Health inspection·June 10, 2022

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure immediate notification of significant change for one of two sampled residents (Resident 9), when Resident 9 had an unwitnessed fall on 6/2/22, and Licensed Vocational Nurse (LVN) 1 did not provide a post (after) fall assessment, interventions, and notification to the physician for further interventions. This failure resulted in Resident 9 to experience pain from 6/2/22 to 6/6/22, experience a decline in mobility, and subsequently had an x-ray completed on 6/5/22 which indicated a non-displaced right hip fracture (break in the bone that stays in place). Resident 9 was sent to the acute care hospital on 6/6/22 and required surgical intervention to repair the right femur (thigh bone). Resident 9 was hospitalized from [DATE] to 6/9/22. Findings: During a review of Resident 9's admission Record (AR), dated 6/9/22, the AR indicated, .Original admission Date 3/7/22 .Diagnosis Information .Nontraumatic Subarachnoid Hemorrhage (bleeding in the space between the brain and the tissue covering the brain) .Age-Related Osteoporosis (gradual and progressive decline in bone mineral density that can lead to bone fractures) . During review of Resident 9's Minimum Data Set, Section C Cognitive Patterns (MDS-comprehensive, standardized assessment of residents' functional capabilities and health needs), dated 3/15/22, the MDS indicated, .BIMS (Brief Interview for Mental Status) Summary Score .99 (indicated resident was unable to complete the interview) . During an interview on 6/9/22, at 11:35 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated she worked on 6/2/22 and saw Resident 9 on the floor (status post fall) sometime before lunch. CNA 1 stated she went into Resident 9's room to assist Resident 9 and he got into his bed on his own. CNA 1 stated CNA 2 went to inform Licensed Vocational Nurse (LVN) 1 about Resident 9's unwitnessed fall. CNA 1 stated later in the day (6/2/22), after Resident 9's fall, she saw Resident 9 not able to do physical therapy (helps individuals develop, maintain and restore maximum body movement and physical function) with the Physical Therapist Assistant (PTA) due to pain in his right leg. CNA 1 stated Resident 9 could ambulated independently and liked to walk around the facility. CNA 1 stated after Resident 9's fall, he did not want to get up that day. During an interview on 6/9/22, at 1:11 p.m., with CNA 2, CNA 2 stated she was informed by CNA 1 Resident 9 was found on the floor. CNA 2 stated she informed LVN 1 about Resident 9's fall. CNA 2 stated LVN 1 was going to check up on Resident 9, to see if Resident 9 was in pain after the fall. CNA 2 Page 1 of 22 555892 555892 06/10/2022 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated she saw Resident 9 refusing to do physical therapy with the PTA. CNA 2 stated the PTA informed LVN 1 about Resident 9's refusal of therapy and the fall. CNA 2 stated she knew the importance of reporting falls to LVN 1 in order to assess Resident 9's condition. During an interview on 6/9/22, at 1:39 p.m., with CNA 3, CNA 3 stated she saw Resident 9 on the floor. CNA 1 and CNA 2 were in Resident 9's room and Resident 9 stood up on his own and got in his bed. During an interview on 6/9/22, at 2:07 p.m., with LVN 1, LVN 1 stated he was informed by CNA 2 about Resident 9 being in pain on 6/2/22. LVN 1 stated he did not know about Resident 9 being found on the floor and having an unwitnessed fall. LVN 1 stated he assessed Resident 9's pain, but Resident 9 refused pain medication after being informed of Resident 9 being in pain. LVN 1 stated he was informed Resident 9 refused to do physical therapy with the PTA. LVN 1 stated the PTA spoke to him about Resident 9's complaint of pain in his legs. LVN 1 stated it was important to assess a resident's fall to give the proper care and interventions. During an interview on 6/9/22, at 2:26 p.m., with CNA 4, CNA 4 stated she recalled CNA 1 and CNA 2 informing CNA 4 about Resident 9 being found on the floor. CNA 4 stated she remembered CNA 1 and CNA 2 reported fall to LVN 1. During a concurrent interview and record review on 6/9/22, at 2:46 p.m., with LVN 2, the following Progress Notes (PN) were reviewed: Resident 9's PN dated 6/4/22, indicated, Change in Condition .sudden onset of severe pain to BLE (bilateral [both] lower extremities) and hips; unclear to specific location of pain. Has limited mobility d/t (due to) pain . Resident 9's PN dated 6/4/22, indicated, [name of x-ray (imaging technique that produces images of bones, providing clear detail of the bony structure) company] called x (times) 2 to inform that there was no available staff to perform x-ray. MD (medical doctor) notified via telephone. Resident refuse to go to ER (emergency room) for evaluation . Resident 9's PN dated 6/4/22, indicated, .Call placed to [MD name] to report finding to right hip X-ray .Resident non weight bearing (not to put any weight through the affected limb) on right leg . LVN 2 stated on 6/4/22, Resident 9 complained of severe pain to his legs and hips. LVN 2 stated he informed the MD and received an order of Oxycodone (medication that is used to treat moderate to severe pain) and an x-ray of hips and legs. LVN 2 stated the x-ray company had canceled the x-ray ordered on 6/4/22 due to staffing and the x-ray was completed on 6/5/22. LVN 2 stated he offered Resident 9 to go to the emergency room to get an x-ray, but Resident 9 refused to go to the hospital. LVN 2 stated the x-ray on 6/5/22 resulted on 6/6/22, as having a right hip fracture. During a review of Resident 9's Vital: Pain Level (PL), dated 6/13/22, the PL indicated, Resident 9's pain level from 3/7/22 to 6/2/22 reported as 0 out of 10 (0 means you have no pain; one to three means mild pain; four to seven is considered moderate pain; eight and above is severe pain). After Resident 9's fall on 6/2/22, Resident 9 reported the following: 6/3/22 at 1:05 a.m., pain 3 out of 10 555892 Page 2 of 22 555892 06/10/2022 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0580 6/4/22 at 1:18 p.m., pain 4 out of 10 Level of Harm - Minimal harm or potential for actual harm 6/6/22 at 12:44 a.m., pain 3 out of 10 6/6/22 at 1:39 a.m., pain 3 out of 10 Residents Affected - Few 6/6/22 at 3:19 a.m., pain 6 out of 10 During a review of Resident 9's PN, dated 6/2/22, the PN indicated, Resident refused PT due to pain in legs per therapist statement. Resident to LN (LVN 1) was having pain in legs. Resident refused comfort measures to help relieve pain. Resident then denied having leg pain but stated having a headache. Resident refused comfort measure to alleviate (ease) headache . During a review of Resident 9's Progress Note, dated 6/3/22, the PN indicated, Acetaminophen (medication used to treat mild pain) Tablet 325 MG (milligram- unit of measurement) Give 2 tablets by mouth every 6 hours as needed for Mild Pain related to Pain, Unspecified .right leg pain 3/10 . During a review of Resident 9's Progress Note, dated 6/4/22, the PN indicated, This shift resident c/o (complained of) pain in legs. Resident has confusion, does not