Health inspection·January 14, 2024

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement a system to oversee grievances in accordance with their policy and procedure (P&P) for one of twelve sampled residents (Resident 15) when the facility's Social Services Director (SSD) failed to document, track, and investigate the grievance reported by Resident 15. This failure had the potential to result in Resident 15 not being able to exercise her rights and lack of appropriate action to resolve her grievances. Findings: During a review of Resident 15's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 1/11/24, the AR indicated, Resident 15 was admitted from an acute care hospital on [DATE] to the facility, with diagnoses which included Fracture of Left Femur (broken left thigh bone), Malignant Neoplasm of the Lung (a type of cancer that starts in the lungs, symptoms includes coughing up blood, shortness of breath, chest pain, weight loss, and bone pain), Type 2 Diabetes Mellitus (a disorder in which blood sugar or glucose levels are abnormally high), Pneumonia (lung infection caused by bacteria), Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and Hypertension (high blood pressure). During a review of Resident 15's Minimum Data Set (MDS-comprehensive, standardized assessment of residents' functional capabilities and health needs), dated 12/18/23, the MDS indicated Resident 15's, Brief Interview for Mental Status (BIMS) Summary Score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 15 was cognitively intact. During a review of Resident 15's MDS, dated [DATE], the MDS indicated, . Functional Limitation in Range of Motion . B. Lower extremity (hip, knee, ankle, foot) . Response: 1. Impairment on one side .Mobility Devices . B. [NAME] . Response: Yes . C. Wheelchair . Response: Yes . During a phone interview on 1/4/27, at 9:27 a.m., with the Ombudsman (OMB), the OMB stated, he received a phone call from Resident 15's son on 12/11/23, Resident 15's son reported that on 12/8/23, around 9 p.m., his mother was left on the bedside commode (BSC) for about an hour and her BSC was not emptied and clean by staff on a regular basis. The OMB stated, after his conversation with Resident 15's son, he called the facility and spoke to the Social Service Director (SSD). The OMB stated, he shared Resident 15's complaint with the SSD and was assured the complaint would be investigated Page 1 of 24 555892 555892 01/14/2024 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0585 immediately. Level of Harm - Minimal harm or potential for actual harm During a phone interview on 1/10/24, at 5:45 p.m., with Resident 15's son, he stated his mother was left on the BSC for about an hour on 12/8/23 and her BSC was not emptied and cleaned by staff on a regular basis. Resident 15's son stated, Resident 15 was left sitting on her BSC for approximately one hour on 12/8/23, between the hours of 9 p.m. and 10 p.m. Resident 15's son stated, he called the Ombudsman office on 12/11/23 to report the incident. Residents Affected - Few During a concurrent observation and interview, on 1/11/24, at 9:45 a.m., with Resident 15, inside Resident 15's room, Resident 15 was observed awake lying in bed, a black wheelchair was positioned next to Resident 15's bed, and a BSC was positioned at the foot of the bed. Resident 15 stated, her memory was sharp and she was able to recall the incident that occurred on her second night at the facility (12/8/23). Resident 15 stated, she pressed her call light on 12/8/23, around 9 p.m. for transfer assistance from her bed to the BSC. Resident 15 stated, a male Certified Nurse Assistant (CNA) came in and assisted her to transfer from the bed to the BSC and handed her the call light with an instruction to press it when she's done using the BSC. Resident 15 stated, she pressed the call light multiple times but no one showed up to help her get up and transfer her back to bed. Resident 15 stated, I don't recall who helped me, I was so tired sitting in the commode. I was sitting in the commode for more than an hour. Resident 15 stated, her BSC was not emptied and cleaned by staff on a regular basis. Resident 15 stated, she complained to a female nurse after the incident and did not receive a written summary of the results of the investigation. Resident 15 stated, I told my son about the incident. I don't want anyone to get fired. I just want them to do their job. Resident 15 appeared emotional during the interview. During a concurrent interview and record review, on 1/11/24, at 1:15 p.m., with the Social Service Director (SSD), a document titled Grievance Concern Log for December 2023, dated 12/23 was reviewed. SSD stated, Resident 15's complaint was not documented in the December 2023 Grievance Concern Log and no Grievance Report was prepared. SSD stated, she received a phone call from the Ombudsman on 12/11/23 and was told of Resident 15's complaint. SSD stated, the complaint was about Resident 15 being left on the BSC for about an hour on 12/8/23 and her BSC was not emptied and cleaned by staff on a regular basis. SSD stated, she went to Resident 15's room after the phone call with the OMB, listened to Resident 15's complaint, and informed Resident 15 that her concerns will be addressed immediately. SSD stated she forgot to document Resident 15's concerns in the Grievance Concern Log and failed to report the alleged neglect to the Administrator and the Director of Nursing (DON). SSD stated, she failed to follow the facility's Grievance Policy. SSD stated, the outcome of the investigation should be documented in the Grievance Report and the resident should be notified about the outcome. SSD stated, her failure to follow the facility's Grievance Policy had the potential to result in Resident 15 not being able to exercise her rights and lack of proper action to resolve her grievances. During an interview on 1/11/24, at 4:40 p.m., with Certified Nurse Assistant (CNA) 1, CNA 1 stated, he worked on 12/8/23, from 2:30 p.m. to 10 p.m. and was assigned to care for Resident 15. CNA 1 stated, at around 9:15 p.m., he answered Resident 15's call light and assisted her to transfer from her bed to the BSC. CNA 1 stated, he gave the call light to Resident 15 and instructed her to press it when she finished using the BSC. CNA 1 stated, It was a busy night. I was not able to return to her room to help her back to her bed. I don't remember the time when I saw her in bed. It was before the end of my shift. Another CNA helped her back to her bed. The Director of Staff Development (DSD) talked to me the following day and they told me that I can't provide care to her anymore because of the incident. 555892 Page 2 of 24 555892 01/14/2024 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review on 1/11/24, at 5:06 p.m., with the Administrator (ADM), a document titled, Daily Stand Up Meeting Agenda, dated 12/11/23, 12/12/23, 12/27/23, and 12/28/23 were reviewed. The document indicated, . COMPLAINTS, THEFT AND LOSS, ABUSE . Response: [blank] . The ADM stated, The alleged neglect was not reported to me. I am not aware the SSD was contacted by the Ombudsman regarding Resident 15's complaint. We conduct daily meeting [Monday to Friday] to review resident issues, including grievance, abuse, and neglect. The ADM stated, her expectation was for the staff to complete the Grievance Report and to document the outcome of the investigation in the Grievance Report and notify the complainant. The ADM stated, the SSD failed to follow the facility's Grievance Policy and had the potential to result in Resident 15 not able to exercise her rights and lack of appropriate action to resolve her grievances. During a concurrent interview and record review on 1/12/24, at 11:21 a.m., with the Director of Nursing (DON), a document titled, Daily Stand Up Meeting Agenda, dated 12/11/23, 12/12/23, 12/27/23, and 12/28/23 were reviewed. The document indicated, . COMPLAINTS, THEFT AND LOSS, ABUSE . Response: [blank] . The DON stated, The alleged neglect was not reported during our stand up meeting. I am not aware the SSD was contacted by the Ombudsman regarding Resident 