Health inspection·May 12, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a homelike environment for 27 of 27 residents. Findings: On 5/12/23 at 10:00 A.M., an observation of all resident accessible areas and concurrent interview with with the Director of Nursing (DON) and Maintenance Specialist (MS) was conducted. 1. In the small dining room of the facility, the following problems were noted (Each problem was reviewed with DON and MS): -The flooring had 3 areas of worn flooring each about 6-8 inches of missing linoleum. - One table had a 2 L brackets that were not secured to the wall and had the potential to do harm to resident. - The top few centimeters of a nail were sticking out of the molding near a bench that had potential to do harm to resident. 2. In the second larger dining room, the following problems were noted (Each identified problem was reviewed with DON and MS): - Four tables had L brackets (8 total brackets) that were not secured to the wall that had potential to do harm to resident. - There were tears in the vinyl to the booth in multiple areas that had potential to collect food and attract pests. - There was a chair with ripped vinyl cover that exposed the cushion that had the potential to collect to food and attract pests. 3. In the hallway of the facility, molding was separated from the wall with the potential of causing harm to a resident in each of the following areas (Each identified problem was reviewed with DON and MS): - On the right side of the entrance of larger dining room. Page 1 of 8 555919 555919 05/12/2023 Imperial Manor 100 East 2nd Street Imperial, CA 92251

F 0584 - On the wall between rooms [ROOM NUMBERS] close to the water cooler. Level of Harm - Minimal harm or potential for actual harm - On the left side of the entrance to the utility room. - On the left side of the entrance of room [ROOM NUMBER]. Residents Affected - Some - On the left side of the entrance to room [ROOM NUMBER]. - On both sides of the entrance of room [ROOM NUMBER]. - On both sides of the entrance of room [ROOM NUMBER]. - On the wall between room [ROOM NUMBER] and 4. - On both sides of the entrance of room [ROOM NUMBER]. - On both sides of entrance of room [ROOM NUMBER]. 4. room [ROOM NUMBER] was observed to have the following problems (Each identified problem was reviewed with DON and MS): - Window with no molding around it. - Bedpost with no cover, sharp edge exposed potential for harm to resident. - Molding at the foot of the bed 1 broken sharp edge exposed with potential harm to resident. 5. room [ROOM NUMBER] was observed to have the following problems (Each identified problem was reviewed with DON and MS): -Window with no molding around it. - A nail was sticking out near window, removed that time of observation. - Bed 2 had a piece of broken headboard still attached to bed frame, sharp edges with potential to harm resident. - Broken floor molding between restroom and closet. - Broken molding near bed 1. 6. room [ROOM NUMBER] was observed to have the following problems (Each identified problem was reviewed with DON and MS): - Broken molding between restroom and closet; molding was bulging out from the wall 7. room [ROOM NUMBER] was observed to have the following problems (Each identified problem was reviewed with DON and MS): 555919 Page 2 of 8 555919 05/12/2023 Imperial Manor 100 East 2nd Street Imperial, CA 92251

F 0584 - Restroom with broken molding, Level of Harm - Minimal harm or potential for actual harm - Molding sticking out near bed 1 potential to harm resident. Residents Affected - Some 8. room [ROOM NUMBER] was observed to have the following problems (Each identified problem was reviewed with DON and MS): - Corner of the restroom with cracked wall, no molding, sharp edge with potential to harm resident - Restroom floor in disrepair, sharp edges coming up; possible pest entry, and black colored residue noted. - Molding behind bed 3 coming off wall. 9. room [ROOM NUMBER] was observed to have the following problems (Each identified problem was reviewed with DON and MS): - Floor and molding between restroom and closet broken. - Restroom floor with damaged linoleum. - Shower wall with water damage above shower. - 2 inch hole in first closet door. 10.room [ROOM NUMBER] was observed to have the following problems (Each identified problem was reviewed with DON and MS): - Bathroom floor with silver tape over linoleum directly in front of door; potential trip hazard for residents. - Restroom molding broken. 11. room [ROOM NUMBER] was observed to have the following problems (Each identified problem was reviewed with DON and MS): - [NAME] paneling on wall with large scrape across entirety of wall. - Broken bedside cabinet with molding on cabinet coming apart from main cabinet; possible trip hazard. - Restroom door entrance with broken molding; sharp edge with potential for harm to resident. - Restroom tile on wall broken. 12. room [ROOM NUMBER] was observed to have the following problems (Each identified problem was reviewed with DON and MS): - Two large areas of, about 2x1 ft linoleum replaced with non-matching pieces of linoleum; one T 555919 Page 3 of 8 555919 05/12/2023 Imperial Manor 100 East 2nd Street Imperial, CA 92251