comprehend Number Pain Scale (pain scale in where a person rates their pain from 0 to 10 indicating severity of pain). Facial expression exhibits moderate pain. Resident refuses medicinal offers to treat pain . During a review of Resident 9's Radiology Interpretation (RI), dated 6/5/22, the RI indicated, .Right Hip 2-3 Views .intertrochanteric region (area pertaining to top of the thigh bone where it is attached to the hip) suggests subtle non displaced fracture . During a review of Resident 9's Progress Note, dated 6/6/22, the PN indicated, .Resident c/o right hip pain. Assessment done to right and left hip. He is guarding (voluntarily or involuntarily tensing up) right hip .Pain medication given for c/o moderate pain .Resident was noted with right hip pain .New order received and noted: Resident to be sent out for CT (imaging procedure that uses x-rays and computer technology to produce images of the inside of the body) right hip evaluation and treatment if indicated .Ambulance here to transfer resident to [name of hospital] for further evaluation . During an interview on 6/9/22, at 4:11 p.m., with the PTA, the PTA stated Resident 9 did not participate in PT on 6/2/22 due to having pain in his legs. The PTA stated CNA 1 told him Resident 9 had a fall before therapy. The PTA stated he did not continue with physical therapy and spoke to LVN 1 about Resident 9's pain in his right leg and Resident 9's fall. During a review of Resident 9's Physical Therapy Treatment Encounter Notes (PTN), dated 6/2/22, the PTN indicated, Performed PROM (passive range of motion- exercises designed to increase the movement by stretching the muscles and tendons) to RLE (right lower extremity) to decrease tightness patient was having. During movement, patient continued to complain of pain to RLE. Attempted to sit at EOB (edge of bed) but patient had difficulty using BLE (bilateral lower extremities) and BUE (bilateral upper extremities) to assist with scooting to HOB (head of bed) to lower BLE to floor. Patient had difficulty moving in general so discontinued with proceeding with therapy . During a review of Resident 9's Occupational Therapy Treatment Encounter Note (OTN), dated 6/2/22, the OTN indicated, .Patient c/o of worsening hip pain 8/10 and grabbing at right hip. Patient began to self-transfer back to bed .Patient left in bed with all needs met and nurse aware of status . 555892 Page 3 of 22 555892 06/10/2022 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 6/9/22, at 3 p.m., with the Director of Nursing (DON), the DON stated Resident 9 refused therapy with the PTA on 6/2/22. The DON stated LVN 1 informed her Resident 9 complained of leg pain and a headache on 6/2/22. The DON stated LVN 1 should have known about Resident 9's fall on 6/2/22 when CNA 1 and CNA 2 informed him on 6/2/22. The DON stated LVN 1 needed to follow up on Resident 9's fall by doing a post fall assessment, pain management, and an order from the MD to do an x-ray in a timely manner. The DON stated Resident 9 had intermittent pain throughout 6/2/22 to 6/6/22. The DON stated the x-ray should have been done immediately on 6/2/22 and not until 6/5/22 (three days after the fall) because Resident 9 was in pain. The DON stated there was a delay in treatment for Resident 9's fall. During an interview on 6/9/22, at 3:22 p.m., with the Administrator (ADM), the ADM stated Resident 9 was found on the floor on 6/2/22 by CNA 1. The ADM stated during her investigation of Resident 9's fall, CNA 2 informed LVN 1 about Resident 9 having pain, but LVN 1 stated he did not know about the fall. The ADM stated Resident 9 did complain of pain in the legs and a headache. The ADM stated Resident 9 had severe pain on 6/4/22. The ADM stated an x-ray was ordered by the MD on 6/4/22 and was completed on 6/5/22. The ADM stated LVN 1 should have completed a post fall assessment that included interventions such as pain management, and x-ray. The ADM stated Resident 9 was in intermittent pain from 6/2/22 to 6/6/22, before he was sent to the hospital on 6/6/22. The ADM stated there was a delay in treatment for Resident 9 that lead to not knowing where Resident 9's pain was attributed to. The ADM stated it was important to give timely post fall interventions to residents to give the best quality of care. The ADM stated she received a call from Resident 9's responsible party (RP) of Resident 9 requiring surgery to the right hip while in the hospital. During a review of Resident 9's hospital ED Provider Notes (records from the acute care hospital), dated 6/6/22, the ED Provider Notes indicated, .Patient presents with Pain Hip Right hip pain per skilled nursing facility staff . During a review of Resident 9's hospital Discharge Summary (DS), dated 6/9/22, the DS indicated, .admission Diagnosis: Femur fracture .Procedures: hip cephallomedullary nail (procedure use to help treat fractures of the femur) . During a review of the facility's policy and procedure (P&P) titled, Change in Resident's Condition or Status, dated May 2017, the P&P indicated, .1. The nurse will notify the resident's Attending Physician or physician on call when there has been an: a. accident or incident involving the resident; b. discovery of injuries of an unknown source .2. A 'significant change' of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions .5. Except in medical emergencies, notifications will be made within twenty-four hours of a change occurring in the resident's medical/mental condition or status . During a review of the facility's P&P titled, Falls/Accident Prevention, dated 7/27/20, the P&P indicated, .5. If a resident accident/incident occurs, the contributing factors will be reviewed by the Interdisciplinary Team (group of healthcare professionals that integrates multiple disciplines through collaboration), appropriate interventions implemented, and the plan of care modified as necessary. These would be summarized on the IDT Post Event Notes. 6. A neurological evaluation will be completed by a licensed nurse for any unwitnessed fall or any fall or accident, where a resident claims he/she hit his/her head on a hard surface . 