15's complaint. Resident issues, including grievance, abuse, and neglect are reviewed during our stand up meeting. The DON stated, the outcome of the investigation should be documented in the Grievance Report and complainant. should be notified about it. The DON stated, the SSD failed to follow the facility's Grievance Policy. During a review of the facility's Policy and Procedure (P&P) titled, Grievances and Complaints, dated 8/2020, the P&P indicated, .When a Facility Staff member overhears or receives a complaint from a resident . concerning the resident's medical care, treatment, food , clothing, or behavior of other residents, etc., the Facility Staff member is encouraged to advise the resident/concerned party that they may file a complaint or grievance without fear of reprisal or discrimination, and will assist the resident . in filing a written complaint with the facility .All alleged abuse, mistreatment, neglect, injuries will be reported to the Administrator immediately .Grievance Investigation .Upon receiving a resident grievance/complaint form, the Grievance Official or designee begins the investigation into the allegations .The facility will inform the resident or his or her representative or concerned party of the findings of the investigation and any corrective actions recommended in a timely manner . During a review of the Lippincott Manual of Nursing Practice 10th Edition dated 2014, page 16-17 indicated, Standards of practice General Principles .These standards provide patients with a means of measuring the quality of care they receive. Common Departures from the Standards of Nursing Care .failure to adhere to facility policy or procedural guidelines . 555892 Page 3 of 24 555892 01/14/2024 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to meet standards of quality for one of seven sampled residents (Resident 26) when Resident 26's morning medications (sertraline-antidepressant and lamotrigine-anticonvulsive) were in a medication cup on Resident 26's bedside table. Residents Affected - Few This failure had the potential to result in Resident 26 not taking her medications and other residents in the facility at risk for taking the unprescribed medications. Findings: During a concurrent observation and interview on 1/9/24 at 9:17 a.m. with Resident 26, in Resident 26's room, Resident 26 lay in bed with a bedside table next to her. Resident 26's bedside table had a cup of juice, a bowl of cream of wheat and a medication cup with two medications in it. The medication cup had one blue pill and one green and white capsule. Resident 26 stated the medications in the medication cup were hers. Resident 26 stated the two medications in the cup were sertraline and lamotrigine. Resident 26 stated she was admitted to the facility on [DATE]. Resident 26 stated she would take about six or seven pills (medications) in the morning. Resident 26 stated she liked her medications spaced out in the morning and would take some at 8 a.m., 9 a.m. and 10 a.m. Resident 26 stated the nurses in the facility would leave her medications at bedside because she would take them slowly and this was done as part of her routine. During an observation on 1/9/24 at 10:33 a.m. with Resident 26, in Resident 26's room, the medication cup was observed empty. During a review of Resident 26's admission Record (AR), undated, the AR indicated Resident 26 was admitted to the facility on [DATE] with a diagnosis which included Major Depressive Disorder (persistent feeling of sadness and loss of interest, it affects how you feel, think and behave and can lead to a variety of emotional and physical problems), Anxiety (a feeling of fear, dread, and uneasiness) and Muscle Spasm (occur when your muscle involuntarily and forcibly contracts uncontrollably and can't relax). During a review of Resident 26's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) Assessment, dated 12/10/2023, the MDS indicated Resident 26's Brief Interview for Mental Status (BIMS -an evaluation of attention, orientation and memory recall) score was 15, (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 26 was cognitively intact. During a review of Resident 26''s Order Summary Report (OSR), dated 1/11/2024 the OSR indicated, .Sertraline .Oral Capsule 200 [milligrams (mg)-unit of measurement] .Give 1 capsule by mouth one time a day for verbalization of sadness related to major depressive disorder . Administer at 0900 AM . Lamotrigine Oral Tablet 200 [milligrams (mg)-unit of measurement], Give 1 tablet by mouth one time a day for Convulsions induced by muscle spasms .Administer at 0900 AM . During an interview on 1/11/24 at 9:09 a.m., with Certified Nursing Assistant (CNA) 6, CNA 6 stated she had been working in the facility for one year and would care for Resident 26. CNA 6 stated Resident 26 would ask her (CNA 6) for help when Resident 26 felt like her medications were stuck and CNA 6 would give her water if resident needed help getting her pills down. CNA 6 stated Resident 26 555892 Page 4 of 24 555892 01/14/2024 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few would take forever to eat her food due to feeling like the food would get stuck. CNA 6 stated she had not observed medications left at bedside but had observed empty medication cups. During a concurrent interview and record review on 1/11/24 at 1:15 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 26's Medication Administration Record (MAR) dated 1/2024, Resident 26's Order Summary Report (OSR) dated 1/2024 were reviewed. LVN 1 stated Resident 26 was admitted to the facility on [DATE]. LVN 1 stated he would administer Residents 26's medications multiple times a week. LVN 1 validated the medications in the medication cup belonged to Resident 26. LVN 1 stated the medications in the medication cup were sertraline (green and white capsule-antidepressant) and lamotrigine (blue pill-anti-convulsant). LVN 1 reviewed the OSR and stated the medications were ordered to be administered at 9 a.m. LVN 1 reviewed the MAR and validated he cared for Resident 26 on 1/5/2024, 1/6/2024, 1/9/2024, 1/10/2024 and 1/11/2024. LVN 1 validated his initials on the MAR indicating he administered Residents 26's medications on 1/9/24 (date medications were found on Resident 26's bedside table). LVN 1 stated on 1/9/2024 during the medication administration pass he observed Resident 26 take her medications. LVN 1 stated Resident 26 would take pills one by one and would take about five to 10 minutes for each medication administration. LVN 1 stated Resident 26 did not have a diagnosis of difficulty swallowing. LVN 1 stated on 1/11/24 he first observed Resident 26 take her pills out of her mouth. LVN 1 stated if residents medications were left at bedside another resident could take them and cause harm if they were not indicated for them. LVN 1 stated residents could have an allergic reaction and die from them. During a concurrent interview and record review on 1/11/2024 at 4:36 p.m. with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Medication Administration General Guidelines, dated January 2021 was reviewed. The P&P indicated, .the resident is always observed after administration to ensure that the dose was completely ingested . The DON stated .nurses should stay at the bedside until residents swallow the medication .and it is a standard of practice even if not in policy . The DON stated the expectation for the nurses was that no medications should be left at bedside or be without the nurses supervision. The DON stated nurses were aware they should stay with residents while taking medications. The DON stated if medications were left at the bedside without supervision another resident could pick up the medications, take them and cause a reaction to the residents. During a professional reference review retrieved from the National Coordinating Council for Medication Error Reporting and Prevention titled Recommendations to Enhance Accuracy of Admisntration of Medications dated 3/30/2023, the reference indicated, . Personnel to whom this applies: 1) nursing staff involved in administration of medications; . Healthcare organizations should also ensure the medication administration processes are designed so that these goals can be achieved without the use of workarounds and/or shortcuts, or unintended consequences . Ongoing patient monitoring (e.g. direct observation, process monitoring) and follow-up should occur for the desired therapeutic effect(s) and for potential adverse drug effects, in accordance with the organization's policies and procedures and generally accepted practices for medications . 