Health inspection·December 1, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure resident was treated with dignity and respect for one of four sampled residents (Resident 5) when Licensed Vocational Nurse (LVN) 5 administered medication to Resident 5 in the hallway. This failure resulted in Resident 5 not being provided with respect and dignity while taking her medications. Findings: During a concurrent observation and interview on 11/28/23 at 7:35 a.m., in B wing hallway, Resident 5 was sitting up in her wheelchair appropriately dressed for the weather. LVN 5 prepared Resident 5's medications. LVN 5 administered Resident 5's medications in the hallway with other residents and staff walking by. During a review of Resident 5's clinical record titled, admission Record, (document containing resident personal information) dated, 11/29/23, indicated Resident 5 was admitted to the facility on [DATE], with diagnoses which included: . dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and hearing loss . During a review of Resident 5's Minimum Data Set (MDS - an assessment tool used to identify resident cognitive [pertaining to reasoning, memory and judgement] and physical functional level), assessment dated [DATE], indicated Resident 5's Brief Interview for Mental Status (BIMS-screening tool used in nursing home to assess cognition) assessment score was four (4) out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 5 had severe cognitive deficit. During a review of Resident 5's Care Plan, dated, 2/1/20, indicated, . Resident has cognitive deficit r/t (related to) Dementia AEB (as evidence by) BIMS 4 . Face the resident when speaking and make eye contact. Reduce any distractions-turn off TV, radio, close doors . During a concurrent interview and record review on 11/29/23 at 9:56 a.m., with LVN 5, LVN 5 reviewed Resident 5's BIMS score and stated resident 5's BIMS was 4 which indicated Resident 5 had cognitive deficit. LVN 5 stated it was her first time to administer Resident 5 her medications in the hallway. LVN 5 stated the practice was to administer medications to residents in their rooms or in private. LVN 5 stated she should not have given the medications to Resident 5 in the hallway. Page 1 of 34 555924 555924 12/01/2023 Bethel Lutheran Home 2280 Dockery Avenue Selma, CA 93662

F 0550 Level of Harm - Minimal harm or potential for actual harm During an interview on 12/1/23 at 2:48 p.m., with LVN 1 and LVN 3, LVN 1 and LVN 3 stated the practice was to not administer medications to any residents in the hallway because it was a privacy issue. LVN 3 stated, other residents, staff and visitors walking by observed residents taking medications in the hallway. LVN 1 and LVN 3 stated, they had to give the medication the right way by bring residents in their room for privacy. Residents Affected - Few During an interview on 12/1/23 at 1:45 p.m., with the Director of Nursing (DON), the DON stated her expectations from licensed nurses during medication administration was to give respect and privacy to residents and offer to take residents in their room to administer medications. The DON stated licensed nurses were not to administer medication in the hallway. The DON stated there were other residents, staff and visitors walking by in the hallway and could see residents taking their medications. During an interview on 12/1/23 at 4:17 p.m., with the Administrator (ADM), the ADM stated medication administration in the hallway should not have happened, the licensed nurses were told not to give medications to residents in the hallway. ADM stated the licensed nurse should have brought the resident in her room or somewhere private so no other residents, staff or visitor around when she administered the medications to resident 5. During a review of facility's Policy and Procedure (P&P) titled, Resident Rights, dated 12/2016, the P&P indicated, be treated with respect, kindness and dignity . be supported by the facility in exercising his or her rights . During a review of facility's policy and procedure (P&P) titled, Medication Administration General Guidelines, dated 1/21, the P&P indicated, . Provide for privacy as appropriate . 555924 Page 2 of 34 555924 12/01/2023 Bethel Lutheran Home 2280 Dockery Avenue Selma, CA 93662

F 0567 Honor the resident's right to manage his or her financial affairs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide access to personal funds for one of two sampled residents (Resident 10) when he was unable to request his personal funds on the weekends. Residents Affected - Few This failure resulted in Resident 10 not being able to access his funds on the weekends for his personal needs. Findings: During a review of Resident 10's admission Record (AR) (undated), the AR indicated, . Resident 10 was admitted to the facility on [DATE] . During an interview on 11/29/23 at 10:57 a.m. with Resident 10, Resident 10 stated the facility held his funds. Resident 10 stated he was able to access funds on the weekdays but was not able to access funds on the weekends or holidays. Resident 10 stated . They do not have anyone [Business office staff] here on weekend . Resident 10 stated accessing funds on the weekends was . something you just don't do . Resident 10 stated he would request his funds from the business office staff and would use the funds to buy gum, cookies, and coffee. During a review of Resident 10's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) Assessment, dated 11/15/23, the MDS indicated Resident 10's Brief Interview for Mental Status (BIMS -an evaluation of attention, orientation, and memory recall) score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 10 had no cognitive impairment. During an interview on 11/29/23 at 11:02 a.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 stated she had been working at the facility for three to four months. LVN 5 stated if residents needed funds, the facility staff would contact social services. LVN 5 stated . not sure of the process [requesting funds] for the weekend and will need to follow up with social services. LVN 5 stated social services was available on the weekdays. During an interview on 11/29/23 at 2:43 p.m. with the Business Office Manager (BOM), the BOM stated her job duties included pay roll (monthly payments for staff) and accounts payable (paying bills). The BOM stated . facility keeps [funds] in cash [For residents to access] in a safe at the facility . The BOM stated residents did not have access to funds on the weekends. The BOM stated residents were aware the business office was closed on the weekends. The BOM stated the facility did not have a process in place for residents to access their funds on the weekends. The BOM stated facility staff was available to assist residents with accessing funds during the week and holidays which landed between Monday to Friday. During a concurrent interview and record review on 11/29/23 at 2:50 p.m. with the BOM, Resident 10's account balance was reviewed. Resident 10 had funds available in his account. During an interview on 11/29/23 at 2:58 p.m. with the Administrator (ADM), the ADM stated residents who had their funds managed by the facility did not have access to the funds on the weekends. The ADM stated residents could plan to request their funds for the weekend, but it had to be done in advance during the weekday. 555924 Page 3 of 34 555924 12/01/2023 Bethel Lutheran Home 2280 Dockery Avenue Selma, CA 93662

F 0567 Level of Harm - Minimal harm or potential for actual harm During an interview on 11/30/23 at 8:43 a.m. with the ADM, the ADM stated the facility's policy did not specify when and how the residents could access their funds managed by the facility. The ADM stated, . residents should have access to funds on the weekend if needed . Residents Affected - Few 555924 Page 4 of 34 555924 12/01/2023 Bethel Lutheran Home 2280 Dockery Avenue Selma, CA 93662