555892 Page 4 of 22 555892 06/10/2022 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement one of two sampled residents' (Resident 29) comprehensive person-centered care plan, when Resident 29 was assessed as being a fall risk, with a history of falls, and a known behavior of getting up unassisted, and the facility created a care plan intervention for Resident 29's bed to be in the lowest position, and facility staff did not implement Resident 29's care plan. This failure resulted in Resident 29's contusion (bleeding under the skin due to trauma of any kind) and abrasion (superficial injuries of the skin, resulting in a break in the continuity of tissue) to her right temple (side of the head behind the eye between the forehead and the ear) and face after falling out of bed on 6/1/22. Findings: During a review of Resident 29's admission Record (a document with personal and medical information), dated 6/7/22, the admission Record indicated, Resident 29 was admitted to the facility with diagnoses which included Metabolic Encephalopathy (chemical imbalance in the blood, affects the brain, it can lead to personality changes), fracture of nasal bones (break in the bone or cartilage over the bridge, or in the sidewall or structure that divides the nostrils), dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), anxiety disorder (an emotion characterized by feelings of tension, worried thoughts and physical changes like increased blood pressure, and will usually have recurring intrusive thoughts or concerns), history of falling, osteoporosis (medical condition in which the bones become brittle and fragile from loss of tissue, typically as a result of hormonal changes, or deficiency of calcium or vitamin D), weakness, and urinary tract infections (is a clinically detectable condition associated with invasion by disease causing microorganisms of some part of the urinary tract). During a review of Resident 29's Initial Report, dated 6/3/22, the Initial Report indicated, .Resident fell from bed and sustained an injury on the right side of her forehead .The LVN (Licensed Vocational Nurse) quickly assessed and reported to medical doctor (MD). MD recommended to send resident out to hospital .Resident was sitting in bed and heard a noise in the hallway. Resident attempted to get up and hit her head on the foot of the bed . Resident is currently placed on seventy-two hours one on one, neuro-checks, low bed, labs, and to place padding on foot board . During a review of Resident 29's Emergency Department Records (ER Records) (from the Acute Care Hospital), dated 6/1/22, the ER Records indicated, .Arrival 6/1/22 at 6:46 p.m. discharge time was 11:06 p.m. History of Present Illness .The fall was described as fell out of bed, unwitnessed but could not have exceeded three hours on the ground with staff rounding .contusion and abrasion to right temple and face .Computed Tomography (CT- diagnostic imaging that produces images of the inside of the body) exam date/time: 6/1/22 8:36 p.m. CT facial bones without contrast .Impression: Nasal fractures . During an observation on 6/6/22, at 10:37 a.m., in Resident 29's room, Resident 29 had a gauze (medical fabric, linen, cotton), which covered her right arm, with dry blood under the gauze. Resident 29 was not interviewable. 555892 Page 5 of 22 555892 06/10/2022 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review on 6/8/22, at 8:37 a.m., with Licensed Vocational Nurse (LVN) 3, Resident 29's Fall Risk Assessment Tool (Fall Risk Assessment), dated 5/5/22 was reviewed. The Fall Risk Assessment indicated, Resident 29 had a score of 7.The Fall Risk Assessment assessed one point for each core element 'Yes' . a score of 4 or more was considered at risk for falling . During a review of Resident 29's Order Summary, dated 6/7/22, the Order Summary indicated, .Low bed with floor mat to be use while resident in bed secondary to poor safety awareness to prevent accidental fall and further injury. Low bed to be in the lowest position when resident in the bed with floor mat on the floor . During a review of Resident 29's Care Plan, dated 5/5/22, the Care Plan indicated, .history of falls .initiated on 5/5/22 .Interventions .Low bed with floor mat to be use while resident in bed secondary to poor safety awareness to prevent accidental fall and further injury. Low bed to be in lowest position when resident in the bed with floor mat on the floor. Revision on: 6/3/22 . During an interview on 6/8/22, at 9:47 a.m., with Certified Nursing Assistant (CNA) 4, CNA 4 stated on the day shift of 6/1/22, nursing assistants were at the nurse's station getting ready to clock out when they heard a thud and a scream. CNA 4 stated she and CNA 2 went to Resident 29's room and found Resident 29 face down above the floor mat, with a quarter sized amount of blood running down her nose. CNA 4 stated CNA 2 lowered the bed because it was not in the lowest position. CNA 4 stated CNA 2 and CNA 4 helped Resident 29 back to bed, and Resident 29 complained her face hurt. During an interview on 6/8/22, at 10:13 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 went to Resident 29's room after CNA 3 had called him to help because Resident 29 had fallen and bled from her nose. LVN 1 stated when he arrived in Resident 29's room, Resident 29 sat on the edge of her bed, and bled on the right side of her nose. LVN 1 stated Resident 29 had a one centimeter (unit of length measure [cm]) diameter hematoma (an area of blood that collects outside of the larger blood vessels) on the right side of her forehead after the fall. During an interview on 6/8/22, at 10:40 a.m., with CNA 3, CNA 3 stated a loud noise was heard from the nurse's station on 6/1/22 at 2:45 p.m., and Resident 28 yelled out Resident 29 needed help. CNA 3 stated Resident 29 was found face down, adjacent the floor mat in Resident 29's room, trying to get up on her own. CNA 3 stated Resident 29's bed was slightly elevated because CNA 2 and CNA 4 had to use the bed remote control to place the bed lower, to get Resident 29 back into her bed. CNA 3 stated Resident 29 had tried to get out of bed before this fall but could not recall dates or times that she attempted to get out of bed. During an interview on 6/8/22, at 3:44 p.m., with LVN 2, LVN 2 stated he was clocking in for his shift (on 6/1/22), when CNA 4 called out to help in Resident 29's room. LVN 2 stated Resident 29 went to the hospital emergency room to be evaluated and returned a few hours later. During an interview on 6/9/22, at 9:48 a.m., with LVN 1, LVN 1 stated he was covering the unit until LVN 2 clocked in for his shift. LVN 2 stated he was on the opposite hall of Resident 29's room, passing medications when Resident 29 fell. During an interview on 6/9/22, at 1:14 p.m., with CNA 2, CNA 2 stated CNA 4 helped her to get 555892 Page 6 of 22 555892 06/10/2022 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 29's back into bed after the fall on 6/1/22 at approximately 2:50 p.m. CNA 2 stated Resident 29's bed needed to be lowered using the remote control to get Resident 29 back into bed. CNA 2 stated the bed was not in the lowest position. CNA 2 stated if the bed was in the lowest position, the bed would not be able to be lowered any further. During an interview on 6/9/22, at 2:19 p.m., with CNA 6, CNA 6 stated Resident 29 had attempted to get out of bed without assistance before the fall on 6/1/22. CNA 6 stated she was in another room getting vital signs (measurements of the body's most basic functions) when CNA 4 told her Resident 29 was found on the floor, bleeding. During an interview and record review on 6/9/22, at 2:59 p.m., with the Director of Nursing (DON), the DON stated Resident 29 was a high fall risk upon admission. During a review of Resident 29's Minimum Data Set (MDS), dated 5/12/22, the MDS indicated, Resident 29 had a fall in the last month prior to admission to the facility, and had a fall in the last two to six months prior to admission to the facility. During a review of Resident 29's General Acute Care Hospital Case Management Discharge Summary (GACH), (from the Acute Care Hospital prior to