555892 Page 5 of 24 555892 01/14/2024 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 residents were free from unnecessary medications for one of four sampled Residents (Resident 25) when Resident 25 was administered oxycodone HCl (a narcotic used to treat severe pain that can result in physical dependence) for treatment of a healed wound. Residents Affected - Few This failure placed Resident 25 at risk for receiving pain medication unnecessarily which could lead to medication dependence. During an interview on 1/9/24 at 11:42 a.m. with Resident 25, Resident 25 stated he was experiencing pain in both shoulders that was progressing down both arms. Resident 25 stated the pain increased when lifting both arms and pain medication was not effective. During a review of Resident 25's admission Record (a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), indicated Resident 25 was admitted to the facility on [DATE] with a diagnosis of, .Unspecified open wound, left foot . Diabetic (condition where blood sugar is too high) Neuropathy (nerve damage) . Chronic Pain Syndrome (long standing pain) . Other Psychoactive substance abuse (substances that affect mental processes) . During a review of Resident 25's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment dated [DATE], the MDS indicated Resident 25's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 15 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills] 8-12 moderate cognitive impairment, (13-15) cognitively intact) which indicated Resident 25 was cognitively intact. During a review of Resident 25's Physician Order Summary, dated 8/8/23, indicated, . Oxycodone HCl Oral Tablet 5 [mg-milligram unit of measurement] give one tablet by mouth two times a day for moderate pain related to Unspecified open wound, left foot . During a review of Resident 25's Medication Administration Record (MAR), dated 12/1/23-12/31/23, the MAR indicated the medication oxycodone HCl oral tablet 5 mg, was administered twice a day for pain ranging from zero to six (numerical pain scale composed of numbers zero-ten with zero meaning no pain at all to ten meaning worst pain imaginable), to unspecified open wound of the left foot. During an interview on 1/11/24 at 9:13 a.m. with Certified Nursing Assistant (CNA) 3, CNA 3 stated, Resident 25 had not complained of pain to left foot and would walk around the facility independently. During a concurrent interview and record review on 1/11/24 at 9:43 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 25's Physician Order Summary, dated 8/8/23, was reviewed. LVN 3 stated Resident 25 was being administered oxycodone HCl Oral Tablet 5 mg twice a day for pain to an open wound of the left foot that was healed. LVN 2 stated Resident 25's physician had not been notified by the charge nurses of the healed wound or notified of potential medication review. LVN 3 stated the administration of oxycodone HCl was unnecessary and had the potential for Resident 25 to become addicted to the pain medication . During a concurrent interview and record review on 1/11/24 at 2:37 p.m. with 555892 Page 6 of 24 555892 01/14/2024 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the Director of Nurses (DON), Resident 25's Physician Order Summary, dated 8/8/23, was reviewed. DON stated Resident 25 was being administered oxycodone HCl Oral Tablet 5 mg twice a day for pain to an open wound of the left foot. The DON stated it was expected that the charge nurses assessed the need for pain medication and communicated with Resident 25's Physician for indication of use. The DON stated Resident 25 should not have been administered oxycodone pain medication as it was unnecessary for treatment of a healed wound if there was no pain to the area. During a concurrent observation and interview on 1/11/24 at 4:47 p.m. with Registered Nurse (RN) 1 Resident 25's left foot was observed. RN 1 described Resident 25's left foot with no open areas. RN 1 stated Resident 25's left foot wound was healed in November 2023. During an interview on 1/11/24 at 4:49 p.m. with Resident 25, Resident 25 stated his left leg felt numb with no pain. Resident 25 stated there was no issue when walking or completing ADL's because his left foot wound had healed. Resident 25 stated the medication oxycodone used for pain was administered every 12 hours and was last administered at 9:30 a.m. for his shoulder pain. Resident 25 stated his current pain level was between a one and two both of his shoulders. Resident 25 stated the medication oxycodone had been administered since admission to facility on 8/7/23. During a review of Resident 25's Skin/Wound note, dated 11/24/23, the note indicated, . post-surgical wound of the left, distal (away from the center of the body), lateral (to the side of the middle of the body) foot full thickness healed, no open area noted . During a review of Resident 25's Physician Medical Progress Note, dated 11/1/23, the note indicated, . Patient states that his left wound foot is completely healed . During an interview on 1/12/24 at 10:18 a.m. with the facility Pharmacy Consultant (PC), the PC stated there was a Food and Drug Administration (FDA) [responsible for assuring the safety of medications biological products, medical devices, food supply] warning for the interaction of the medication oxycodone with Resident 25's other medications and it was recommended that Resident 25 be assessed by the physician. The PC stated Resident 25 was receiving an unnecessary medication when oxycodone was administered for a healed wound that could potentially cause slow respirations for the resident. During a review of the facility's policy and procedure (P&P) titled, Pain Management, dated 11/2022, indicated, . facility will . evaluate the resident for pain and the cause(s) upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs . example: new pain or an exacerbation(worsening) of pain . based on professional standards of practice, an assessment or evaluation of pain . the facility in collaboration with the attending physician/prescriber . will develop, implement, monitor, and revise as necessary to prevent or manage each individual resident's pain . facility will . evaluate the resident's medical condition, current medication regimen, cause and severity of the pain and course of illness . reassess and adjust the medication dose to optimize the resident's pain relief while monitoring the effectiveness . if pain has resolved or there is no longer an indication for pain medication, the interdisciplinary team(team that consists of various staff that are involved with resident's care) will work to discontinue or taper (slowly decrease) (as needed to prevent withdrawal symptoms) analgesics . During a review of the facility's P&P titled, Administering Pain Medication, dated 10/2022, the P&P indicated, . when opioids (prescription pain medication) are used for pain management, the resident is monitored for . potential overdose (taking too much of a substance) . any resident who uses opioids for long-term management of chronic pain is at risk for opioid overdose . 555892 Page 7 of 24 555892 01/14/2024 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