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 observations, interviews, and record reviews, the facility failed to provide residents with accessibility to file a grievance, anonymous grievance or complaint and did not update the grievance policy to ensure the prompt resolution of grievances for seven of ten sampled residents (Resident 25, Resident 10, Resident 17, Resident 18, Resident 19 and Resident 48, Resident 37) when: 1. Resident 37 filed a grievance in September 2023 requesting a room change and the grievance was not documented and followed up on by the facility staff. 2. Resident 25, Resident 10, Resident 17, Resident 18, Resident 19 and Resident 48 did not know how to file a grievance anonymously. 3. The facility's policy and procedure (P&P) titled Grievances did not include the right to file a grievance in writing or orally, the right to file a grievance anonymously, the right to obtain the review in writing, the required contact information of the grievance official, the contact information of independent entities with whom grievances may also be filed and that it would ensure written grievance decisions meets documentation requirements. This failure resulted in Resident 37 feeling frustrated and being unaware of the status of the grievance. This failure had the potential to result in Resident 25, Resident 10, Resident 17, Resident 18, Resident 19 and Resident 48 not being able to file grievances or complaints anonymously and their grievances not being resolved promptly. Findings: 1. During an interview on 11/28/23 at 2:20 p.m. with Resident 37, in the Resident Council meeting, Resident 37 stated she would like to know why she was moved from the B wing to the C wing. Resident 37 stated the facility staff had promised to put her back in the B wing. During a review of Resident 37's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) Assessment, dated 9/13/23, the MDS indicated Resident 37's Brief Interview for Mental Status (BIMS - an evaluation of attention, orientation and memory recall) score of 13 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 37 had no cognitive impairment. During an interview on 11/30/23 at 9:09 a.m. with Certified Nursing Assistant (CNA) 7, CNA 7 stated she had been working at the facility for 20 years. CNA 7 stated room changes were made by the SSD. CNA 7 stated she was familiar with Resident 37 but did not know why Resident 37 was moved from the B wing to C wing. CNA 7 stated she was aware Resident 37 did not like having roommates. CNA 7 stated Resident 37 was by herself for a while but was moved over to the C wing to see if Resident 37 liked it better. CNA 7 stated she did not know about grievances or grievance forms. CNA 7 stated if a resident notified her they wanted to switch rooms, she would go talk to the SSD. During an interview on 11/30/23 at 9:14 a.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated she had been working at the facility since July 2023. LVN 3 stated if a resident wanted to switch rooms, she would let the SSD know. LVN 3 stated if a resident had a room change, she would do a 555924 Page 5 of 34 555924 12/01/2023 Bethel Lutheran Home 2280 Dockery Avenue Selma, CA 93662

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Situation Background Assessment & Recommendations (SBAR- verbal or written communication tool that helps provide essential, concise information), call the Residents Representative (RP), and inform the doctor. LVN 3 stated she would check if the resident was getting along or not with the roommate or having a hard time adjusting in the room. LVN 3 stated rooms changes happened because a resident was having issues with the roommate. LVN 3 stated she was not working at the facility when Resident 37 was moved from the B wing to the C wing. During a review of Resident 37's admission Record (AR) (undated), the AR indicated, . Resident 37 was admitted to the facility on [DATE] . During a review of Resident 37's Notification of Room Change (NRC), dated 6/22/23, Resident 37's NRC indicated . reason(s) for room change/comments AC [air conditioning] unit out in room and anticipating higher temps and in anticipation for male admissions. Resident in agreement . Resident 37's NRC indicated the RP was informed via phone. During a concurrent interview and record review on 11/30/23 at 11:25 a.m. with the Activities Director (AD), the facility's documents Resident Council For Skilled B and C Wing Month of August, dated 8/30/23 and Resident 37's Resident Council Response (RCR) dated 8/31/23 were reviewed. The Resident Council For Skilled B and C Wing Month of August indicated, . [Resident 37] . mentioned wants a room change back to B wing . The AD stated she would record the meeting minutes for the Resident Council meeting. The AD stated she would document the residents' concerns on the RCR. The AD stated she completed the RCR for Resident 37 on 8/31/23. The RCR indicated, . Department Response . administrator response room changes will be made when room is available . Has issue(s) been resolved to resident(s) satisfaction? . If not, explain reasons or barriers to resolution . [Room change unavailable at this time staff will keep in mind residents request upon availability] . During a concurrent interview and record review on 11/30/23 at 11:27 a.m. with the AD, the facility's document Resident Council For Skilled B and C Wing Month of September, dated 9/27/23 was reviewed. The Resident Council For Skilled B and C Wing Month of September indicated, . [Resident 37] would like to be moved back to . B wing . The AD stated the room was not available in September. The AD stated an RCR had not been completed for Resident 37's concern in September. The AD stated Resident 37 was still in the C wing. The AD stated she was not aware on the meaning of a grievance. The AD stated if there was a complaint, she would bring it up to the ADM. The AD stated when residents brought up concerns during the Resident Council meetings, the facility would try to solve the issues. The AD stated the facility had a complaint form, but she had not filled one out before. The AD stated she would bring up the Resident Council meeting concerns to the ADM. The AD stated she had not seen a Concern Card (complaint/grievance form) before. The AD stated she should know about the Concern Card in case a resident had a concern she could document it for the concern to get resolved. During an interview on 11/30/23 at 2:54 p.m. with the SSD, the SSD stated she did not attend the Resident Council meetings on a routine basis (meetings are held once a month). The SSD stated she did not read the meeting minutes when she was not in attendance. The SSD stated she was not made aware of Resident 37's complaint for the room change in the Resident Council meeting in September 2023 and should have been made aware. The SSD stated there was no follow up for Resident 37's complaint that reported in the Resident Council meeting on 9/27/23. The SSD stated she reviewed the Concern Cards and the ADM would also review them. During an interview on 12/1/23 at 9:06 a.m. with Resident 37, Resident 37 stated she was informed by the ADM she would be moved back to her old room in the B wing. Resident 37 stated the facility had 555924 Page 6 of 34 555924 12/01/2023 Bethel Lutheran Home 2280 Dockery Avenue Selma, CA 93662