Resident 29's admission to the facility) dated 5/4/22, the GACH Summary indicated, .History XXX[AGE] year-old female with a history of dementia is brought in by ambulance from home after an unwitnessed ground level fall prior to arrival. Per Emergency Medical services (EMS), the patient fell while using her walker in the hallway and her daughter was able to assist her to her before calling EMS . During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, dated July 2017, the P&P indicated, Policy Statement .Our facility strives to make environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accident are facility-wide priorities. Policy Interpretation and Implementation .Individualized, Resident-Centered Approach to Safety .4. Implementing interventions to reduce accident risks and hazards shall include the following: d. Ensuring that interventions are implemented .Resident Risks and Environmental Hazards .These risk factors and environmental hazards include: c. Falls; . During a review of the facility's P&P titled, Falls/Accident Prevention, dated July 2020, the P&P indicated, Policy Statement .It is the policy of this facility to prevent injurious falls, accidents and incidents and eliminate preventable occurrences, practices, or systems, which negatively impact residents and/or resident care and environmental hazards whenever possible .Prevention and Management .3. A licensed nurse will complete a Fall Risk Evaluation upon admission and quarterly, at a minimum. If a resident has a fall risk factor(s) identified, regardless of the Fall Risk Assessment score, preventive interventions will be initiated on the resident's plan of care . 555892 Page 7 of 22 555892 06/10/2022 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to ensure medications were administered to meet the needs for one of 10 sampled residents (Resident 34), when Licensed Vocational Nurse (LVN) 1 administered [brand name of Sucralfate] (used to treat and prevent ulcers in the intestines) seven minutes late, from the time to be administered. This failure resulted in Resident 34 to receive his medication later than prescribed and had the potential for Resident 34 to not get the therapeutic effect of the medication on a timely basis. Findings: During an observation on 6/7/22, at 12:07 p.m., near Resident 34's room, LVN 1 administered medications to Resident 34. LVN 1 administered one tablet of Sucralfate. During a review of Resident 34's Order Summary Report (OS), dated 6/8/22, the OS indicated, .[brand name of Sucralfate] Tablet Give 1 tablet by mouth four times a day related to Gastroesophageal Reflux Disease (disease in which stomach acid or bile irritates the food pipe lining) .Administer medication at .11 a.m . During an interview on 6/8/22, at 9:58 a.m., with LVN 1, LVN 1 stated medications needed to be given an hour before or an hour after the scheduled time of the physician order. LVN 1 stated Resident 34's [brand name Sucralfate] was given at 12:07 p.m., which was not within the time frame of hour from 11 a.m. (seven minutes later). During an interview on 6/10/22, at 9:13 a.m., with the Director of Nursing (DON), the DON stated the expectation for passing medications to residents was for medication to be administered one hour before or one hour after the scheduled time of the medication. The DON stated LVN 1 should have administered the [brand name Sucralfate] to Resident 34 on time. The DON stated medications needed to be given to residents at the time of the physician order to manage the medical conditions of the resident. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, dated January 2021, the P&P indicated, .Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so .14. Medications are administered within 60 minutes of scheduled time .Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center . 555892 Page 8 of 22 555892 06/10/2022 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure residents received food that was palatable (tasteful and flavorful) for four of 10 sampled residents (Resident 27, Resident 28, Resident 34 and Resident 36) when residents complained about the food's palatability, and on 6/7/22, a test tray was tasted and the risotto (rice dish cooked with broth until it reaches a creamy consistency) and vegetables had no flavor. Residents Affected - Some This failure had the potential for Resident 27, Resident 28, Resident 31, Resident 34 and Resident 36 to not consume their meals and placed residents at risk for unintentional weight loss. Findings: During an interview on 6/6/22, at 9:51 a.m., with Resident 27, Resident 27 stated he ordered food from outside the facility because the food had no taste. Resident 27 stated the flavor of the food varied in taste and could not say which food were without flavor. During an interview on 6/6/22, at 10:50 a.m., with Resident 34, Resident 34 stated he did not like the food served in the facility because it did not taste good. Resident 34 stated he enjoyed certain foods, such as Mexican food like beef steak and pork tacos that his son would bring for him. Resident 34 stated he told the Dietary Supervisor (DS) what types of food he enjoyed. During a concurrent observation and interview on 6/6/22, at 12:15 p.m., with Resident 36, in Resident 36's room, Resident 36 ate lunch. Resident 36 stated the pork, rice and zucchini lacked in flavor. During a concurrent observation and interview on 6/6/22, at 12:20 p.m., with Resident 28, in Resident 28's room, Resident 28 did not eat his lunch because he ordered pizza. Resident 28 stated the facility's lunch meal had no taste. Resident 28 stated the food needed seasoning. During a concurrent observation and interview on 6/6/22, at 12:29 p.m., with Resident 36, in Resident 36's room, Resident 34 ate 25 percent of her lunch. Resident 34 stated the pork, sauce, rice and zucchini had no taste. During a concurrent observation and interview on 6/7/22, at 11:09 a.m. with [NAME] (CK) 2, in the kitchen, CK 2 cooked risotto for residents in the facility. CK 2 stated the food would be placed on a steam table (a table with slots to hold food containers which are kept hot by steam circulating beneath them) on the second floor by a dumbwaiter (a small elevator for carrying things, especially food and dishes, between the floors of a building) after the food was cooked. During an observation on 6/7/22, at 11:57 a.m., in the second-floor dining room, CK 2 took roasted chicken, risotto, peas and carrots, and gravy off the dumb waiter and placed it on the steam table. During a concurrent observation and interview on 6/7/22, at 11:58 a.m., with CK 2, on the second-floor dining room at the steam table, CK 2 checked the temperatures of the lunch foods before lunch was served. The temperatures at the start of the meal service were roasted chicken was 199 degrees Fahrenheit (unit of measure for temperature), risotto 205 degrees Fahrenheit, peas and carrots 193 degrees Fahrenheit, roll, strawberry mousse dessert 37 degrees Fahrenheit and beverage 36 degrees Fahrenheit. The pureed (very smooth, crushed or blended food - like applesauce or mashed potatoes) meal 555892 Page 9 