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, interviews and record review, the facility failed to store and secure medications in a locked compartment for five of five sampled medications when discontinued medications albuterol sulfate inhalation aerosol (medication for breathing), ipratropium and albuterol (nebulizer solution, used to open the airways in lung diseases where spasm may cause breathing problems), and two boxes of loperamide hydrochloride and simethicone tablets (antidiarrheal and anti-gas tablets) and guaifenesin (helps clear mucus) were stored in an unlocked drawer in the nurse's station. This failure had the potential for residents and staff to have access to the medications. Findings: During a concurrent observation and interview on 1/10/24 at 4:20 p.m. with Licensed Vocational Nurse (LVN) 1 in the nurses' station, five medication boxes were stored in an unlocked drawer. LVN 1 validated the medications observed were albuterol sulfate inhalation aerosol with a handwritten date of 12/3/23, ipratropium and albuterol with a handwritten date of 12/28/23, loperamide hydrochloride and simethicone tablets, with a handwritten date of 11/11/23, and two boxes of guaifenesin with a handwritten date of 12/24/23 and 12/28/23. LVN 1 stated the handwritten date on the medication boxes indicated the date the medications were opened. LVN 1 stated the medications had been discontinued and was not aware why the medications were in the nurses station unlocked drawer. LVN 1 stated the medications should be kept in a locked medication cart or the locked medication room. LVN 1 stated discontinued medications should be destroyed by two nurses. LVN 1 stated the medications should have been destroyed per the facility's policy and procedure. LVN 1 stated the medications should not have been left at the nurses station unsecured. LVN 1 stated if residents take medications that are not indicated for them this could harm them. During a concurrent interview and record review on 1/11/24 at 5:02 p.m. with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled Medication Storage dated November 2022 and Discarding and Destroying Medications, dated October 2014 were reviewed. The Medication Storage P&P indicated, .All drugs, and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers . medication rooms) . The Discarding and Destroying Medications P&P indicated, .Take the medication out of the original containers .Mix medication, either liquid or solid, with an undesirable substance. Undesirable substances include sand, coffee grounds, kitty litter, or other absorbent materials, Place the waste mixture in a sealable bag, empty can or other container to prevent leakage . Dispose with the solid waste (i.e., regular trash) in the presence of two witnesses .Document the disposal on the medication disposition record Include the signature(s) of at least two witnesses . The DON stated medications should have been stored in a locked compartment. The DON stated only authorized staff had keys to access the locked compartments. The DON stated facility staff should follow the policy for destruction of medications and the storage of medications. The DON stated the destruction and disposal of medication should be done by two licensed nurses and it should be documented. The DON stated the medications should not have been stored in the nurse's station drawer to await destruction. The DON stated the discontinued medications should have been in a designated area in the medication room. The DON stated the drawer in the nurse's station did not have a lock. The DON stated the nurse's station was not a secure location for medications to be stored and staff and residents had access. 555892 Page 8 of 24 555892 01/14/2024 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 30 of 30 sampled residents when: 1. The cabinet storing clean pots and pans had dust and food crumbs, and a drawer that stored clean utensils had food crumbs. 2. The side wall of the stove was caked with black grime and grease, and the floor behind the stove had a build-up of black grime and crumbs. The upstairs dining room food serving area had a dirty wall with a yellow drip stain and wadded paper observed behind the steam table. Food particles and dirt were observed next to the steam table along the space between the wall and floor where there was no baseboard in place. 3. The floor under the dishwasher was not smooth and easily cleanable. 4. There was an opening in the wall of the kitchen that was open to the outside. This had the potential to allow insects and rodents to enter from the outside. 5. The ice machine and food prep sink did not have an air gap (a vertical space between the end of a pipe and the top of a nearby sink that prevents the backflow of contaminated water). 6. There were dirty dishes in the handwashing sink in the food serving area in the upstairs dining room. 7. There was unlabeled and expired food in the nourishment refrigerator. This had the potential to cause foodborne illness (illness caused by ingestion of contaminated food or beverages) to residents who consumed the food. 8. Food preparation was being done right next to the handwashing sink in the kitchen while staff were washing their hands. 9. The surface sanitizer was not the correct concentration. 10. Under the handwashing sink in the food serving area in the upstairs dining room it was dirty, medical equipment was being stored, and the drywall needed to be repaired. 11. A floor cleaning machine was stored next to the steam table. 12. The basement room outside the kitchen where a refrigerator, freezers, and a rack of clean, uncovered pitchers were located had dust and dirt, the floor was not easily cleanable, and it was open to the air handler room. These failures had the potential to result in the growth of microorganisms (organisms that can only be seen through a microscope) that could accidently be transferred to food and provide an environment that could attract insects and rodents. 555892 Page 9 of 24 555892 01/14/2024 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0812 Findings: Level of Harm - Minimal harm or potential for actual harm 1. During a concurrent observation and interview on 1/9/24 at 9:59 a.m. with the Kitchen Supervisor (KS) in the kitchen, the KS stated he had been here for two years. There was a cabinet that stored clean pots and pans that was dusty and had food crumbs. Food crumbs were also observed in a kitchen drawer where clean utensils were stored. The KS stated areas should be clean and free of crumbs. Residents Affected - Many During an interview on 1/10/24 at 2:02 p.m. with the Registered Dietician (RD), the RD stated her expectation was that no food debris, or dust was in the kitchen; it should be clean. The RD stated utensil drawers should be clean. During a review of the professional reference titled, FDA Food Code 2022, section 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, indicated, . cleaned EQUIPMENT and UTENSILS . shall be stored: (1) In a clean, dry location . In addition, section 4-602.13, indicates, The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. During a review of the facility policy and procedure titled, Sanitation Policy, dated 11/2022, indicated, .All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects . 2. During a concurrent observation and interview on 1/9/24 at 9:59 a.m. with the Kitchen Supervisor (KS) in the kitchen, there was a sticky buildup on the side wall of the stove, and food and trash was observed under the stove. The KS stated it was hard to clean the floor under the stove near the back wall because it was difficult to reach with the broom. During an observation on 1/10/24 at 9:03 a.m. in the upstairs dining room food serving area, a wall with a yellow drip stain was observed behind the steam table. Wadded paper, dust, and dirt was observed behind the steam table. Food particles and dirt were observed next to the steam table between the wall and floor where there was no baseboard in place. During an interview on 1/10/24 at 2:02 p.m. with the Registered Dietician (RD), the RD stated her expectation was that the back and under the stove should still be clean even if it's hard to get to. The RD stated the stove can be moved. The RD stated the expectation was the food serving area by the steam table should be clean. The RD stated the expectation was the baseboard should be clean and there should be baseboards. During an interview on 1/11/24 at 9:34 a.m. with the KS, the KS stated his expectation for the dining room food serving area was the same as the kitchen area no dust, crumbs, or spills. During a review of professional reference titled, FDA Food Code 2022, section 4-602.13 Nonfood-Contact Surfaces, indicated, NonFOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues. In addition, The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms (organisms that can only be seen through a microscope) which employees may inadvertently (accidently) transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. 