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few fixed the AC in her room but had placed another resident in the room. Resident 37 stated she was happy on the B wing. Resident 37 stated she had been frustrated not being able to go back to her old room. During a concurrent interview and record view on 12/1/23 at 9:16 a.m. with the SSD, the Concern Cards binder was reviewed. The SSD validated there were no Concern Cards filed for Resident 37 in September 2023 and October 2023. During an interview on 12/1/23 at 10:25 a.m. with the ADM, the ADM stated Resident 37 was not moved back to her original room due to the unpredictability of the air conditioner unit. The ADM stated Resident 37 was moved due to the air conditioner issues in the room. The ADM stated the air conditioner unit was replaced on 7/13/23. The ADM stated the SSD would go talk to the residents to see how they were adjusting to the new room. The ADM stated Resident 37 had adapted to her new room in the C wing. The ADM stated the room in the B wing was not currently occupied. The ADM stated Resident 37 was notified she could move back to the B wing once the AC had been fixed. The ADM stated the facility did not see the urgency to move Resident 37 back. During a concurrent interview and record review on 12/1/23 at 10:47 a.m. with the ADM, the facility's documents Resident Council For Skilled B and C Wing Month of September, dated 9/27/23 and Resident 37's RCR dated 8/31/23 were reviewed. The facility's Resident Council For Skilled B and C Wing Month of September, indicated Resident 37 wanted to move back to the B wing. The ADM stated she was present in the September Resident Council meeting. The ADM stated she would consider this a grievance. The ADM stated if the resident was unhappy about their care in the facility or had a concern that was considered a grievance. The ADM stated Resident 37's complaint was not documented on the Concern Card or RCR for September, but it was explained to her again that she would be moved when back to the B wing when the room became available. The ADM stated the RCR should had been completed for Resident 37's complaint and followed up on. During a review of the facility's policy and procedure (P&P) titled Grievances dated July 2019, the P&P indicated, . grievances should be investigated and discussed with the reporting individual within 5 business days of receipt . During a review of the facility's P&P titled Room Change/Roommate Assignment, dated May 2017, the P&P indicated, . changes in room or roommate assignment shall be made .when the resident requests the change . 2. During an interview on 11/28/23 at 2:34 p.m. with Resident 10, in the Resident Council meeting, Resident 10 stated the Grievance Official was the SSD. Resident 10 stated the SSD would assist the Residents in the facility to file a grievance. During a concurrent observation and interview on 11/28/23 at 2:43 p.m. with Resident 25, Resident 10, Resident 17, Resident 18, Resident 19 and Resident 48 in the Resident Council meeting, Resident 25, Resident 10, Resident 17, Resident 18, Resident 19 and Resident 48 stated they did not know how to file a grievance anonymously and did not know if there was a form to be filled out. Resident 25, Resident 10, Resident 17, Resident 18, Resident 19 and Resident 48 raised their hands indicating they did not know how to file a grievance. Resident 10 stated the facility staff would notify the residents to write down their complaints, but they did not know where to document their grievance and sometimes the residents did not want anyone to know about it and wanted to file anonymously. 555924 Page 7 of 34 555924 12/01/2023 Bethel Lutheran Home 2280 Dockery Avenue Selma, CA 93662

F 0585 Level of Harm - Minimal harm or potential for actual harm During a review of Resident 25's AR (undated), the AR indicated, . Resident 25 was admitted to the facility on [DATE] . During a review of Resident 25's MDS Assessment, dated 11/20/23, the MDS Assessment indicated Resident 25's BIMS score of 15 indicating Resident 25 had no cognitive impairment. Residents Affected - Few During a review of Resident 10's AR (undated), the AR indicated, . Resident 10 was admitted to the facility on [DATE] . During a review of Resident 10's MDS Assessment, dated 11/15/23, the MDS indicated Resident 10's BIMS score of 15 indicating Resident 10 had no cognitive impairment. During a review of Resident 17's AR (undated), the AR indicated, . Resident 17 was admitted to the facility on [DATE] . During a review of Resident 17's MDS Assessment, dated 9/5/23, the MDS indicated Resident 17's BIMS score of 12 indicating Resident 17 had moderate cognitive impairment. During a review of Resident 18's AR (undated), the AR indicated, . Resident 18 was admitted to the facility on [DATE] . During a review of Resident 18's MDS Assessment, dated 9/20/23, the MDS indicated Resident 18's BIMS score of 15 indicating Resident 18 had no cognitive impairment. During a review of Resident 19's AR (undated), the AR indicated, . Resident 19 was admitted to the facility on [DATE] . During a review of Resident 19's MDS Assessment, dated 11/1/23, the MDS indicated Resident 19's BIMS score of 15 indicating Resident 19 had no cognitive impairment. During a review of Resident 48's AR (undated), the AR indicated, . Resident 48 was admitted to the facility on [DATE] . During a review of Resident 48's MDS Assessment, dated 9/5/23, the MDS indicated Resident 48's BIMS score of 11 indicating Resident 48 had moderate cognitive impairment. During an observation on 11/29/23 at 11:45 a.m. outside of the SSD's office in the B wing, there were two file folders on the wall located above one another. One of the file folders indicated in small letters, This box contains the following: Concern Cards . please place completed forms in box below. The second file folder indicated in large letters Return Forms Box. The file folders were located about five feet off the ground. During an observation on 11/29/23 at 11:51 a.m. in the nurse's station in the C wing, there was one file folder labeled Concern Cards. The file folder was located about five feet off the ground and was located inside the nurse's station. The entrance to the nurse's station was secured with a wooden gate that indicated Employees Only. During an interview on 11/29/23 at 11:57 a.m. with the SSD, the SSD stated she filed the grievances (Concern Cards) and would keep them in a binder. 555924 Page 8 of 34 555924 12/01/2023 Bethel Lutheran Home 2280 Dockery Avenue Selma, CA 93662

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 11/30/23 at 8:52 a.m. with the Dietary Supervisor (DS), the DS stated she was not aware what a grievance was but was aware of a complaint. The DS stated when a resident had a complaint there was a form she would fill out and would give it to the SSD and Administrator (ADM). The DS stated the SSD would call the Ombudsman if needed. The DS stated residents were able to fill out the form and staff would help them. During an interview on 11/30/23 at 9:15 a.m. with LVN 3, LVN 3 stated she had been working in the facility since July 2023. LVN 3 stated she did not know what a grievance was or where a grievance form was located. LVN 3 stated she was aware of what to do if received a complaint. LVN 3 stated she would first try to help the resident and if she was not able to, she would go to the Director of Nursing (DON). During an interview on 11/30/23 at 9:15 a.m. with LVN 4, LVN 4 stated she had been working in the facility for five months. LVN 4 stated when residents had concerns, she would talk to the LVN, DON or SSD and assist with filling out the form. LVN 4 stated the forms were kept at each nursing station. LVN 4 stated the resident would speak to social services directly to address concerns. LVN 4 stated residents would inform the staff to get the forms to be filled out and update the SSD. LVN 4 stated if the resident wanted to report complaints anonymously, she would leave their name out from the form. During an observation on 11/30/23 at 9:20 a.m. in the nurse's station in the B wing, the B wing nurses station did not have a grievance form or file folder box. During a concurrent interview and record review on 11/30/23 at 1:51 p.m. with the SSD, the facility's policy and procedure (P&P) titled Grievances, dated July 2019 was reviewed. The P&P indicated . grievances should be investigated and discussed with the reporting individual within 5 business days of receipt . The SSD stated in June 2023 she became the SSD. The SSD stated when a staff or resident had a concern or grievance, the staff, residents or family would fill out a Concern Card and place it in the second file folder outside of her office labeled Return Forms Box. The SSD stated there were two file folders outside her office, one was the file folder with the Concern Cards and the second one was Return Forms Box that was labeled with large letters. The SSD stated she would review the completed Concern Cards and she would notify the appropriate departments of the concerns identified. The SSD stated the responsible department would take care of the concern then report back with a corrective action. The SSD stated the residents did not have access to the forms outside her office because the file folders were placed higher where the residents could not reach the forms. The SSD stated residents would bring up their concerns to staff then staff would fill out the Concern Card. The SSD stated she attempted to address concerns right away and the facility had five business days from receipt to respond back to the reporting individual. The SSD stated residents were made aware of the process during the resident council meetings by the AD and verbally through rounds on how to file a grievance. The SSD stated a resident was unable to file an anonymous grievance because they needed assistance in retrieving the Concern Card from the file folder and the resident would need assistance in filling out and returning the form so then staff would be aware who filed the grievance. The SSD stated the residents were able to verbalize their complaints but were unable to write them. 3. During a concurrent interview and record review on 12/1/23 at 10:23 a.m. with the ADM, the facility's P&P titled Grievances dated July 2019 was reviewed. The ADM stated if Residents verbalized concerns or complaints, they would be written on the Concern Cards by the facility staff. The ADM stated the Concern Cards would be given to the SDD and the SSD would follow up. The ADM stated once the Concern Card had been followed up on and completed, she would review it to see if the complaint had been resolved or not. The ADM stated if she received a complaint during her rounds in the facility, she would fill out the Concern Card. The ADM stated she would give the Concern Card to the 555924 Page 9 of 34 555924 12/01/2023 Bethel Lutheran Home 2280 Dockery Avenue Selma, CA 93662