of 22 555892 06/10/2022 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some tray consisted of pureed chicken 205 degrees Fahrenheit, risotto 185 degrees Fahrenheit, pureed peas and carrots 193 degrees Fahrenheit, strawberry mousse dessert 37 degrees Fahrenheit, and beverage 36 degrees Fahrenheit. CK 2 did not check the temperature of the gravy or pureed roll before serving lunch. During a concurrent test tray observation and interview on 6/7/22, at 12:42 p.m., with the DS, in the conference room, a regular and pureed lunch tray was on the cart farthest from the kitchen. The trays were tasted and evaluated by two nurse surveyors and the DS. The temperatures at the start of the meal tasting were roasted chicken was 160 degrees Fahrenheit, risotto 158 degrees Fahrenheit, peas and carrots 164 degrees Fahrenheit, strawberry mousse dessert 41 degrees Fahrenheit, and beverage 41 degrees Fahrenheit. The pureed meal tray consisted of pureed chicken 159 degrees Fahrenheit, risotto 155 degrees Fahrenheit, pureed peas and carrots 145 degrees Fahrenheit, pureed roll was 140 degrees Fahrenheit, strawberry mousse dessert 41 degrees Fahrenheit, and beverage 41 degrees Fahrenheit. Two of two surveyors thought the risotto, and the peas and carrot mixture on both trays tasted bland (no flavor, tasteless, plain). During a concurrent observation and interview on 6/7/22, at 1 p.m., with Resident 34, in Resident 34's room, Resident 34 ate a cup (unit of measurement) of ice cream and drank the chocolate nutritional shake. Resident 34 stated he did not like the taste of any food at the facility. During an interview on 6/8/22, at 1:24 p.m., with the Registered Dietician (RD), the RD stated her last test tray audit was done on 5/26/22. The RD stated during the audit on 5/26/22, she did not make a note about the taste of the foods. During a review of the facility's policy and procedure (P&P) titled, Food and Nutrition Services, dated October 2017, the P&P indicated, .7. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. a. If an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the Food Service Manager so that a new food tray can be issued . 555892 Page 10 of 22 555892 06/10/2022 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on interview and record review, the facility failed to ensure each resident received food that accommodated residents' preferences for one of 10 sampled residents (Resident 14), when the facility staff were aware Resident 14 did not like sandwiches, but Resident 14 continued to received sandwiches. This failure had the potential to cause Resident 14 to not eat their meals, which had the potential for unplanned weight loss and malnutrition. Findings: During a review of Resident 14's admission Record (AR), dated 6/8/22, the AR indicated, .Original admission Date 3/29/13 . During review of Resident 14's Minimum Data Set Section C Cognitive Patterns (MDS-comprehensive, standardized assessment of residents' functional capabilities and health needs), dated 3/26/22, the MDS indicated, .BIMS (Brief Interview for Mental Status) Summary Score .15 (indicating normal cognition) . During an interview on 6/6/22, at 11:11 a.m., with Resident 14, Resident 14 stated she did not like grilled cheese nor tomato soup. Resident 14 stated she had informed the dietary staff about her dislikes. Resident 14 stated her dislikes used to be on her dietary slip she received with every meal, but had not seen her dislikes on her dietary slip in a while. Resident 14 stated she received a grilled cheese for dinner one night and did not eat dinner because she did not like grilled cheese sandwiches. During a review of the facility's undated Menu, the Menu indicated, .Wednesday (Day 25) .Supper .Grilled Cheese Sandwich .Saturday (Day 28) .Supper .Cream of Tomato Soup . During a review of Resident 14's undated dietary slip, the dietary slip indicated Resident 14 had no likes or dislikes for food preferences. During a review of Resident 14's Care Plan (CP), dated 7/2/21, the CP indicated, .Resident's food preferences. Resident dislikes peas and sandwiches. Dietary staff notified . During an interview on 6/8/22, at 11:49 a.m., with the Dietary Supervisor (DS), the DS stated Resident 14's dietary slip did not have her food preferences nor dislikes. The DS stated it was important to have residents' likes and dislikes upheld to ensure residents received the food they desired to eat. The DS stated if residents did not receive the food they wanted, they would not eat and could have weight loss. The DS stated residents' food preferences needed to be assessed quarterly to update their preferences. The DS stated Resident 14's likes, and dislikes were overlooked when Resident 14 received food items she did not like. During an interview on 6/10/22, at 9:25 a.m., with the Director of Nursing (DON), the DON stated it was important to uphold residents' food preferences so that residents could eat. The DON stated the facility should talk to residents and family about what kind of food residents like to ensure they accommodate those food items. The DON stated if residents' food preferences were not upheld it could 555892 Page 11 of 22 555892 06/10/2022 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few lead to residents not liking the food and not eat which could lead to weigh loss. The DON stated providing residents with the food they enjoyed would provide an emotional satisfaction and ensure residents' dignity. During a review of the facility's policy and procedure (P&P) titled, Nutritional Management, dated 2/1/21, the P&P indicated, .b. The dietary manager or designee shall obtain the resident's food and beverage preferences upon admission, significant change in condition, and periodically throughout his or her stay .5. Monitoring/revision: a. Monitoring of the resident's condition and care plan interventions will occur on an ongoing basis. Examples of monitoring include: i. Interviewing the resident and/or resident representative to determine it their personal goals and preferences are being met . During a review of the facility P&P titled, Food and Nutrition Services, dated October 2017, the P&P indicated, .1. The interdisciplinary staff, including nursing staff, the attending physician and the dietician will assess each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization .4. Reasonable efforts will be made to accommodate resident choices and preferences . 555892 Page 12 of 22 555892 06/10/2022 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