F 0584 shaped and one rectangular with wear and tear around edges. Level of Harm - Minimal harm or potential for actual harm - Molding around bed 6, 5, 1, 2, 3 all broken. - 2 inch hole in the wall behind entrance door; potential entry of pests and rodents. Residents Affected - Some On 5/12/23 at 11:55 A.M., an interview was conducted with the DON. The DON stated that the expectation was the facility environment should make the residents feel safe and comfortable and that all problem areas should be fixed to accommodate the safety of the residents. Furthermore, she stated that the importance of repairing any disrepair was to make the residents feel at home. A review of the facility policy entitled Homelike Environment dated February 2021 was conducted. Policy indicates .Residents are to be provided with a safe, clean, comfortable and homelike environment . 555919 Page 4 of 8 555919 05/12/2023 Imperial Manor 100 East 2nd Street Imperial, CA 92251

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure food safety and sanitation for 27 of 27 residents when the kitchen staff failed to follow the 3 sink compartment method for dishwashing and the sanitizer solution was out of range and tested at 200 parts per million (ppm) , twice the facility policy. This failure had the potential to place the residents at risk for developing a foodborne illness. Findings: On 5/9/2023 at 10:31 A.M., an observation was conducted in the kitchen. The 3 sink compartment method was used for cleaning and disinfecting the dishware and kitchen utensils. A review of the dishwashing procedure indicated Sanitize for at least 45 seconds using: Hot water at least 77 degrees Centigrade (C) (170 degrees Fahrenheit (F)) or A solution not less than 24 degrees C (75 degrees F) of one of these 100 ppm Chlorine . A review of the sanitation of dishware log for month of May 2023 indicated chemical strip test of sanitize sink (third sink with chlorine) indicated from 5/1/2023 to 5/8/2023 at 5 A.M. and 5 PM and 5/9/2023 at 5 A.M., was recorded at 200 ppm. On 5/9/2023 at 10:50 P.M., an observation and interview was conducted with the Dietary Supervisor (DS) and Kitchen Staff (KS) 1. Per DS, the facility used the 3 sink compartment method for dishwashing. The hot water and chemical were used on the third sink to sanitize the dishes and utensils. The DS stated the sanitation dishware log for month of May 2023 indicated chemical test results of 200 ppm. KS 1 filled the third sink with the hot water and was tested with a temperature of 120 degrees F. Per DS, there was no log sheet for water temperature. Per DS the chemical test strip result of 200 ppm was a .bit high and the water temperature of 120 degrees F was low and should be 180 degrees F. On 5/11/2022 at 11:15 A.M., the KS stated it was important that the facility's 3 sink compartment method for dishwashing was followed, water temperature and chemical test strip was documented to ensure proper sanitation and prevention of food borne illness. On 5/12/2023 at 12:30 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated it was important to follow the 3 sink compartment method for dishwashing to ensure the residents' safety from food borne illness. A review of facility's policy and procedure on Temperature and Chlorine testing dated 12/10/2010 indicated .It is the policy of this facility to record temperature and chlorine data on a daily basis for all three meals . the final rinse temperature . minimum of 180 degrees F . Chlorine must be 100 ppm . 555919 Page 5 of 8 555919 05/12/2023 Imperial Manor 100 East 2nd Street Imperial, CA 92251