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few appropriate department or the SSD to follow up. The ADM stated the facility staff would fill out the Concern Cards because she did not know if the residents could physically write down their complaints or concerns and needed assistance. The ADM stated the residents could not file an anonymous grievance because the facility needed to know who filed the grievance in order to resolve the complaint. The ADM stated the residents had the right to call the ombudsman or state department. The ADM stated the facility staff would attend to the concern immediately if it was reasonable. The ADM stated the Grievances policy indicated the residents' complaints should be investigated within five business days of receipt. The ADM stated she was the Grievance official, and the SSD was the designee. The ADM stated the SSD would inservice facility staff on the Grievances policy every six months. The ADM stated the residents were made aware of Grievances policy during the Resident Council meetings. The ADM stated there had not been a situation where a resident wanted to file a complaint anonymously. The ADM stated the facility had the ombudsman's information on the facility's walls when the residents had a complaint. The ADM stated she would not know how to help the resident with a complaint if she did not know who filed the grievance. The ADM stated the residents did not have access to the Concern Cards. During a concurrent interview and record review on 12/1/23 at 11:15 a.m. with the ADM, the facility's P&P titled Grievances was reviewed. The P&P: indicated, page 1 of 1 the ADM validated there were no additional pages. The ADM stated the policy did not include the right to file a grievance in writing or orally. The ADM stated the policy did not include the right to file a grievance anonymously. The ADM stated the policy did not include the right to obtain the review in writing. The ADM stated the policy did not include the contact information of the grievance officials. The ADM stated the policy did not include the contact information of independent entities with whom grievances may also be filed. The ADM stated the policy did not include it would ensure written grievance decisions met documentation requirements. The ADM stated the Grievance policy was last updated in July 2019. The ADM stated the policy had been reviewed this year but there had been no changed made to the Grievance policy. The ADM stated the policies were reviewed yearly. The ADM stated she was not aware of recent changes to the regulation and the policy should reflect the regulations. During a review of the facility's P&P titled, Grievances, dated July 2019 was reviewed. The P&P indicated, . 1. When a grievance is addressed by an individual, the individual receiving the grievance will put the concern in writing. 2. The individual who received the grievance will give the written grievance to the Grievance Official for follow up. 3. The Grievance Official, and/or his or her designee will investigate the grievance and address the conclusion(s) of the investigation either by telephone, or in person, with the individual who brought the grievance(s). 4. Unless otherwise not possible by extenuating circumstances', grievances should be investigated and discussed with the reporting individual within 5 business days of receipt. 5. Grievance logs and the resolution of such grievances shall be maintained for three (3) years . 555924 Page 10 of 34 555924 12/01/2023 Bethel Lutheran Home 2280 Dockery Avenue Selma, CA 93662

F 0641 Ensure each resident receives an accurate assessment. 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 the Minimum Data Set (MDS-a resident assessment tool used to identify resident care needs) assessment accurately reflected the residents' current status for one of six sampled residents (Resident 19) when Resident 19's MDS assessment of Health Conditions (Section J) was not coded accurately. Residents Affected - Few This failure placed Resident 19's at a potential of her smoking needs to be not met. Findings: During a concurrent observation and interview on 11/28/23 at 9:33 a.m., in Resident 19's room. Resident 19 stated she was a smoker and the facility provided her with a smoking schedule. Resident 19 pointed to a sheet with the smoking times listed, pinned to the bulletin board in her room. During an interview on 11/28/23 at 10:33 a.m., with Certified Nursing Assistant (CNA) 9, CNA 9 stated Resident 19 was a smoker. During a review of Resident 19's MDS assessment Section C Cognitive Patterns, dated 11/1/23, the MDS assessment, Section C Cognitive Patterns indicated a BIMS (Brief Interview for Mental Status- a test given by medical professionals to determine cognitive understanding on a scale of 1-15 with 15 being the highest score a score of 0-7 indicated severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 cognitively intact) score of 15. During a review of Resident 19's MDS assessment, Section J -Health Conditions dated 6/12/23, the MDS assessment, Section J indicated, . Current Tobacco Use 0 (coded for response was 0 for No, or 1 for Yes) . During a concurrent interview and record review on 12/01/23 1:31 p.m., with MDS Coordinator (MDSC) 1, MDSC 1 stated Resident 19's MDS assessment dated [DATE] indicated Resident 19 was not a smoker. MDSC 1 stated it was important to have the records be accurate to ensure resident care was planned properly. MDSC 1 stated if the coding was incorrect the residents would not receive the appropriate care. During an interview on 12/1/23 at 12:26 p.m., with the Assistant Director of Nursing (ADON), the ADON stated she expected the MDS assessments to be accurate. The ADON stated Resident 13's MDS assessment should have been accurately assessed and coded in the MDS assessment section J. The ADON stated assessments and accurate documentation was important to be able to provide resident care needs. Assessment Instrument (RAI) 3.0 User's Manual Version 1.17.1 October 2023 19. The RAI process indicated, . 1. the assessment accurately reflects the resident's status . 555924 Page 11 of 34 555924 12/01/2023 Bethel Lutheran Home 2280 Dockery Avenue 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 observation, interview and record review, the facility failed to ensure a comprehensive, person-centered care plan (A plan that provides direction for individualized care of the resident) was developed and implemented to meet the needs for two of five sampled residents (Resident 47, Resident 7) when: 1. Resident 47 did not have a care plan for activities. This failure had the potential to result in Resident 47's activities to go unmet and could result to self isolation. 2. Resident 7 did not have a care plan for milk allergy. This failure had the potential for Resident 7 to receive milk products which could result in breathing difficulty or other health complications. Findings: 1. During a concurrent observation and interview on 11/27/23 at 11:29 a.m., with Resident 47, in Resident 47's room, Resident 47 was observed laying in bed with eye patch covering her eyes. Resident 47 stated this was her second time in the facility. Resident 47 stated she did not feel like getting out of bed. Resident 47 stated she only got out of bed when working with therapy and for doctor's appointments. During a review of Resident 47's admission Record, dated 12/1/23, the admission Record indicated, Resident 47 was admitted in the facility on 10/13/23 with diagnoses which included, . Osteoarthritis (degenerative [gradual decline] joint disease in which the tissues in the joint break down overtime) left hip, muscle weakness and osteoporosis (bones become weak and brittle) . During a concurrent interview and record review on 11/30/23 at 8:37 a.m., with Activities Director (AD), AD reviewed the care plans for Resident 47. AD stated she did not find an activity care plan for Resident 47. AD stated there should have been an activity care plan in Resident 47's record. AD stated a care plan was very important because it provided a guide to the staff of the care needs of Resident 47. AD stated she was responsible in making sure there was a care plan for all residents in the facility. During a concurrent interview and record review on 12/1/23 at 9:55 a.m., with Certified Nursing Assistant (CNA) 7, CNA 7 stated Resident 47 did not like attending group activities. During an interview on 12/1/23 at 3:15 p.m., with the Director of Nursing (DON), the DON stated care plan was very important to make sure everyone (staff) was aware of the plan of care, interventions and goals for each resident. DON stated the AD was responsible in ensuring all residents had activity care plans. During a review of the facility's policy and procedure (P&P) titled, Activity Programs, dated 6/2018, the P&P indicated, . Activities are considered any endeavor, other than routine . to enhance his or her sense of well-being and to promote or enhance physical, cognitive or emotional health . During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated 12/2016, the P&P indicated, . The comprehensive person-centered care plan will: a. Include measurable 555924 Page 12 of 34 555924 12/01/2023 Bethel Lutheran Home 2280 Dockery Avenue Selma, CA 93662

