Health inspection·February 6, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 follow skin and wound care policy and procedure when Resident 69 's pressure ulcer dressing was not appropriately labeled with last change date and the treatment nurse's initials. Residents Affected - Few This failure has the potential to result in missed monitoring and treatment, leading to delayed wound healing, increased wound size, and infections. Findings: During a review of Resident 69's Detailed Summary printed on 2/5/25, it indicated Resident 69 was originally admitted to the facility on [DATE], with diagnoses including pneumonia (an infection of one or both of the lungs caused by bacteria, viruses, or fungi), pressure ulcer (refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) of the left buttock (stage 2), Type 1 diabetes (a long-term (chronic) disease in which the body cannot regulate the amount of sugar in the blood), and chronic kidney disease. During a record review of Resident 69's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), Section C, dated 12/15/24, it indicated Resident 69 had a Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 12, indicating intact cognition. During a review of Resident 69's MDS, Section M, dated 12/26/24, it indicated Resident 69 did not have any pressure ulcers. During a review of Resident 69's Skin Evaluation Form, dated 1/5/24, it indicated Resident 69 had a 1.5 cm (centimeter, a unit of measure) long by 0.5 cm wide open area on the left buttock, described as pinkish, with serosanguineous (contains or relates to both blood and the liquid part of blood (serum)) drainage, type 2 partial thickness wound. During a review of Resident 69's Physician Orders for 2/2025, printed 2/5/25, it indicated the following treatment order, Order date 1/5/24, Start date 1/5/24, Left gluteal stage 2 PI (pressure injury)/CAPI (community-acquired pressure injury- a pressure ulcer that develops at home or in a nursing home)-three times per week cleans with NS (normal saline-a solution used to supply water and salt (sodium chloride) to the body). Apply Medihoney (a medical-grade honey intended for wound care. Offers Page 1 of 10 555843 555843 02/06/2025 Masonic Home 34400 Mission Blvd Union City, CA 94587

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few protection against invading bacteria, is effective against a wide variety of bacteria, cleans the wound, rapidly lifting dead tissue, reduces wound odor, and provides a moist environment to aid healing) + foam dressing. Change 3x(times)/week. No stop date. During a review of Resident 69's Skin Evaluation Form, dated 1/27/25, it indicated Resident 69's left buttock wound had increased in size, and was described as, 2 cm long x 2 cm wide area open superficial area, no bleeding described as wound edge: undermining. During a record review of Resident 69's Resident Weight Tracking System Report, printed 2/5/25, it indicated Resident 69 experienced a weight loss of 9.02% in one month (1/5/25 to 2/3/25), During a review of Resident 69's Interdisciplinary Notes dated 1/21/25, it indicated PI (pressure injury) stage 2 to buttock, on Prostat (a medical food used to increase protein intake in low volumes. It can be used to treat a variety of conditions, including wounds, pressure injuries, and muscle loss) BID (twice a day). During a concurrent observation/interview on 2/6/25 at 9:46 a.m. with Certified Nursing Assistant (CNA) in Resident 69's bedroom, consent to view and photograph Resident 69's left gluteal dressing was verbally obtained. A one inch by one inch square, white, foam dressing was directly taped above the gluteal cleft (separation between each buttock). The skin around the dressing was intact but reddened. The tape on and around the dressing did not have any markings indicating who changed it, or when it was last changed. During an interview on 2/6/25 at 9:54 am with Licensed Vocational Nurse 2 (LVN 2), LVN 2 indicated it is facility policy and good nursing practice to date and initial a dressing when it is changed, to make sure it is done as ordered, and dressing changes are not missed. LVN 2 also stated sometimes nurses forget because they are busy. During a record review of facility policy and procedure (P & P) titled, SNF -Nursing Services - Chapter 12 Skin and Wound Care 008 Wound Care, dated 11/17/17, the P & P indicated, Steps in Procedure .18. Dress wound. Pick up sponge with paper and apply directly to area. [NAME] tape with initials, time and date and apply dressing. 555843 Page 2 of 10 555843 02/06/2025 Masonic Home 34400 Mission Blvd Union City, CA 94587

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 ensure safe medication storage practices when expired medications in an emergency drug kit (a collection of medications used to treat medical emergencies) were available for use. This failure had the potential to result in residents receiving expired and ineffective medications. Findings: During a concurrent observation and interview on 2/3/25, at 11:04 AM, with Licensed Registered Nurse (RN2), in medication room on the third floor, several emergency drug kits were audited and observed one of them had an expiration date of 11/2024. RN2 confirmed that it had been expired since 11/2024. During a concurrent observation and interview on 2/3/25, at 11:20 AM, with the Pharmacy Manager (PM), in the medication room, the PM stated the emergency drug kit was expired on 11/2024, and she would have it replaced today. During a review of the facility's policy and procedure (P&P) titled, Medication Storage In The Facility undated, the P&P indicated, Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy . 555843 Page 3 of 10 555843 02/06/2025 Masonic Home 34400 Mission Blvd Union City, CA 94587