F 0836 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to comply with the State regulation for not submitting a written notice and report to the State Agency per Title 22, § 72541 - Unusual Occurence (any condition or event which has jeopardized or could jeopardize the health, safety, security or well-being of any patient) when Resident 28 eloped from the facility on 3/27/2023 and 4/1/2023. This failure has put the facility out of compliance with Federal and State Regulations in regards to reporting unusual occurences. Findings: A review of undated Facesheet indicated that Resident 28 was admitted in the facility on 1/5/2023 for Schizoaffective Disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania.) On 5/11/2023 at 9 A.M., an interview was conducted with Resident 28's mother. Resident 28's mother stated she was concerned about Resident 28's safety; Resident 28 jumped over the facility's back patio's gated fence twice a few weeks ago. He was missing for a few hours the first time and was found in a store unharmed. The second time, he was caught immediately on the the other side of the fence. On 5/11/2023 at 10 A.M., an interview was conducted with the Assistant Administrator (AA). The AA stated that Resident 28 eloped twice a few weeks ago. Per AA, both incidents of elopement were reported the local police department, but not reported to California Department of Public Health (CDPH). On 5/11/2023 at 11:30 A.M., an interview and record review was conducted with the Director of Nursing (DON). The DON stated that on 3/27/2023 at 6:20 A.M., the staff noticed that Resident 28 was missing. Resident 28 was later found in a convenient store at around 8:30 A.M. Resident 28's mother was informed your son eloped. The DON stated the review of camera footage indicated that Resident 28 jumped over the back patio's gated fence. The DON further stated Resident 28 eloped again and jumped over the back patio's gated fence the second time on 4/3/2023 at 8:30 A.M. Per DON, both elopements were not reported to CDPH and to the State Ombudsman. It was important to report to CDPH and to the Ombudsman the elopements to be in compliance with Federal and State Regulations in regards to reporting unusual occurences. A review of Resident 28's Licensed Personnel Weekly Progress Notes dated 3/27/2023 at 6:20 A.M., indicated .While taking change of shift report, NOC (Night) staff notified NOC nurse that Resident 28 in [Room number] was nowhere to be found . Review of the cameras showed resident jumping over gate in back yard . A review of Resident 28's Licensed Personnel Weekly Progress Notes dated 4/3/2023 at 8:30 A.M., indicated .Resident re-attempts to AWOL (Absent without leave) - ran towards the gate in back of the building. And jumped over fence {sic} but was detained by the staff . A review of the facility's policy and procedure titled Policy and Procedure for Unusual Occurrences 555919 Page 6 of 8 555919 05/12/2023 Imperial Manor 100 East 2nd Street Imperial, CA 92251

F 0836 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated .Policy: The unusual occurrence report is a guide to walk through a thorough investigation for a root cause analysis. An unusual occurrence report is to be completed for all injuries/accidents or any situation/occurrence that could pose a safety risk to patients or staff . What constitutes a serious incident: .G. Elopement . Immediate steps need taken: .F. Administrator and/or DON will notify the Dept. of Health Services within 24 hours of Incident. A written report to follow within 24 hours to either the local Ombudsman or local law enforcement agency . Report send to: California Department of Public Health . 555919 Page 7 of 8 555919 05/12/2023 Imperial Manor 100 East 2nd Street Imperial, CA 92251

F 0880 Provide and implement an infection prevention and control program. 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 that two glucometers (machine that measures blood sugar) were disinfected according to facility policy. Residents Affected - Few This failure increased the potential of spreading a bloodborne (from blood) infection from the glucometer. Findings: On [DATE] at 9:45 A.M., a concurrent observation of medication cart 1 and interview with Licensed Nurse 1 (LN) was conducted. A glucometer was stored in the medication cart. LN1 stated they have 2 patients who get blood sugars drawn, and each has their own glucometer. LN1 stated the process he used to clean the exterior of the glucometers was to wipe them with alcohol pads. LN1 stated that he did not get formal training how to clean the glucometer, but using alcohol swabs was the way he was taught in nursing school. LN1 stated he was not sure if there was a facility policy for cleaning the glucometers. At 10:00 A.M., a concurrent interview with LN1 and record review of the manufacturer's manual for Evencare brand glucometer was conducted. User's manual indicates .Prepare CaviWipes towelette or other EPA-registered disinfecting wipe . LN1 stated they had CaviWipes, but they were expired so they had been using Lysol wipes for household disinfection, but he had always used only alcohol wipes for the glucometer. LN1 stated the importance of following manufacturer's guidelines in cleaning the glucometer was to prevent the spread of infection and to keep glucometer working correctly. On [DATE] at 3:30 P.M., an interview was conducted with Infection Preventionist (IP). IP stated that the licensed nurses should be using CaviWipes between use of glucometers, but that the facility's CaviWipes supply had expired and they were ordered. The IP stated that the expectation was to follow manufacturer's guidelines for care of glucometer. She stated the importance of following manufacturer's guidelines was to prevent spread of bloodborne infections to residents and staff. On [DATE] at 12:00 P.M., an interview was conducted with the Director of Nursing (DON) . The DON stated that the expectation was that licensed nurses should be following manufacturer's guidelines and facility's policy in disinfecting the glucometers. She stated the importance of disinfecting the glucometers was to prevent the spread of bloodborne illness to other residents and staff. A review of the facility's policy entitled, Obtaining a Fingerstick Glucose Level dated [DATE] was conducted. Policy indicates, Steps in procedure .18. Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice . 555919 Page 8 of 8