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS) . 2. During a review of Resident 7's admission Record (AR) (undated), the AR indicated, . Resident 7 was admitted to the facility on [DATE] . allergies . milk and milk products . During a review of Resident 7's Minimum Data Set (MDS - a resident assessment tool used to identify resident's cognitive and physical function) Assessment, dated 10/12/23, the MDS indicated Resident 7's Brief Interview for Mental Status (BIMS -an evaluation of attention, orientation, and memory recall) score of 11 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 7 had moderate cognitive impairment. During a review of the facility's Allergy Report (AR) dated 11/30/23, the AR indicated, . Resident 7 .Allergen . milk and milk products . reaction note .hard time breathing . During a concurrent interview and record review on 11/30/23 at 8:41 a.m. with the Dietary Supervisor (DS), Resident 7's Dietary Assessment Quarterly (DAQ) . type: Admission dated 10/9/23, was reviewed. The DAQ indicated, . Food Allergies/Intolerances . All milk and milk products . The DS stated Resident 7 had a milk allergy. The DS stated the facility did not develop a care plan for Resident 7's allergies. The DS stated it was important to have Resident 7's food allergies care planned to avoid any reactions to Resident 7 and communicate to facility staff. The DS stated she was responsible to develop dietary care plans. During an interview on 12/1/23 at 8:53 a.m. with Certified Nursing Assistant (CNA) 8, CNA 8 stated she provided care to Resident 7. CNA 8 stated she was not aware of Resident 7 having any allergies. CNA 8 stated staff would check the tray cards for allergies if they were to give any food to the residents. During a concurrent interview and record review on 12/1/23 at 12:10 p.m. with Licensed Vocational Nurse (LVN) 3, Resident 7's care plans were reviewed. LVN 3 stated Resident 7 was allergic to milk and milk products. LVN 3 stated Resident 7 did not have a care plan for his milk allergy. LVN 3 stated it was important to have a care plan for allergies, for the staff to be aware on how to provide care to the resident. During an interview on 12/1/23 at 3:33 p.m. with the Director of Nursing (DON), the DON stated her expectation for staff was that care plans should be completed accurately and upon admission to the facility and updated as needed in a timely manner. The DON stated care plans should be updated to align with the resident's plan of care and should include allergies. 555924 Page 13 of 34 555924 12/01/2023 Bethel Lutheran Home 2280 Dockery Avenue 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 observation, interview, and record review, the facility failed to meet professional standards of practice for one of six sampled residents (Resident 46) when Licensed Vocational Nurse (LVN) 4 left Resident 46's morning medication at bedside accessible to others. Residents Affected - Few This failure placed Resident 46 at risk for not taking the medications, medication error, other residents or unauthorized personnel to access Resident 46's medications. Findings: During a review of Resident 46's admission Record (AR-a document containing resident medical and personal information), undated, the AR indicated, Resident 46 was admitted to the facility on [DATE] with diagnoses which included, atrial fibrillation (afib- abnormal heartbeat which can lead to blood clots in the heart), anemia (lower than normal healthy red blood cells), muscle weakness, protein-calorie malnutrition (lack of sufficient nutrients in the body) and adult failure to thrive (a decline of health and ability in older adults). During a review of Residents 46's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 46's Brief Interview of Mental Status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 15 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 46 was cognitively intact. During a concurrent observation and interview on 11/28/23 at 9:05 a.m. in Resident 46's room, Resident 46 was lying in bed with her breakfast tray on the bedside table. There were four pills lying on the breakfast tray next to a plastic medication cup: a round white tablet, a cream-colored tablet, a dark round tablet and an orange-colored tablet. Resident 46 had a family member (FM) 1 at bedside. FM 1 stated she was in the room when the nurse (LVN 4) came in and left the pills on the breakfast tray. During an interview on 11/28/23 at 9:37 a.m. with LVN 4, LVN 4 stated she had left Resident 46's morning medications with Resident 46 and continued her medication pass. LVN 4 stated when she had returned, four pills were left on the breakfast tray: apixaban (an anticoagulant- [blood thinner] to prevent blood clots for afib), vitamin B1 (vitamin supplement), magnesium (dietary supplement) and iron (mineral supplement to treat anemia). LVN 4 stated apixaban was a blood thinner which could cause adverse side effects if a confused resident had wandered into the room and taken the medication. LVN 4 stated she did not follow the correct procedure for medication administration and should have remained with the resident until she swallowed the medications. During a record review of Resident 46's Order Summary Report, dated 11/29/2023, the orders indicated, . Apixaban oral tablet 2.5 mg [milligrams- unit of measurement] give 1 tablet by mouth every 12 hours related to chronic atrial fibrillation . Ferrous sulfate give 1 tablet by mouth two times a day related to anemia . Magnesium Gluconate Oral Tablet 500 (27 Mg) MG . Give 2 tablet[s] by mouth two times a day for Supplement . Vitamin B1 Oral Tablet 100 MG . Give 1 tablet by mouth one time a day for Supplement . 555924 Page 14 of 34 555924 12/01/2023 Bethel Lutheran Home 2280 Dockery Avenue Selma, CA 93662

F 0658 Level of Harm - Minimal harm or potential for actual harm During an interview on 11/28/23 at 11:40 a.m. with the Director of Nursing (DON), the DON stated the correct medication administration procedure was to observe the resident until all medication had been swallowed. The DON stated, it is a huge thing [important] to make sure the resident swallows the medication. The DON stated medications should never be left at bedside because it placed other residents at risk of taking medication not prescribed to them. Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled, Medication Administration Orals, dated 2007 was reviewed. The P&P indicated, . To administer oral medications in an organized, accurate and safe manner . 10. Administer medication and remain with resident while medication is swallowed. Do not leave a medication in a resident's room without orders to do so along with documentation of self-administration . 555924 Page 15 of 34 555924 12/01/2023 Bethel Lutheran Home 2280 Dockery Avenue Selma, CA 93662