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 record review, the facility failed to ensure storage of food under sanitary conditions when the following food items in the walk-in-refrigerator were not dated and labeled with received, open and use-by dates : One open package of hot dog Six opened containers of salad cream One bowl of peeled mandarin oranges Ice machine cover and surface areas were dusty; inside panel area with brownish, rusty discoloration, and dusty grayish discolored water tubing sleeves. These deficient practices had the potential to cause food borne illness. Findings: During the initial tour of the kitchen on 2/3/25 at 9:20 a.m. with Director of Dining Services (DD) and Registered Dietician (RD), the following food items in the walk-in refrigerator were not labeled with use-by date: opened package of hot dog, six opened containers of salad cream and one bowl of peeled mandarin oranges. During an interview on 2/4/25 at 8:55 a.m. with [NAME] (CK 1), CK 1 stated she was trained to label and date food items in the refrigerator. CK 1 stated containers of salad creams were to be replaced on a daily basis. CK 1 said she did not know why package of hot dog and containers of salad cream in the walk-in-refrigerator not label with use by date. During an interview on 2/4/25 at 9:06 a.m. with Dietary Clerk (DC 1), DC 1 stated she was trained to label and date food items in the refrigerator. DC 1 stated ice cubes were used to serve with drinks during meals. During an interview on 2/4/25 at 9:26 a.m. with the Chef (Chef 1), Chef 1 stated the expectation was for dietary staff to label and date food items placed in the refrigerators. Chef 1 stated labeling machine was out of papers. Chef 1 said opened perishable food items must be disposed after three days. During an interview on 2/5/25 at 1:26 p.m. with DD, DD stated the expectation was for dietary staff to label all food items in the refrigerator. During a concurrent observation and interview on 2/4/25 at 10:15 a.m. with Maintenance Staff (MS), Facility Manager (FM), RD and DD in the kitchen, ice machine cover and surface areas were dusty; interior panel area of the ice machine had brownish rusty discoloration and dusty grayish discolored water tubing sleeves. During an interview on 2/5/25 at 11:13 a.m. with Administrator (Admin), FM, MS, RD and DD, FM 555843 Page 4 of 10 555843 02/06/2025 Masonic Home 34400 Mission Blvd Union City, CA 94587

F 0812 stated he will request for a new ice machine. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, Food and Supply Storage, revised date 1/25, the P&P indicated, All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Cover, label and date unused portions and open packages. Use the Medvantage/Freshdate labeling system or complete all sections on a [NAME] orange label. Products are good through the close of business on the date noted on the label. Residents Affected - Some 555843 Page 5 of 10 555843 02/06/2025 Masonic Home 34400 Mission Blvd Union City, CA 94587

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 garbage and refuse storage area was maintained in a sanitary condition when the dumpster's surrounding area was littered with trash and used gloves. Residents Affected - Few This failure had the potential of harborage and feeding of pest. Findings: During a concurrent observation and interview on 2/5/25 at 9:05 a.m. with Maintenance Staff (MS) and Registered Dietician (RD) the dumpster's surrounding area located behind the kitchen building had stagnant water and littered with trash and used gloves. MS stated littering around the dumpster with trash and used gloves was not an acceptable practice. During an interview on 2/5/25 at 11:13 a.m. with Administrator (Admin), Facility Manager (FM), MS, RD, and Director of Dining Services (DD), dumpster sanitation findings were reviewed. FM stated the dumpster area was scheduled for cleaning weekly and recently there had been a lot of staff who called off work due to illness. FM stated that he was sorry surveyor found the dumpster area like that. During a review of the facility's policy and procedure (P&P) TITLED, Sanitation and Infection Prevention/Control, revised date 1/25, the P&P indicated, Food waste and rubbish in the Food and Nutrition Services Department will be disposed of in an approved manner to prevent contamination of food, clean dishes or clean working area. 555843 Page 6 of 10 555843 02/06/2025 Masonic Home 34400 Mission Blvd Union City, CA 94587

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 three of 71 sampled residents' call lights were within easy reach (Residents 3,59 and 64). Residents Affected - Some This failure had the potential for the residents' inability to use the call light when in need of assistance. Findings: 1. During an initial tour of the facility on 2/6/25 at 10:09 a.m., in Resident 3's room, the resident was observed to be sitting in bed, alert and was able to answer questions. The call light was observed to be beyond the resident's reach as it was hanging on the wall beside the resident's bed. Resident 3 stated he did not know where his call light was, and stated he needed his call light to request for assistance occasionally. During a review of the clinical record for Resident 3, it indicated that Resident 3 was admitted to the facility on [DATE] with diagnoses which included muscle weakness and abnormalities of gait and mobility. During a concurrent observation and interview on 2/6/25 at 10:16 a.m., with Licensed Vocational Nurse (LVN) 1 in Resident 3's room, LVN 1 confirmed that Resident 3 could not reach his call light. LVN 1 acknowledged that Resident 3's call light should always be within reach so he could call the staff for help when needed. 2. During an initial tour of the facility on 2/6/25 at 10:09 a.m., in Resident 59's room, the resident was observed to be lying in bed. The call light was hanging on the wall towards the left side of the resident's bed. During a review of the clinical record for Resident 59, it indicated that Resident 59 was admitted to the facility on [DATE] with diagnoses which included palliative care (medical care that focuses on improving the quality of life for people with serious illnesses) and hemiplegia (weakness on one side of the body). During a concurrent observation and interview on 2/6/25 at 10:16 a.m., LVN 1 confirmed Resident 59 could not reach her call light. LVN 1 stated that Resident 59 used the call light to communicate her needs, and that the call light should be within the resident's reach at all times. 3. During an initial tour of the facility on 2/6/25 at 10:12 a.m., in Resident 64's room, the resident was observed to be lying in bed. The call light was observed to be hanging in the wall beside the resident's bed. During a review of the clinical record for Resident 64 indicated that Resident 64 was admitted to the facility on [DATE] with diagnoses which included muscle weakness and anxiety disorder (excessive and persistent worry, fear, and nervousness). During a concurrent observation and interview on 2/6/25 at 10:16 a.m., LVN 1 confirmed that Resident 64 could not reach his call light. Stated Resident 64 used the call light to communicate his needs 555843 Page 7 of 10 555843 02/06/2025 Masonic Home 34400 Mission Blvd Union City, CA 94587