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 ensure food was stored and served in accordance with professional standards for food service safety when: Residents Affected - Some 1. One of one beverage drink pitcher was stored in the ready to be used area in the kitchen, and the pitcher was observed to have water droplets on the inside surfaces; and 2. Two of nine food items' (gravy and pureed [very smooth, crushed or blended food - like applesauce or mashed potatoes] dinner roll) temperatures were not checked on the tray line, prior to serving lunch to residents. These failures had the potential to place residents at risk for foodborne illness (illness caused by consuming contaminated food or drink). Findings: 1. During a concurrent observation and interview on 6/6/22, at 9:10 a.m., with [NAME] (CK) 1, in the kitchen, water droplets were inside a beverage pitcher facing down on a dry storage mat. CK 1 stated the beverage pitcher should be dry since it was stored on the ready to use mat. CK 1 stated water left inside a drink pitcher could lead to cross contamination (unintentional transfer from one substance to another with harmful effect) of bacteria (a large number of single-celled, microscopic organisms that live in the soil, water, or animals, including humans. They come in several different shapes, including spheres, rods, and spirals, and may organize themselves into clusters or chains). During a concurrent observation and interview on 6/6/22, at 9:11 a.m., with the Dietary Supervisor (DS), in the kitchen, the DS removed the beverage pitcher with the water droplets from the storage mat and placed it in the dirty sink to be cleaned. The DS stated the drink pitcher should not be left wet when it was on the mat ready to be used for residents. The DS stated this practice could lead to bacteria growth and cause resident to get sick. During an interview on 6/8/22, at 8:56 a.m. with Dietary Aide (DA) 2, DA 2 stated storage of beverage pitchers should not be wet on the dry mat because it can cause cross contamination of bacteria on beverage pitcher. DA 2 stated bacteria had the potential to make a resident sick. During an interview on 6/9/22, at 2 p.m., with the Registered Dietician (RD), the RD stated beverage pitchers should not be on a storage mat ready for use. The RD stated the water left in a drink pitcher had the potential for bacteria growth and cross contamination could lead to residents getting sick. During a review of the facility's policy and procedure (P&P) titled, Equipment Operation and Sanitation, dated December 2020, the P&P indicated, .G. Blender, mixer, and food processor bowls should be washed and sanitized, and inverted to air dry on shelves with vented slots to allow for adequate air circulation . During a professional reference review of the FDA 2017 Food Code Manual; Annex 3, the Annex 3 indicated, .Items must be allowed to drain and to air-dry before being stacked or stored . 555892 Page 13 of 22 555892 06/10/2022 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. During a review of the facility's Menu, dated 2022, the Menu indicated, on 6/7/22, the facility served Roasted Chicken, Creamy Risotto, Peas and Carrots, Dinner roll/margarine, Strawberry Mousse and Beverage for lunch. During a concurrent lunch meal preparation observation and interview on 6/7/22, at 11:09 a.m. with CK 2, CK 2 prepared lunch for the facility. CK 2 stated the food would be placed on a steam table (a table with slots to hold food containers which are kept hot by steam circulating beneath them) on the second floor by a dumb waiter (a small elevator for carrying things, especially food and dishes, between the floors of a building) after the food was cooked. During an observation on 6/7/22, at 11:28 a.m., in the kitchen with CK 2, CK 2 checked the temperature of the gravy on the stove. The temperature of the gravy was 175 degrees Fahrenheit (unit of measure for temperature). CK 2 removed the gravy from the stove and stated cooking of lunch was completed. During a lunch meal preparation observation on 6/7/22, at 11:52 a.m., in the kitchen, the lunch meal was placed on the dumb waiter from the oven. During a lunch meal preparation observation on 6/7/22, at 11:57 a.m., in the second-floor dining room, CK 2 took the lunch meal off the dumb waiter and placed it on the steam table. During a concurrent observation and interview on 6/7/22, at 11:58 a.m., with CK 2, on the second-floor dining room at the steam table, CK 2 checked the temperatures of the lunch foods before lunch was served. CK 2 did not check the temperature of the gravy or pureed dinner roll before serving lunch. During an interview on 6/7/22, at 12:42 p.m., with the Dietary Supervisor (DS), the DS stated CK 2 was expected to check the temperatures of the gravy and pureed roll before serving lunch to the residents. During an interview on 6/8/22, at 1:24 p.m., with the Registered Dietician (RD), the RD stated the expectation for staff would be to check and record the temperatures of the food before serving to residents. The RD stated not checking a temperature of gravy or pureed food could potentially cause illness to the residents if the food was not at a proper temperature. During a review of the facility's P&P titled, Food Temperatures, dated December 2020, the P&P indicated, .E. Record the reading on the Food Temperature Log at the beginning of the tray line. F. Take the temperature of each pan of product before serving . 555892 Page 14 of 22 555892 06/10/2022 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observation, interview, and record review, the facility failed to ensure two of four sampled residents' (Resident 29 and Resident 33) medical records were in accordance with accepted professional standards and practice when: 1. Resident 29's Minimum Data Set (MDS- a resident assessment tool used to identify resident care needs) assessment, specifically the Brief Interview for Mental Status (BIMS- an evaluation of attention, orientation, and memory recall) Summary Score was blank; and 2. Resident 33's MDS, specifically the BIMS Summary Score, was blank. These failures resulted in incomplete medical records for Resident 29 and Resident 33, and had the potential for facility staff to not provide the necessary care and services to meet the residents' individualized needs. Findings: 1. During a concurrent observation and interview on 6/6/22, at 10:37 a.m., in Resident 29's room, Resident 29 laid in bed while Certified Nursing Assistant (CNA) 10 spoke in Spanish. Resident 29 did not answer simple questions. CNA 10 stated Resident 29 was confused. During a concurrent interview and record review on 6/9/22, at 10:35 a.m., with the Social Services Director (SSD), Resident 29's MDS assessment Section C- Cognitive Patterns (MDS Section C), dated 5/12/22 was reviewed. The MDS Section C indicated, .Section C0500. BIMS Summary Score [was blank] . During a concurrent interview and record review on 6/9/22, at 1:45 p.m., with the Minimum Data Set Coordinator (MDSC), Resident 29's MDS Section C, dated 5/12/22 was reviewed. The MDS Section C indicated, .Section C0500. BIMS Summary Score [was blank] . The MDSC stated if the score was not in the box, the assessment was not completed. During an interview on 6/9/22, at 2:59 p.m., with the Director of Nursing (DON), the DON stated if the BIMS score was blank, the BIMS section was incomplete. During a review of the facility's policy and procedure (P&P) titled, Resident Assessment Instrument (RAI), dated May 2022, the P&P indicated, .The facility will utilize the RAI process as the basis for the accurate assessment of each resident's functional capacity and health status, as outlined in the Centers for Medicare and Medicaid Service's (CMS) RAI MDS 3.0 Manual .The RAI process will be completed in accordance with CMS's RAI Version 3.0 Manual .Each MDS section will be completed by the responsible individual as designated per facility . Assessment Instrument (RAI) 3.0 User's Manual Version 1.17.1, dated October 2019, the RAI process indicated, .The total score: Allows comparison with future and past performance. Decreases the change of incorrect labeling of cognitive ability and improves detection of delirium. Provides staff with a more reliable estimate of resident function and allow staff interactions with residents that are based on more accurate impressions about resident ability . 