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **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 psychotropic medications (medications which affect the mind, emotions, and behavior) for one of four residents (Resident 34) when Resident 34 was given divalproex (an anticonvulsant medication used to treat seizures [a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations or states of awareness]) without consistent indication for use, documented non-pharmacological interventions, and clinical justification to support the use of divalproex. This failure resulted in Resident 34 receiving unnecessary psychotropic medications and placed the Resident 34 at an increased risk for developing adverse (harmful) side effects due to taking divalproex. Findings: During a review of Resident 34's admission Record (AR), dated 11/29/23, the AR indicated, Resident 34 was admitted on [DATE] with diagnoses which included, hemiplegia (paralysis [the loss of the ability to move and sometimes to feel anything] of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). During an observation on 11/27/23 at 11:43 a.m. in the therapy area, Resident 34 was in a wheelchair and did not respond when spoken to. During an interview on 11/28/23 at 8:37 a.m. with Certified Nursing Assistant (CNA) 5, CNA 5 stated Resident 34 communicated by pointing and hand gestures. CNA 5 stated she kept asking Resident 34 questions until Resident 34 responded as though she understood. During an interview on 11/30/23 at 9:39 a.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 stated she had been working at the facility for 5 months. LVN 4 stated Resident 34's behaviors were yelling. LVN 4 stated Resident 34 did not want to use the call light. LVN 4 stated Resident 34 sought attention. LVN 4 stated Resident 34 wanted to be turned one way then 2 minutes after, wanted to be turned another way. LVN 4 stated Resident 34's medication for behaviors was divalproex. LVN 4 stated she gave the medication for irritability and yelling. LVN 4 stated Resident 34's demeanor before the medication was she would be on her call light often and wanted someone in with her at all times. LVN 4 stated Resident 34 would calm down after she was given the medication (divalproex). LVN 4 stated she was not aware of Resident 34 hitting staff, it was mostly yelling. LVN 4 stated she had not witnessed any seizures with Resident 34. LVN 4 stated she had not received report from other staff noting Resident 34 had seizures. LVN 4 stated she had not had incidents of Resident 34 behaviors affecting the health and safety of others. During a concurrent interview and record review on 11/30/23 at 11:16 a.m. with the Minimum Data Set (MDS) Coordinator, Resident 34's Minimum Data Set (MDS), dated 9/11/23, was reviewed. The MDS 555924 Page 16 of 34 555924 12/01/2023 Bethel Lutheran Home 2280 Dockery Avenue Selma, CA 93662

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Section C indicated Resident 34 had a BIMS (Brief Interview for Mental Status - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 with 15 being the highest score) of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact). During an interview on 11/30/23 at 11:24 a.m. with the Social Services Director (SSD), the SSD stated Resident 34 was her own responsible party. The SSD stated Resident 34's communication had been more difficult this past last week. The SSD stated Resident 34 was able to communicate her needs up through 11/21/23. During a concurrent interview and record review on 11/30/23 at 1:30 p.m. with the Director of Nursing (DON), Resident 34's Medication Administration Record (MAR), dated June 2023 was reviewed. The DON stated Resident 34 was on divalproex as an antipsychotic. During an interview on 12/1/23 at 9:21 a.m. with the Assistant Director of Nursing (ADON), the ADON stated the pharmacist emailed recommendations to the ADON and the DON. The ADON stated the doctor decided yes or no on the recommendations. The ADON stated even if the Interdisciplinary Team (IDT) did not agree with the recommendation, they would still send the form to the Medical Doctor (MD) for his input and recommendations. The ADON stated if the MD did not agree, the ADON would put a note or orders in the computer. During a concurrent interview and record review on 12/1/23 at 9:49 a.m. with the ADON, Resident 34's Physician's Orders dated 6/21/23 were reviewed. The ADON stated she could not find the divalproex recommendation note for Resident 34 in here electronic record. Resident 34's Medication Regimen Review (MRR) dated 10/18/23 was reviewed. The MRR indicated blank areas on the recommendation follow-through fields. The ADON stated, I did not follow up on the divalproex recommendation. During a concurrent interview and record review on 12/1/23 at 9:53 a.m. with the DON, Resident 34's Progress Note, dated 6/21/23 was reviewed. The Progress Note indicated an order was received to start divalproex. The DON stated no documentation was found of the reason divalproex was started on Resident 34. The DON stated the indication for the use of divalproex for Resident 34 was for behaviors, irritability, destructibility, and insomnia. The DON stated irritability was not a reason to put a patient on a psychotropic medication. The DON stated there was no supporting documentation. The DON stated divalproex was an unnecessary medication for Resident 34. During a concurrent interview and record review on 12/1/23 at 10:23 a.m. with the DON, Resident 34's Psychologist Consultation, dated 6/20/23 was reviewed. The Psychologist Consultation indicated Resident 34 was stable on current medication. The DON stated the Psychologist made no recommendations for changes to Resident 34's medication to include divalproex. Resident 34's MAR dated 7/2023 was reviewed. The MAR indicated blank fields in the administration section and Resident 34's behavior monitoring. The DON stated the blank fields in the MAR meant it was not charted. The DON stated the nurses' documentation was not complete. The DON reviewed the blank fields in Resident 34's behavior monitoring. The DON stated documentation for Resident 34 dated 7/17/23 noted behaviors, not destructible. The DON stated irritability was not destructible. The DON stated the indications for giving Resident 34 divalproex medication were not appropriate. Resident 34's Behavior Monitoring, dated 6/2023 was reviewed. The Behavior Monitoring indicated non-pharmacological interventions for staff to use prior to giving medications. The DON stated there were no documentation indicating staff used non-pharmacological interventions prior to Resident 34 starting divalproex. The DON stated a psychotropic medication was not indicated for yelling. The DON stated the indications for giving divalproex did not 555924 Page 17 of 34 555924 12/01/2023 Bethel Lutheran Home 2280 Dockery Avenue Selma, CA 93662