F 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to the staff. Further stated, the call light should be within the resident's reach at all times so that the resident could call and ask for help from the staff. During an interview with Director of Nursing (DON) on 2/6/25 at 9:46 a.m., stated the residents should be able to reach their call lights at all the times while they are in bed, so they could get help timely and their needs met promptly. During a review of the facility's policy and procedure (P&P) titled, Nursing Services-Chapter 7- Nursing Procedures 001 Answering the Call Light, revised on 12/30/21, the P&P indicated, . 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident . 555843 Page 8 of 10 555843 02/06/2025 Masonic Home 34400 Mission Blvd Union City, CA 94587

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a safe, sanitary, and comfortable homelike environment when the hand sanitizer dispenser in one of ten resident bedrooms was non-operational for four consecutive days. This failure resulted in an unsanitary living condition and the potential for the spread of infection between residents, staff, and visitors. Findings: During a review of Resident 45's Detailed Summary, printed 2/05/25, it indicated Resident 45 was admitted to the facility on [DATE] with diagnoses including right lower leg open wound, Proteus mirabilis infection (a bacteria that can cause various infections, primarily in the urinary tract), Staphylococcus aureus infection (a bacteria cause skin infection. This can produce boils, blisters, and redness on your skin), chronic venous hypertension (a condition where the veins in the legs become enlarged and weakened, leading to increased pressure in the veins) with ulcer and inflammation of right lower extremity (leg), and latent tuberculosis (a condition where a person is infected with Mycobacterium tuberculosis bacteria, but does not have active tuberculosis disease). During a review of Resident 45's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 12/7/24, indicated Resident 45 had a Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 13, indicating intact cognition. During a review of Resident 273's admission Record, printed on 2/6/25, it indicated Resident 273 was admitted to the facility on [DATE] with diagnoses including chronic (long-term) kidney disease, acute systolic congestive heart failure (a sudden and severe condition where the left ventricle of the heart is unable to contract properly, leading to a significant decrease in the amount of blood pumped out to the body, causing symptoms like shortness of breath, fatigue, swelling in the legs, and rapid heartbeat), and candidal stomatitis (also known as oral thrush, a fungal infection of the mouth caused by an overgrowth of Candida albicans yeast). During a review of Resident 273's MDS, dated [DATE], it indicated Resident 45 had a BIMS score of 13, indicating intact cognition. During a review of the facility provided census (a complete count of population) dated 2/2/25, it indicated the facility's residential room (RM 1) was occupied by Resident 45 and Resident 273. During an observation on 2/3/25 at 10:20 a.m. in RM [ROOM NUMBER], the automatic hand sanitizer dispenser did not dispense hand sanitizer. The machine instead displayed a blinking red light, and the sanitizer level inside the machine was visibly full. There were no hand sanitizing machines in the hallway directly outside RM [ROOM NUMBER], or in the hallway outside any adjacent resident rooms. During a concurrent observation/interview on 2/4/25 at 9:46 a.m. in RM [ROOM NUMBER], the automatic hand sanitizer dispenser did not dispense hand sanitizer but continued to display a blinking red 555843 Page 9 of 10 555843 02/06/2025 Masonic Home 34400 Mission Blvd Union City, CA 94587

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few light. Registered Nurse 1 (RN 1) was alerted and came to check the machine. RN 1 removed the outside casing but could not repair the machine. RN 1 stated he would email maintenance about the issue. During a concurrent observation/interview on 2/5/25 at 3:00 p.m., the automatic hand sanitizer dispenser in RM [ROOM NUMBER] was still non-operational. The Administrator was alerted and stated she would follow up. During an interview on 2/6/25 at 9:19 a.m. with the CNA, the CNA stated she used the hand sanitizer machines inside the resident rooms when performing hygiene and other tasks with residents, and it was especially important to clean her hands when caring for multiple residents. During a review of facility policy and procedure titled INC-Chapter 1-Oversight 001 Policies and Practices-Infection Prevention and Control, dated 2/11/19, it indicated, an infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 555843 Page 10 of 10