555892 Page 15 of 22 555892 06/10/2022 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a professional reference review titled, Documentation in the Long-Term care Record, retrieved from http://ahimaltcguidelines.pbworks.com/w/page/46508844/Documentation%20in%20the%20Long%20Term%20Care%20Re dated October 2010, the professional reference indicated, .A complete record contains an accurate and functional representation of the actual experience of the individual in the facility. It must contain enough information to show that the facility knows the status of the individual, has plans of care identified to meet the resident's identified condition/s, and provides sufficient documentation of the effects of the care provided . 2. During a concurrent observation and interview on 6/6/22, at 10:40 a.m., in Resident 33's room, Resident 33 sat on the side of the bed, looking at a magazine and talking with CNA 10 in Spanish. CNA 10 stated she answered simple questions. During a concurrent interview and record review on 6/9/22, at 10:35 a.m., with the SSD, Resident 33's MDS Section C, dated 5/18/22 was reviewed. The MDS Section C indicated, .Section C0500. BIMS Summary Score [was blank] . During a concurrent interview and record review on 6/9/22, at 1:45 p.m., with the MDSC, Resident 33's MDS Section C dated 5/12/22 was reviewed. The MDS Section C indicated, .Section C0500. BIMS Summary Score [was blank] . The MDSC stated if the score was not in the box, the assessment was not completed. During an interview on 6/9/22, at 2:59 p.m., with the DON, the DON stated if the BIMS score was blank, the BIMS was incomplete. During a review of the facility's P&P titled, Resident Assessment Instrument (RAI), dated May 2022, the P&P indicated, .The facility will utilize the RAI process as the basis for the accurate assessment of each resident's functional capacity and health status, as outlined in the Centers for Medicare and Medicaid Service's (CMS) RAI MDS 3.0 Manual .The RAI process will be completed in accordance with CMS's RAI Version 3.0 Manual .Each MDS section will be completed by the responsible individual as designated per facility . Assessment Instrument (RAI) 3.0 User's Manual Version 1.17.1 October 2019. The RAI process indicated, .The total score: Allows comparison with future and past performance. Decreases the change of incorrect labeling of cognitive ability and improves detection of delirium. Provides staff with a more reliable estimate of resident function and allow staff interactions with residents that are based on more accurate impressions about resident ability . During a professional reference review titled, Documentation in the Long-Term care Record, retrieved from http://ahimaltcguidelines.pbworks.com/w/page/46508844/Documentation%20in%20the%20Long%20Term%20Care%20Re dated October 2010, the professional reference indicated, .A complete record contains an accurate and functional representation of the actual experience of the individual in the facility. It must contain enough information to show that the facility knows the status of the individual, has plans of care identified to meet the resident's identified condition/s, and provides sufficient documentation of the effects of the care provided . 555892 Page 16 of 22 555892 06/10/2022 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

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, two of two Licensed Vocational Nurses (LVN 1 and LVN 2) failed to implement infection control practices to maintain a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections when: Residents Affected - Some 1. LVN 1 administered medications to Residents 17 and Resident 33, whom were both considered exposed to COVID-19 (a contagious serious respiratory infection transmitted from person to person via small respiratory droplets in the air) and located in the yellow zone (mitigation strategy used for residents who have been exposed to COVID-19 and must be under isolation precautions until cleared by the public health department) without the use of an isolation gown (a protective article used by medical personnel to avoid exposure to blood, body fluids, and other infectious [likely to spread infection] materials, or to protect patients from infection); and 2. LVN 1 and LVN 2 prepared and administered medications to Residents 25, 31, and Resident 36's with the use of a medication tray (small stainless steel tray used to prepare medications) and did not disinfect the medication tray after resident use. These practices potentially placed Residents 17, 25, 31, 33, 36 and staff at risk for the spread and transmission of COVID-19. Findings: 1. During an interview on 6/6/22, at 9:12 a.m., with the Administrator (ADM), the ADM stated the facility was in a yellow zone strategy for COVID-19. The ADM stated staff needed to enter resident rooms with a gown, mask and face shield. During an observation on 6/7/22, at 11:22 a.m., outside of Resident 17's room, LVN 1 donned (put on) an isolation gown and administered insulin (medication used to treat low blood sugar levels) to Resident 17. LVN 1 removed the isolation gown and disposed the gown in the trash receptacle. LVN 1 went to the medication cart and prepared Hydroxyzine (medication used to treat anxiety, nausea, vomiting and itching) and administered the medication to Resident 17, without wearing a gown. During an observation 6/7/22, at 12:30 p.m., outside Resident 33's room, LVN 1 crushed calcium acetate (used to control high levels of phosphate in the blood used for formation of bone and teeth) and calcium carbonate (used to treat low levels of calcium that help with bone formation) and placed the medications in a cup with water and administered Resident 33's medications while wearing an isolation gown. LVN 1 removed the isolation gown and disposed of it in a trash receptacle. LVN 1 went back to Resident 33 to ensure Resident 33 had swallowed the crushed medications in the water without donning a new isolation gown. During an interview an interview on 6/8/22, at 9:58 a.m., with LVN 1, LVN 1 stated the entire facility was under yellow zone precautions which meant staff needed to enter residents' room with a gown, mask, and a face shield. LVN 1 stated he needed to keep his gown on at all times, specifically while administering Resident 17 and Resident 33's medications. LVN 1 stated it was important to have a gown on while in Resident 17 and 33's room to prevent cross contamination (process by which microorganisms are unintentionally transferred from one substance or object to another with harmful effect) from resident to resident. 