555892 Page 10 of 24 555892 01/14/2024 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a review of the facility policy and procedure titled, Sanitation Policy, dated 11/2022, indicated, .All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects . 3. During a concurrent observation and interview on 1/9/24 at 10:03 a.m. with the Kitchen Supervisor (KS) in the kitchen, the flooring under the dishwasher was cement and did not have tile. The KS stated he was not sure why the tile did not extend to under the dishwasher. During an interview on 1/10/24 at 2:02 p.m. with the Registered Dietician (RD), the RD stated she was not sure of the plan to place tile under the dishwasher. The RD stated she would expect the area under the dishwasher to be a smooth and easily cleanable surface. During a review of professional reference titled, FDA Food Code 2022, section 6-201.11 Floors, Walls, and Ceilings, indicated, . floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are SMOOTH and EASILY CLEANABLE. In addition, section 6-201.12 indicates, Floors that are of smooth, durable construction and that are nonabsorbent are more easily cleaned . 4. During a concurrent observation and interview on 1/9/24 at 10:03 a.m. with the Kitchen Supervisor (KS) in the kitchen, an open vent from the outside to the kitchen without a cover or screen was observed. The KS stated it had been like that for a while. During an interview on 1/10/24 at 2:02 p.m. with the Registered Dietician (RD), the RD stated she was aware of the vent in the kitchen wall being open. The RD stated she had this on her report that it needed to be closed. During a review of the RD's audit titled Quality Assessment for Performance Improvement (QAPI), dated 10/25/23, the QAPI indicated, Large hole near dish machine area and smaller holes in wall between dish machine room and ice machine . holes to be covered completely . ASAP. During a review of the facility P&P titled, Sanitation Policy, dated 11/2022, indicated, .all food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects . During a review of professional reference titled, FDA Food Code 2022, section 6-202.15 Outer Openings, Protected, indicated, . outer openings of a FOOD ESTABLISHMENT shall be protected against the entry of insects and rodents by filling or closing holes and other gaps along floors, walls, and ceilings .Insects and rodents are vectors of disease-causing microorganisms (organisms that can only be seen through a microscope) which may be transmitted to humans by contamination of food and food-contact surfaces. The presence of insects and rodents is minimized by protecting outer openings to the food establishment . 5. During a concurrent observation and interview on 1/9/24 at 10:35 a.m. with the Maintenance Director (MAIND) 1 in the basement next to the kitchen, observed the ice machine did not have an air gap. A drainage line that carried water to be pumped out of the ice machine was observed to have dark, dirty areas throughout the line. The MAIND 1 stated the ice machine should have an air gap from the drainage line to the pump. During an observation on 1/10/24 at 8:20 a.m. in the kitchen, there was ground beef thawing in the 555892 Page 11 of 24 555892 01/14/2024 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0812 Level of Harm - Minimal harm or potential for actual harm food preparation sink with cold water running. The drainage pipe under the sink was directly connected to the sewer, there was no air gap. During an interview on 1/10/24 at 2:02 p.m. with the Registered Dietician (RD), the RD stated her expectation was that there should be an air gap for the ice machine and the food preparation sink. Residents Affected - Many During a review of the professional reference titled, FDA Food Code 2022, section 5-202.14 Backflow Prevention, Device, indicated, A PLUMBING SYSTEM shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the FOOD ESTABLISHMENT . backflow prevention is required by LAW . In addition, section 5-202.13 indicated, During periods of extraordinary demand, drinking water systems may develop negative pressure in portions of the system. If a connection exists between the system and a source of contaminated water during times of negative pressure, contaminated water may be drawn into and foul the entire system. Standing water in sinks, dipper wells, steam kettles, and other equipment may become contaminated with cleaning chemicals or food residue . Providing an air gap between the water supply outlet and the flood level rim of a plumbing fixture or equipment prevents contamination that may be caused by backflow. 6. During an observation on 1/9/24 at 11:56 a.m. in the dining room food serving area, dirty dishes were observed in the handwashing sink. During an interview on 1/10/24 at 2:02 p.m. with the Registered Dietician (RD), the RD stated the upstairs sink in the dining room food serving area should not have had dirty dishes in the handwashing sink. During an interview on 1/11/24 at 9:34 a.m. with the Kitchen Supervisor (KS), the KS stated the handwashing sink was only for handwashing. During a review of the professional reference titled, FDA Food Code 2022, section 5-205.11 Using a Handwashing Sink, indicated, . A HANDWASHING SINK may not be used for purposes other than handwashing. In addition, . sinks used for food preparation and warewashing can become sources of contamination if used as handwashing facilities by employees returning from the toilet or from duties which have contaminated their hands. 7. During a concurrent observation and interview on 1/10/24 at 8:30 a.m. with the Kitchen Supervisor (KS) in the downstairs kitchen staff lounge, the resident nourishment refrigerator was observed. Expired and undated resident food was observed in the resident nourishment refrigerator. The KS stated the resident nourishment refrigerator was monitored by housekeeping and food was kept for three to seven days then thrown out. Observed food dated November 28, 2023, unlabeled wrapped food, and two compromised soft drink cans. KS stated expired food should be discarded. During a review of the facility policy and procedure titled, Use and Storage of Food Brought in by Family or Visitors, dated 11/2022, indicated, . all food items that are already prepared by the family or visitor brought in must be labeled with content and dated . the prepared food must be consumed by the resident within 3 days. If not consumed within 3 days, food will be thrown away . the facility staff will assist residents in accessing and consuming food that is brought in by resident and family or visitors if the resident is not able to do so on their own. 8. During an observation on 1/10/24 at 10:20 a.m. in the kitchen, the Dietary Aide (DA) was observed preparing uncovered food trays next to a handwashing sink as staff washed their hands. 555892 Page 12 of 24 555892 01/14/2024 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview on 1/10/24 at 2:02 p.m. with the Registered Dietician (RD), the RD stated she would expect staff to keep distance between the food and sink or put up splash guards to prevent cross-contamination of dirty water with the food. During a review of professional reference titled, FDA Food Code 2022, indicated, If handwashing sinks and fixtures are located where splash may contaminate food contact surfaces or food, then splash guards should be installed or food-contact surfaces should be relocated to prevent cross-contamination . 