). For Resident 40, this deficient practice had the potential to result in delayed care for an unrecognized bleeding emergency. Findings: Review of Resident 40's Detailed Summary, undated, indicated Resident 40 was admitted to the facility with diagnoses that included atrial fibrillation (a quivering or irregular heartbeat (arrhythmia) that can lead to blood clots, stroke, heart failure and other heart-related complications). Review of Resident 40's physician's order, dated 7/31/19, indicated Resident 40 had an order to receive 2.5 milligrams of Eliquis twice a day for atrial fibrillation. During an interview and concurrent record review on 7/31/19, at 8:42 a.m., Minimum Data Set Coordinator (MDSC) 2 stated Resident 40 did not have a care plan to address him taking Eliquis in his clinical record, but he needed one. Review of the facility's policy and procedure titled SNF-Chapter 10- Resident Assessment & Care Planning 003 Care Plans, Comprehensive Person-Centered, revised 11/2/17, indicated .12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS) 555843 Page 3 of 7 555843 08/02/2019 Masonic Home 34400 Mission Blvd Union City, CA 94587

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, for one of 22 sampled residents (Resident 32), the facility failed to ensure supervision to prevent accidents when Resident 32's wander guard device (an alarm system for wandering or flight risk residents) was not in place. For Resident 32, this deficient practice had the potential to result in elopement from the facility. Findings: Review of Resident 32's medical record Detailed Summary indicated, resident was admitted to the facility with diagnoses that included Alzheimer's dementia (loss of cognitive function and memory). Review of Resident 32's Minimum Data Set (MDS - an assessment tool used to direct care), dated 5/26/19, indicated Resident 32 was severely impaired in his attention, orientation, and ability to register and recall new information of three. The MDS also indicated Resident 32 had daily use of a wander/elopement alarm (a device that monitors resident movement and alerts the staff when movement is detected). Review of Resident 32's Physician's Order, dated 11/28/19, indicated instructions to Apply Wander guard device on the resident's left foot to alert staff when resident attempts to leave the unit/floor unsupervised or unassisted. Check proper placement of the Wander guard device every shift Review of the Care Plan Wandering/Elopement, dated 3/23/19, with revised date 5/26/19, indicated Resident 32 had a history of elopement/wandering room to room, within the building, or out of the facility. The care plan further indicated instructions to .Apply wander guard as ordered During a concurrent observation and interview on 7/30/19, at 9:14 a.m., Resident 32 was inside his room, seated in a reclining chair, with his eyes closed. Certified Nursing Assistant (CNA) 3 stated Resident 32 was ambulatory (could walk) and was an elopement risk. CNA 3 checked Resident 32 lower leg and ankles and both wrists for a wander guard device, but no wander guard device was found on Resident 32. 555843 Page 4 of 7 555843 08/02/2019 Masonic Home 34400 Mission Blvd Union City, CA 94587

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to follow proper sanitation and food storage practices when: Residents Affected - Some a. A fluffy, gray material was observed on the filters and filter covers of two ice machines; and b. A medication refrigerator temperature log was used for the Resident food refrigerator temperature log for Station #2. These deficient practices had the potential to result in foodborne. Findings: a. During an observation and concurrent interview with the RD on 8/1/19, at 7:40 a.m., there were two ice machines (ice machines #1 and #2) that had fluffy, gray material located on the filters and on the filter covers. RD stated the fluffy gray material was dust. RD stated the maintenance staff cleaned the ice machines' filters and filter covers, but did not know when. RD was not able to show a record of when the filters and filter covers had been cleaned. During an interview with the Assistant Facility Director (AFD) on 8/1/19, at 7:45 a.m., AFD stated the dietary staff needed to clean the ice machines' filters and filter covers because the filters and covers could be accessed without the assistance of the maintenance staff. AFD stated the maintenance staff last sanitized the ice machines on 7/19/19. Review of facility's policy and procedure titled, DTY Chapter 4-Sanitation and Infection Control-004 General Sanitation of Kitchen, undated, indicated .1. Cleaning and sanitation tasks for the kitchen will be recorded. 2. Tasks will be assigned to be the responsibility of specific positions Review of facility's policy and procedure titled, INC-Chapter 3-Environmental Infection Control 008 Ice Machines and Ice Storage Chests, revised 10/26/17, indicated .3. Our facility has established procedures for cleaning and disinfection ice machines b. During an observation on 8/1/19, at 9:50 a.m., Station #2's resident food refrigerator temperature log indicated it had the same temperature range (36 to 46 degrees Fahrenheit) as the medication refrigerator. During an interview with Licensed Vocational Nurse (LVN) 2 on 8/01/19 at 12:09 p.m., LVN 2 stated she checked the resident food refrigerator temperature log today, and she stated the temperature should be between 36-46 degrees. LVN 2 showed a log that had medication refrigerator temperature and resident food refrigerator temperature ranges on the same log. During an interview with the Director of Nursing (DON) on 8/01/19, at 10 a.m., DON stated the medication refrigerator temperature log and the resident food refrigerator temperature log should be on separate logs due to different temperature range requirements. Review of facility's policy and procedure titled, INC-Chapter 3-Environmental Infection Control 023 Refrigerators: Medication, Food and Specimens, indicated food refrigerators were to be maintained 555843 Page 5 of 7 555843 08/02/2019 Masonic Home 34400 Mission Blvd Union City, CA 94587

F 0812 between 33-41 degrees Fahrenheit. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 555843 Page 6 of 7 555843 08/02/2019 Masonic Home 34400 Mission Blvd Union City, CA 94587

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 observe infection control practices when Registered Nurse (RN 1) and Assistant Director of Nursing (ADON) handled Resident 63's oxygen tubing while wearing gloves and did not wash their hands after removing their gloves. Residents Affected - Few This deficient practice had the potential to result in the spread of infection. Findings: Review of Resident 63's Face Sheet, undated, indicated Resident 63 was admitted to the facility with diagnoses that included chronic respiratory failure (when the respiratory system is unable to remove enough carbon dioxide from the blood, causing it to build up in the body). Review of Resident 63's physician's orders, dated 7/31/19, indicated Resident 63 had an order for oxygen at 2 liters per minute (LPM) via nasal cannula (a hollow tube used for oxygen administration) when needed for shortness of breath/comfort. During an observation and concurrent interview on 7/30/19, at 10:02 a.m., RN 1 handled Resident 63's oxygen tubing while wearing gloves and did not perform hand hygiene after removing the gloves. RN 1 left Resident 63's room, walked to a medication cart, opened and closed the Medication Administration Record (MAR) binder, left the cart and walked into another resident's room. RN 1 stated she should have sanitized hands after she removed her gloves in Resident 63's room. During an observation and joint interview on 7/30/19, at 10:07 a.m., ADON handled Resident 63's oxygen tubing while wearing gloves and did not perform hand hygiene after removing her gloves. ADON did not wash/sanitize her hands before she opened the medication cart and touched its contents. ADON stated she should have washed her hands after removing her gloves. During an interview with the Director of Staff Development (DSD) on 7/30/19 at 10:15 a.m., DSD stated the staff should wash their hands after removing gloves. Review of the facility's policy and procedure titled, INC-Chapter 7-Standard Precautions 003 Handwashing/Hand Hygiene, revised 20/26/17, indicated .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations .m. After removing gloves 555843 Page 7 of 7