555892 Page 17 of 22 555892 06/10/2022 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0880 Level of Harm - Minimal harm or potential for actual harm During an interview on 6/10/22, at 9:13 a.m., with the Director of Nursing (DON), the DON stated LVN 1 should have kept his gown on during the entirety of administering medications to Resident 17 and to Resident 33. The DON stated it was important to have gowns on while entering residents' rooms since the facility was under COVID-19, yellow zone precautions to prevent residents from possibly acquiring the COVID-19 virus. Residents Affected - Some During a review of the facility policy and procedure (P&P) titled, Personal Protective Equipment, dated June 2020, the P&P indicated, .A. Gowns .i. Facility Staff wear a gown whenever performing a task that are likely soil the staff's clothing with .body fluids, secretions, or excretions . During a review of the profession reference titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html on 6/20/22, dated 2/2/22, the professional reference indicated, .2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection .Personal Protective Equipment .HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to .higher-level respirator, gown, gloves, and eye protection . 2. During an interview on 6/6/22, at 9:12 a.m., with the ADM, the ADM stated the facility was in a yellow zone strategy for COVID-19. During an observation on 6/7/22, at 11:30, near Resident 36's room, LVN 1 entered Resident 36's room with a medication tray, set in on Resident 36's bedside table and administered medications to Resident 36. LVN 1 did not disinfectant the tray after he exited Resident 36's room. During on observation on 6/7/22, at 11:48 a.m., LVN 1 entered Resident 31's room with a medication tray, set in on Resident 31's bedside table, and administered medications to Resident 31. LVN 1 did not disinfectant the tray he exited Resident 31's room. During an observation on 6/7/22, at 4:26 p.m., LVN 2 entered Resident 25's room with a medication tray, set in on Resident 25's bedside table and administered medications to Resident 25. LVN 1 did not disinfectant the tray after he exited Resident 25's room. During an observation on 6/7/22, at 4:38 p.m., LVN 2 entered Resident 36's room with a medication tray, set in on Resident 36's bedside table and administered medications to Resident 36. LVN 1 did not disinfectant the tray after he exited Resident 36's room. During an interview on 6/8/22, at 9:58 a.m., with LVN 1, LVN 1 stated he needed to prepare medications at the medication cart and not bring in the medication tray into the residents' rooms and set it on the bedside table. LVN 1 stated because the facility was under COVID-19 yellow zone precautions, he needed to ensure no equipment was on any surfaces in the residents' rooms or to disinfect the medication tray after every resident use. LVN 1 stated it was important to keep all equipment that entered residents' sanitary (clean) to prevent from cross-contamination from resident to resident. During an interview on 6/10/22, at 9:13 a.m., with the DON, the DON stated LVN 1 and 2 should have disinfected the medication tray after they exited residents' rooms. The DON stated it was important to disinfect the medication tray because the facility was under COVID-19 yellow zone precautions and 555892 Page 18 of 22 555892 06/10/2022 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0880 LVN 1 and 2 needed to prevent residents from possibly acquiring the COVID-19 virus. Level of Harm - Minimal harm or potential for actual harm During a review of the facility P&P titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated July 2014, the P&P indicated, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected .d. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes and durable medical equipment) . Residents Affected - Some During a review of the profession reference titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html on 6/21/22, dated 2/2/22, the professional reference indicated, .2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection .Environmental Infection Control .Dedicated medical equipment should be used when caring for a patient with suspected or confirmed SARS-CoV-1 infection. All non-dedicated, non-disposable medical equipment used for that patient should be cleaned and disinfected according to manufacturer's instructions and facility policies before use on another patient . 555892 Page 19 of 22 555892 06/10/2022 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Many Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation and interview during the survey period of 6/6/22 to 6/10/22, the facility failed to provide the minimum of at least 80 square feet (sq. ft- unit of measurement) per resident in multiple resident bedrooms, and at least 100 sq. ft in single residents rooms for 16 of 20 rooms (Rooms 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 14, 16, 18, 19, 20), when the amount of useable living space was not adequate for residents. This failure had the potential for residents in Rooms 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 14, 16, 18, 19, and 20 to not have reasonable privacy or adequate space. Findings: The amount of usable living space of the residents' rooms was as follows: Room Number Square Feet 1 Resident A = 59.95 sq. ft Resident B = 59.95 sq. ft 2 Resident A = 59.69 sq. ft Resident B = 60.21 sq. ft 3 Resident A = 58.27 sq. ft Resident B = 59.75 sq. ft 4 Resident A = 58.84 sp. ft Resident B = 58.84 sq. ft 5 92.17 sq. ft (single resident room) 6 555892 Page 20 of 22 555892 06/10/2022 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0912 173.72 sq. ft (three residents) Level of Harm - Potential for minimal harm 7 101.7 sq. ft (single resident room) Residents Affected - Many 8 Resident A = 59.54 sq. ft Resident B = 58.06 sq. ft 9 Resident A = 59.67 sq. ft Resident B = 57.78 sq. ft 10 Resident A = 58.22 sq. ft Resident B = 59.22 sq. ft 11 Resident A = 58.35 sq. ft Resident B = 58.35 sq. ft 12 Resident A = 55.4 sq. ft Resident B = 55.4 sq. ft 13 113.68 sq. ft (single resident room) 14 Resident A = 53.5 sq. ft Resident B = 56.42 sq. ft 15 112.84 sq. ft (single resident room) 16 555892 Page 21 of 22 555892 06/10/2022 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0912 Resident A = 54.88 sq. ft Level of Harm - Potential for minimal harm Resident B = 62.67 sq. ft 17 Residents Affected - Many 110.97 sq. ft (single resident room) 18 Resident A = 56.34 sq. ft Resident B = 60.29 sq. ft 19 92.25 sq. ft (single resident room) 20 94.83 sq. ft (single resident room) However, variations were in accordance with the particular needs of the residents. The residents had a reasonable amount of privacy. Closets and storage space were adequate. There was sufficient room for nursing care and for residents to ambulate. The waiver will not adversely affect the health and safety of residents. Recommend waiver to be continue in effect. 555892 Page 22 of 22