9. During an observation and interview on 1/10/24 at 10:20 a.m. in the kitchen, the [NAME] (CK) 1 was observed wiping the dumbwaiter (a small freight elevator or lift intended to carry food) with a cloth that was in a red sanitizer bucket. CK 1 was requested to test the sanitizer to verify it had the appropriate sanitizer concentration. A test strip was dipped in the bucket, and it was observed to not register a sanitizer concentration. CK 1 changed the sanitizer and retested with a new test strip. The test strip was observed to register 200 parts-per-million (ppm) (describes the concentration of sanitizer in water). CK 1 stated the range for sanitizer should be between 150ppm and 200ppm. CK 1 was observed placing utensils and serving bowls on the dumbwaiter without re-sanitizing the surface. During an interview on 1/10/24 at 2:02 p.m. with the Registered Dietician (RD), the RD stated she would expect the red sanitizer bucket to have the appropriate levels of sanitizer in the red bucket. During a review of professional reference titled, FDA Food Code 2022, section 3-304.14 Wiping Cloths, Use Limitation, indicated, . (B) Cloths in-use for wiping counters and other EQUIPMENT surfaces shall be: (1) Held between uses in a chemical sanitizer solution at a concentration specified under § 4-501.114 . 10. During an observation on 1/10/24 at 9:03 a.m. in the dining room food serving area, observed under the handwashing sink to be dirty with sheet rock missing on back wall. Observed stored wheelchair leg holders, plunger, painting supplies, and brown markings on the floor of the cabinet. During an interview on 1/10/24 at 2:02 p.m. with the Registered Dietician (RD), the RD stated her expectation was the area under the handwashing sink in the dining room area should be clean and sanitary. During a review of the facility policy and procedure titled, Sanitation Policy, dated 11/2022, indicated, All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects . During a review of professional reference titled, FDA Food Code 2022, section 6-201.11 Floors, Walls, and Ceilings, indicated, . floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are SMOOTH and EASILY CLEANABLE . In addition, section 4-602.13 indicated, The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. In addition, section 6-501.114 indicated, The presence of unnecessary articles, including equipment which is no longer used, makes regular and effective cleaning more difficult and less likely. It can also provide harborage for insects and rodents. Areas designated as equipment storage areas and closets must be maintained in a neat, clean, and sanitary manner. They must be routinely 555892 Page 13 of 24 555892 01/14/2024 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0812 cleaned to avoid attractive or harborage conditions for rodents and insects. Level of Harm - Minimal harm or potential for actual harm 11. During an observation on 1/10/24 at 9:03 a.m. in the dining room food serving area, a housekeeping floor cleaner machine was observed in the corner of the food serving area, next to the steamer table and the food prep table. Residents Affected - Many During an interview on 1/10/24 at 2:02 p.m. with the Registered Dietician (RD), the RD stated floor cleaning equipment should not be close to the food serving area, it should be separated. During an interview on 1/11/24 at 9:34 a.m. with the Kitchen Supervisor (KS), the KS stated the floor cleaning machine and supplies were not touching other food serving equipment. The KS stated he did not think it was a problem. The KS stated he would want to keep cleaning supplies away from the kitchen food serving area. During a review of the facility's policy and procedure titled, Housekeeping Storage Areas, Environmental Services, (undated), indicated, . cleaning supplies, etc., shall be stored in areas separate from food storage rooms . During a review of professional reference titled, FDA Food Code 2022, Section 6-501.113 Storing Maintenance Tools, indicated, . Maintenance tools such as brooms, mops, vacuum cleaners, and similar items shall be: (A) Stored so they do not contaminate FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES . In addition, Brooms, mops, vacuum cleaners, and other maintenance equipment can contribute contamination to food and food-contact surfaces. These items must be stored in a manner that precludes such contamination. To prevent harborage and breeding conditions for rodents and insects, maintenance equipment must be stored in an orderly fashion to permit cleaning of the area. 12. During a concurrent observation and interview on 1/9/24 at 10:03 a.m. with the Kitchen Supervisor (KS) in the basement area next to the kitchen, observed an open area to the air handler space without a door to separate where the Meat Freezer #1, Meat Freezer #2, refrigerator, and ice machine were stored. Observed an open, uncovered rack that stored clean water pitchers in the same area. The flooring was concrete and not easily cleanable. Dirt and dust were observed behind the refrigerator. Pipes and water lines overhead observed uncovered and were dirty and dusty. KS stated due to space restrictions, they had to store items in the basement area. During a review of professional reference titled, FDA Food Code 2022, section 4-202.16 Nonfood-Contact Surfaces, indicated, NonFOOD-CONTACT SURFACES shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance. In addition, section 6-201.11 indicated, . floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are SMOOTH and EASILY CLEANABLE . During a review of professional reference titled, FDA Food Code 2022, section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, indicated, . NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. In addition, section 4-602.13 indicated, The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. 555892 Page 14 of 24 555892 01/14/2024 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a review of professional reference titled, FDA Food Code 2022, section 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, indicated, (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS . shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination . In addition, section 4-903.12 indicated, . cleaned and SANITIZED EQUIPMENT, UTENSILS . may not be stored: . Under sewer lines that are not shielded to intercept potential drips; Under leaking water lines including leaking automatic fire sprinkler heads or under lines on which water has condensed; . Under other sources of contamination. During a review of professional reference titled, FDA Federal Food Code 2022, section 6-201.11 Floors, Walls, and Ceilings, indicated, .floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are SMOOTH and EASILY CLEANABLE. In addition, 6-201.12 indicated, (A) Utility service lines and pipes may not be unnecessarily exposed. (B) Exposed utility service lines and pipes shall be installed so they do not obstruct or prevent cleaning of the floors, walls, or ceilings. Floors that are of smooth, durable construction and that are nonabsorbent are more easily cleaned. Requirements and restrictions regarding floor coverings, utility lines, and floor/wall junctures are intended to ensure that regular and effective cleaning is possible, and that insect and rodent harborage is minimized. When cleaning is accomplished by spraying or flushing, coving, and sealing of the floor/wall junctures is required to provide a surface that is conducive to water flushing. Grading of the floor to drain allows liquid wastes to be quickly carried away, thereby preventing pooling which could attract pests such as insects and rodents or contribute to problems with certain pathogens such as Listeria monocytogenes, (a disease causing bacteria that can be found in moist environments, soil, water, decaying vegetation and animals, and can survive and even grow under refrigeration and other food preservation measures). 555892 Page 15 of 24 555892 01/14/2024 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards and practices for three of eight sampled residents (Resident 12, Resident 13 and Resident 20) when: 1.Resident 12's Physician Orders for Life Sustaining Treatment (POLST-a written portable medical order form with instructions for emergency medical care that travels with a resident ) was not completely documented with Resident 12's information. 