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few match Resident 34 for destructibility. The DON stated other things (interventions) should have been started before starting Resident 34 on divalproex. The DON stated the Policy and Procedure (P&P) were not followed for starting divalproex. During a telephone interview on 12/1/23 at 9:26 a.m. with the Consultant Pharmacist (PHARM), the PHARM stated I would look at resident consents, vitals, labs, medications and would make recommendations to the MD. The PHARM. stated I do not recall making recommendations on Resident 34. The PHARM reviewed Resident 34's chart and stated, I do not see a diagnosis that would support divalproex. The PHARM stated divalproex was unnecessary for Resident 34. The PHARM stated Resident 34 was a high risk for falls. The PHARM stated he missed reviewing divalproex during the MRR in October for Resident 34. The PHARM was not able to state the reason divalproex was being given. The PHARM stated the FDA indications for divalproex was seizures, simple complex, manic and polar disorder. PHARM stated divalproex for Resident 34 was being used off-label. PHARM stated for post traumatic brain injury (PTBI), divalproex should not be used for more than 7-14 days. PHARM stated the information should have been brought up when the divalproex was written (ordered) and during the last MMR in October. The PHARM stated some of the possible side effects of divalproex were GI (gastro-intestinal) upset, loss of appetite, nausea, dizziness, increased fall risk, and insomnia (a sleep disorder characterized by difficulty falling asleep, staying asleep, or both). PHARM stated other side effects of divalproex were migraine, musculoskeletal pain, headache, somnolence (excess sleepiness), and blurred vision. During an interview on 12/1/23 at 2:17 p.m. with the DON, the DON stated Resident 34's indication for divalproex appeared to be given as a psychotropic medication. The DON reviewed the Black Box Warning for divalproex and stated it listed hepatic (liver) failure and hepatic toxicity risks. The Black Box Warning for divalproex further indicated hepatic labs to be drawn prior to administering divalproex. The DON was unable to find any hepatic labs drawn for Resident 34. During a telephone interview on 12/1/23 at 12:05 p.m. with the Nurse Practitioner (NP), the NP stated Resident 34 still had behaviors which were not under control. The NP stated divalproex was being given as a mood stabilizer. The NP stated Resident 34 should have been evaluated every 14 days while being on the medication. The NP stated there were other alternatives to divalproex. The NP stated I did not see that Resident 34 was a danger to herself or others, only the nurse said Resident 34 was destructive and combative, but I did not see that. During a telephone interview on 12/1/23 at 1:33 p.m. with the Psychologist (PH.D), the PH.D stated Resident 34 was last seen on 6/20/23. The PH.D stated at the time of the consultation, Resident 34 had no evidence of behaviors. The PH.D stated Resident 34 was stable on the current medications at that time, with no suicidality. The PH.D stated divalproex was not appropriate for behavior monitoring and irritability. PH.D stated there was no diagnosis of psychosis for Resident 34. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medications, dated 7/2019, the P&P indicated, It is the policy . not to administer psychoactive medications in the absence of medical or clinical necessity . not to use as chemical restraints for the purpose of discipline or convenience . 555924 Page 18 of 34 555924 12/01/2023 Bethel Lutheran Home 2280 Dockery Avenue Selma, CA 93662

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure the facility medication error rate did not exceed five percent (eight percent) when: Residents Affected - Some 1. Licensed Vocational Nurse (LVN) 5, administered Resident 5's (brand name) calcium tablet (used to prevent or treat low blood calcium levels in people who do not get enough calcium from their diets.) with vitamin D (nutrient the body needs for building and maintaining healthy bones) for an order of (brand name) Calcium 500 mg. This failure had the potential for Resident 5's Vitamin D level to go higher and lead to serious medical condition. 2. LVN 2 administered Resident 30's Multivitamin (used to treat or prevent vitamin deficiency due to poor diet, certain illnesses or during pregnancy) gummies (chewy gelatin-based) for an order of multivitamins-minerals. This failure had the potential for Resident 30's daily mineral needs to be not met. Findings: 1. During a concurrent observation and interview on 11/28/23 at 7:35 a.m., in B-wing, LVN 5 was passing medication. LVN 5 prepared Resident 5's medications. LVN 5 administered seven medications scheduled for Resident 5 including (brand name calcium) with D. During a review of Resident 5's, admission Record, dated 11/29/23, the admission record indicated, Resident 5 was admitted in the facility on 4/19/19, with diagnoses which included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and osteoporosis (weak and brittle bone). During a review of Resident 5's eMAR (Electronic Medical Administration Record) dated 11/1/23-11/30/23, the eMAR indicated, . [band name] Calcium Tablet 500 MG [milligram-unit of measurement] . Give 1 (one) tablet by mouth two times a day related to AGE-RELATED OSTEOPOROSIS . Resident 5 received the medication from 11/1/23-11/29/23. During a review of Resident 5's Order Summary Report, dated 11/29/23, the Order Summary Report, indicated, . [brand name] Calcium Tablet 500 MG Give 1 tablet by mouth two times a day . During a concurrent interview and record review on 11/29/23, at 9:56 a.m., with LVN 5, Resident 5's clinical record was reviewed, LVN 5 stated she did not administer the correct medication order to Resident 5. LVN 5 stated she administered (band name calcium) with D to Resident 5 and the order was (brand name calcium). LVN 5 stated Resident 5's vitamin D level could go higher and if it was already high it could put Resident 5 at risk for side effects. According to Lexicomp, a nationally recognized drug reference, . Excessive vitamin D: Excessive vitamin D administration may lead to over suppression of parathyroid hormone (PTH - regulates calcium levels in the blood), progressive or acute hypercalcemia [too much calcium in the blood], hypercalciuria [excretion of calcium in the urine], hyperphosphatemia [too much phosphate in the blood] and adynamic bone disease [chronic kidney disease that weakens the bones]. Withhold pharmacologic doses of vitamin D and its derivatives during therapy to avoid the potential for hypercalcemia to develop. In addition, several months may be required for ergocalciferol levels to return to baseline in patients switching from ergocalciferol [type of vitamin D found in food] therapy to calcitriol [treats low 555924 Page 19 of 34 555924 12/01/2023 Bethel Lutheran Home 2280 Dockery Avenue Selma, CA 93662