2. Resident 13 and Resident 20's POLST did not have the second page completed. These failures resulted in Resident 12, Resident 13, and Resident 20's medical information to not be readily accessible and portable in case of an emergency. Findings: During a review of Resident 12's Physician Orders for Life Sustaining Treatment (POLST), dated 10/3/19, the back side of the POLST form that provides resident information, supervising physician, and additional contact information was not completed. During a review of Resident 12's admission Record (a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), indicated Resident 12 was admitted to the facility on [DATE]. During a review of Resident 12's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment dated [DATE], the MDS indicated Resident 12's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 15 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills] 8-12 moderate cognitive impairment, (13-15) cognitively intact) which indicated Resident 12 was cognitively intact. During a concurrent interview and record review on 1/10/24 at 8:27 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 12's POLST, dated 10/3/19 was reviewed. The POLST indicated the back side of the form was not completed. LVN 2 stated, the back of the POLST form was not signed by the physician and there was no information completed for Resident 12. LVN 2 stated it was important to have the POLST form complete. LVN 2 stated it did not have Resident 12's identifying information, who to call in case of an emergency and was not signed. During a concurrent interview and record review on 1/10/24 at 9:43 a.m. with the Medical Records Supervisor (MRS), Resident 12's POLST, dated 10/3/19 was reviewed. The POLST indicated the back side of the form was not completed. The MRS stated, the POLST was not a completed documented and needed to be filled out to ensure Resident 12 received the correct emergency care. MRS stated it was important to have the entire POLST form complete in case of an emergency. During a concurrent interview and record review on 1/12/24 at 11:46 p.m. with the Director of 555892 Page 16 of 24 555892 01/14/2024 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Nurses (DON), Resident 12's POLST, dated 10/3/19 was reviewed. The POLST indicated the back side of the form was not completed. The DON stated, the POLST form was not complete because the back side of the form was left blank. DON stated the POLST form should have been filled out completely to have the information staff needs for Resident 12's care in an emergency. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, revised July 2017, indicated . Documentation in the medical record may be electronic, manual or a combination .Documentation in the medical record will be objective .complete, and accurate . During a review of the facility's policy and procedure titled, Advanced Directives, dated 9/2022, indicated, .Physician Orders for life sustaining Treatment (POLST) . a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patients current medical condition into consideration . During a review of a professional reference titled, American Nurses Association: Principles of Nursing Documentation, dated 2010, page 8 indicated, .Patient documentation frequently is used by professionals who are not directly involved with the patient's care. If patient documentation is not timely, accurate, accessible, complete, legible, readable, and standardized, it will interfere with the ability of those who were not involved in and are not familiar with the patient's care to use the documentation . During a professional reference review retrieved from the National Library of Medicine titled Health professionals' routine practice documentation and its associated factors in a resource-limited setting: a cross-sectional study dated 2/16/2023, the professional reference indicated, .Documentation is a standard way of keeping ongoing patient care information. It is the relevant facts of routine health information .Documenting routine practices is essential for the continuity of patient care . communication among healthcare professionals . Healthcare facilities' . policies should require health professionals to complete patient records . Whether the documentation is a paper-based or electronic system, it should be . accurate clear, permanent, confidential and timely . Poor documentation practice affects patient management, continuity of patient care . which arise from incomplete and inadequate documentation, lack of accuracy . 2. During a review of Resident 13's POLST, dated 3/9/23, the Paper Chart (PC) and the Electronic Medical Record (EMR), the POLST in the PC indicated it had been signed by Resident 13 on 3/9/23. The POLST in the PC did not have a Physicians signature and the second page of the POLST was not completed. Resident 13's POLST was reviewed in the EMR and the POLST was signed by the physician on 3/9/23 and the second page of the POLST was not in EMR. During a review of Resident 20's POLST, dated 8/30/22, the PC and the ERM were reviewed. The POLST indicated it was signed by Resident 20 and Physician on 8/30/22. Resident 20's POLST was reviewed in the PC and the second page of the POLST was not in the PC. Resident 20's POLST was reviewed in the EMR and the second page of the POLST was not in EMR. During a concurrent interview and record review on 1/11/24 at 10:59 a.m. with the Social Services (SS), Resident 13's POLST dated, 3/9/23 and Resident 20's, POLST dated, 8/30/22 were reviewed. The SS reviewed Resident 13's PC and stated the POLST did not have a physician's signature and the second page was missing. The SS stated Resident 13's POLST in the PC was incomplete. The SS reviewed Resident 13's EMR and stated the POLST was signed by the physician but did not have the second page of the 555892 Page 17 of 24 555892 01/14/2024 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some POLST. The SS stated Resident 13 and Resident 20's POLST should have the second page completed in the PC and the EMR but did not. The SS stated the nurse who completed the admission paperwork was responsible for completing the POLST on both sides (page one and page two). The SS stated the front page (page 1) should be filled out and signed by the physician and the back page (page 2) should be signed by the nurse or whoever filled out the POLST. The SS stated the PC and EMR should both be accurate. The SS stated the medical records department completed chart audits in the EMR to ensure records were complete and accurate. During an interview on 1/11/24 at 4:33 p.m. with the Activities Director/Medical Records (AD/MR), the AD/MR stated she had been working at the facility for five years and had been in the role of MR for a year or two. The AD/MR stated the admission packet had a POLST form to be completed which was double sided and both sides needed to be filled out. The AD/MR stated she would review the POLST to ensure it was completed and if incomplete she would return the POLST to the nurse to complete. The AD/MR stated chart audits had been completed in the EMR to ensure POLST were complete and accurate but was unaware of the date. The AD/MR stated her practice was to scan all medical records into the EMR system at least once per week and included POLST forms for Residents. During a concurrent interview and record review on 1/12/24 at 12:03 p.m. with the Director of Nursing (DON), Resident 13's POLST in the EMR and PC dated 3/9/23 and Resident 20's POLST dated 8/30/22 were reviewed. The DON validated Resident 13 and Resident 20's POLST was incomplete due to no second page being in the EMR and PC. The DON stated both pages of the POLST, front and back should be completed. The DON stated the POLST should be completed and accurately documented in the Resident's EMR and in the Resident's PC. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, revised July 2017, indicated . Documentation in the medical record may be electronic, manual or a combination .Documentation in the medical record will be objective .complete, and accurate . During a review of the facility's P&P titled, Advance Directives, revised September 22, indicated .Physician Orders for Life-Sustaining Treatment (or POLST) paradigm form- a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patients current medical condition into consideration. A POLST paradigm form is not an advanced directive . During a review of Physician Orders for Life-Sustaining Treatment (POLST) blank form, effective 4/1/2017, the POLST indicated on the first page/front page, .A copy of the signed POLST form is a legally valid physician order. Any section not completed implies full treatment for that section. POLST complements an Advanced directive and is not intended to replace that document . [second page/back page] Patient Information ., NP/PA's [Nurse Practitioner/Physician Assistant] Supervising Physician, Preparer's name (if other than signing Physician NP/PA) . Additional Contact . Directions for Health Care Provider .Reviewing POLST it is recommended that POLST be reviewed periodically . During a professional reference review retrieved from the National Library of Medicine titled Health professionals' routine practice documentation and its associated factors in a resource-limited setting: a cross-sectional study dated 2/16/2023, the professional reference indicated, .Documentation is a standard way of keeping ongoing patient care information. It is the relevant facts of routine health information .Documenting routine practices is essential for the continuity of patient care . communication among healthcare professionals . Healthcare facilities' . policies should require 555892 Page 18 of 24 555892 01/14/2024 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0842 Level of Harm - Minimal harm or potential for actual harm health professionals to complete patient records . Whether the documentation is a paper-based or electronic system, it should be . accurate clear, permanent, confidential and timely . Poor documentation practice affects patient management, continuity of patient care . which arise from incomplete and inadequate documentation, lack of accuracy . Residents Affected - Some 555892 Page 19 of 24 555892 01/14/2024 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0908 Keep all essential equipment working safely. 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 maintain and provide one of one resident (Resident 12) beds in safe operating condition when Resident 12's head of the bed and foot of the bed would not raise up or lower. Residents Affected - Few This failure resulted in Resident 12 being uncomfortable while in her bed. During a concurrent observation and interview on 1/9/24 at 9:17 a.m. with Resident 12, Resident 12's bed would not raise or lower at the head of the bed (HOB) or the foot of the bed (FOB). Resident 12 stated, the bed had not functioned for six months, and she had made staff aware of the issue. Resident 12 stated when she wanted to sit upright, the staff would position pillows behind her back in bed, causing discomfort. Resident 12 stated she would have to sit up in her wheelchair during her meals or sit up at the edge of the bed having to adjust frequently. Resident 12 stated she felt uncomfortable because she did not always want to lay flat on the bed. During a review of Resident 12's admission Record (a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), indicated Resident 12 was admitted to the facility on [DATE] with a diagnosis of, .Morbid Obesity (weight that is more than 80 to 100 pounds above the ideal body weight). Acute Respiratory failure (lungs cannot release enough oxygen into the blood) . muscle weakness . During a review of Resident 12's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment dated [DATE], the MDS indicated Resident 12's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 15 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills] 8-12 moderate cognitive impairment, (13-15) cognitively intact) which indicated Resident 12 was cognitively intact. During an interview on 1/10/24 at 3:24 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated, Resident 12's bed had not been working for a few weeks. CNA 2 stated the broken bed was reported to the charge nurse for that day but could not recall what day that was. During an interview on 1/10/24 at 3:26 p.m. with CNA 4, CNA 4 stated, Resident 12's bed had not been working for a few weeks and recalled Resident 12 reported the issue to the charge nurse and Maintenance Supervisor (MS) but could not recall the date. CNA 4 stated the broken bed could have caused Resident 12 to feel uncomfortable. During an observation on 1/10/24 at 3:21 p.m. with the Maintenance Supervisor (MS), the MS was observed in Resident 12's room fixing the bed. During an interview on 1/10/24 at 3:42 p.m. with the MS, the MS stated, the bed was reported as broken last week by staff. The MS stated there was no documentation the broken bed was reported and there was no documentation there was an attempt to fix the bed last week. The MS stated staff notified him again today of the broken bed. During an interview on 1/10/24 at 3:46 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated 555892 Page 20 of 24 555892 01/14/2024 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the facility process for reporting a maintenance issue was for the staff to submit a ticket into the maintenance log that is located electronically and accessible to all staff. LVN 3 stated after the ticket is submitted to the MS electronically, there was no follow up with the completion. LVN 3 stated it was assumed the MS completed the maintenance issues that were submitted. LVN 3 stated Resident 12's broken bed resulted in Resident 12 feeling uncomfortable and unable to move her head up and down while lying in bed, stretch or move easily. LVN 3 stated Resident 12 had to eat her meals in the wheelchair instead of in her bed. During an interview on 1/11/24 at 2:58 p.m. with the Director of Nurses (DON), the DON stated the expectation was for the facility MS to fix the issues reported and for the MS to track the maintenance issues reported in the facility. The DON stated it was not ok for Resident 12 to lie flat in bed because of the potential to be uncomfortable during meal consumption and constant repositioning in bed. During a review of the facility's Policy and Procedure (P&P) titled, Preventative Maintenance Program, dated 11/2022, indicated, . The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the . equipment are maintained in safe and operable manner . 555892 Page 21 of 24 555892 01/14/2024 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 1/9/24 to 1/12/24, 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 usable 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: During an environment tour with the Maintenance Director on 1/12/24 at 9:17 a.m., the inspection indicated the following rooms did not meet the minimum square footage as required by regulation. These rooms were 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) 555892 Page 22 of 24 555892 01/14/2024 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0912 6 Level of Harm - Potential for minimal harm 173.72 sq. ft (three residents) 7 Residents Affected - Many 101.7 sq. ft (single resident room) 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) 555892 Page 23 of 24 555892 01/14/2024 Rolling Hills Care Center 2108 Stillman Selma, CA 93662

F 0912 16 Level of Harm - Potential for minimal harm Resident A = 54.88 sq. ft Resident B = 62.67 sq. ft Residents Affected - Many 17 110.97 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 needs of the residents. The residents had a reasonable amount of privacy. Closets and storage space were adequate. Bedside stands were available. There was sufficient room for nursing care and for residents to ambulate. Wheelchairs and toilet facilities were accessible. The waiver will not adversely affect the health and safety of residents. Recommend waiver to be continue in effect. _____________________________________ Health Facilities Evaluator Supervisor Signature Date: 555892 Page 24 of 24