F 0759 calcium] . Level of Harm - Minimal harm or potential for actual harm 2. During a concurrent observation and interview on 11/28/23 at 4:05 p.m., in C-wing, LVN 2 was passing medications. LVN 2 prepared Resident 30's medications. LVN 2 administered four medications scheduled for Resident 30 including Multivitamin gummies. Residents Affected - Some During a review of Resident 30's eMAR (Electronic Medical Administration Record) dated 11/1/23-11/30/23, the eMAR indicated, Multivitamin Gummies Adult Tablet Chewable (Multiple Vitamins-Minerals) Give 1 (one) gummy by mouth in the evening . Resident 30 received medication from 11/1/23 to 11/29/23. During a review of Resident 30's Order Summary Report, dated 11/29/23, the Order Summary Report, indicated, . Multivitamin Gummies Adult tablet Chewable [Multiple Vitamins -Minerals] Give 1 gummy by mouth . During a concurrent interview and record review on 11/30/2, at 3:30 p.m., with LVN 2, Resident 30's clinical record was reviewed. LVN 2 stated she did not administer the correct medication to Resident 30. LVN 2 stated the medication available at hand and was administered to Resident 30 did not contain minerals. LVN 2 stated Resident 30 did not received the medication ordered by her MD. LVN 2 stated the licensed nurses should have clarified the medication order and the medication at hand. During an interview on 12/1/23, at 3:20 p.m., with the Director of Nursing (DON), the DON stated licensed nurses should follow the medication order as ordered by the Medical Doctor (MD). The DON stated, . It was medication errors, the licensed nurses should have made sure the correct medications were administered to Residents 5 and 30 . During a review of the facility's policy and procedure (P&P) titled, Medication Error reporting and Adverse Drug Reaction Prevention and Detection, dated, 2007, the P&P indicated, . Facility staff monitor the resident for possible medication-related adverse consequences, including mental status and level of consciousness when the following conditions occur: . Medication error; e.g., wrong or expired medication . According to Lexicomp, a nationally recognized drug reference, . Know Your Drugs Keep a list of all the drugs you take. This includes prescription and over-the-counter (OTC) drugs, natural products, and vitamins. Update your list when your drugs change. Keep this list in your wallet or purse. Make sure you know the name of the drug. Know the difference between the brand name and the generic name . Always read the label on the container. Do this each time you take a drug to be sure you have the right one . 555924 Page 20 of 34 555924 12/01/2023 Bethel Lutheran Home 2280 Dockery Avenue 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, interview, and record review, the facility failed to ensure medications used were labeled and stored in accordance with professional standards when: 1. Resident 5's (linaclotide brand name - medication used to treat constipation) medication label did not match the medication order. This failure had the potential for the medication not to be administered according to the physician's order and resident's need. 2. A medication cart in B-wing unit was left unlocked and unattended by Licensed Vocational Nurse (LVN) 5. This failure placed all residents' health and safety at risk when drugs were left unattended and accessible to unauthorized individuals. 3. A bottle of over the counter (OTC) medication was left on top of the medication cart, unattended by LVN 5. This failure placed all residents' health and safety at risk when drugs were left unattended and accessible to unauthorized individuals. Findings: 1. During a review of Resident 5's Order Summary Report, dated 11/29/23, the Order Summary Report, indicated, . [linaclotide brand name] capsule 290 MCG [microgram-unit of measurement] (linaCLOtide) Give 1 (one) capsule by mouth one time a day for Constipation . order date 07/13/2021 . During a concurrent observation, interview and record review on 11/28/23, at 9:56 a.m., in B-wing with Licensed Vocational Nurse (LVN) 5, Resident 5's clinical record was reviewed and LVN 5 stated Resident 5 had an order for (brand name) 290 mcg (microgram-unit of measurement) one capsule a day. LVN 5 stated the medication was ordered on 7/13/21 as a routine medication. Resident 5's medication bottle was reviewed. The label on the bottle indicated, . linaclotide . GIVE 1 CAPSULE BY MOUTH DAILY AS NEEDED FOR CONSTIPATION . LVN 5 stated the label on the medication bottle did not match the order. LVN 5 stated the medication order and the medication label should have matched. LVN 5 stated it was the responsibility of the nurse receiving the medication to ensure the medication label direction match the medication order. During a concurrent interview and record review on 11/28/23, at 3:30 p.m., with LVN 1, Resident 5's clinical record was reviewed. LVN 1 stated Resident 5's medication order and the medication label did not match. LVN 1 stated it was the licensed nurse responsibility to ensure the medication order and the medication label matched. LVN 1 stated licensed nurse should have contacted pharmacy and placed a direction changed sticker in the medication bottle. During an interview on 12/1/23 at 1:50 p.m., with the Director of Nursing (DON), the DON stated she expected the licensed nurses to check medications ordered and ensure the medication order and the medication label matched. The DON stated if there was discrepancy of the label and direction and pharmacy the policy was to return the medication back to the pharmacy will send new medication. During a review of facility's policy and procedure (P&P) titled, Medications and Medication Labels, dated 2007, the P&P indicated, . Improperly or inaccurately labeled medications are refused and returned to the dispensing pharmacy . If the prescriber's directions for use change or the label is 555924 Page 21 of 34 555924 12/01/2023 Bethel Lutheran Home 2280 Dockery Avenue Selma, CA 93662

F 0761 inaccurate, the nurse may place a direction change . taking care not to cover important label information . Level of Harm - Minimal harm or potential for actual harm 2. During a concurrent observation and interview on 11/28/23, at 7:55 a.m., in B-wing hallway, LVN 5 parked the medication cart in the hallway with bottom drawer unlocked. LVN 5 turned her back and walked away from the medication cart. LVN 5 returned to her medication cart and pulled out the other drawers of the medication cart. LVN 5 stated the medication cart did not automatically lock itself because the bottom drawer was open. LVN 5 stated she did not realize she left the bottom drawer open. LVN 5 stated the practice was to never leave the medication cart unlocked when turning your back or walking away from the medication cart. LVN 5 stated the unlocked medication cart was easily accessible to residents, staff and visitors. LVN 5 stated it (unlocked cart) allowed anyone to take and use the medications which could lead to side effects and overdose. Residents Affected - Few During an interview on 11/28/23 at 3:35 p.m., with LVN 1, she stated medication cart should not be left unlocked when not in view of the licensed nurses. LVN 1 stated residents, staff and families could have accessed the medications inside the medication cart which could lead to side effects and overdose. During an interview on 12/1/23 at 1:50 p.m., with the DON, the DON stated her expectations was for the licensed nurses to make sure medication carts were locked before they turned their back and walk away from the medication cart. The DON stated anybody could take medications out of the unattended and unlocked medication cart, ingest the medications and developed allergic reactions which could lead to serious medical condition. During a review of the facility's policy and procedure (P&P) titled, Medication Administration General Guidelines, dated 2007, the P&P indicated, . the medication cart is kept closed and locked when out of sight of the medication nurse. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications when unlocked . 3. During an observation on 11/28/23 at 7:45 a.m., in B-wing hallway, LVN 5 left a bottle of OTC medication on top of the medication cart and turned her back to go inside a resident room. LVN 5 did not have a view of the medication cart. During an interview on 11/28/23 at 3:45 p.m., with LVN 1, LVN 1 stated the practice was to never leave medications on top of medication cart when turning ones back and walking away from the medication cart. LVN 1 stated anyone could take the medications and if consumed could lead to side effects or serious medical condition. During an interview on 11/29/23 at 10:15 a.m., with LVN 5, LVN 5 stated she should not have left the bottle of OTC medication on top of the medication cart when she turned her back. LVN 5 stated the practice was to make sure medications were not left on top of the medication cart. LVN 5 stated anybody including residents could have taken the bottle of medications and ingest the medication which could lead to allergic reaction and or overdose. During an interview on 12/1/23 at 1:50 p.m., with the DON, the DON stated her expectations was to not leave any medications on top of the medication cart. The DON stated anybody could grab the medication left on top of the med cart or take medications out of the unattended and unlocked medication cart, ingest the medications and developed allergic reactions which could lead to serious medical condition. 555924 Page 22 of 34 555924 12/01/2023 Bethel Lutheran Home 2280 Dockery Avenue Selma, CA 93662

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled, Medication Administration General Guidelines, dated 2007, the P&P indicated, . the medication cart is kept closed and locked when out of sight of the medication nurse. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications when unlocked . During a review of the facility's policy and procedure titled, Storage of Medications, dated 2020, the P&P indicated, . Drugs and biologicals used in the facility are stored in locked compartments . Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling . 555924 Page 23 of 34 555924 12/01/2023 Bethel Lutheran Home 2280 Dockery Avenue Selma, CA 93662

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure garbage was properly contained in dumpsters (garbage containers) covered with lids for one of five dumpsters when one garbage dumpsters outside of the facility was left uncovered, with lids to the side. Residents Affected - Few This failure had the potential to attract rodents, insects and flies and spread infection placing residents at risk of foodborne illness. Findings: During a concurrent observation and interview on 11/27/23 at 9:50 a.m., with the Dietary Supervisor (DS), outside the trash collection area, there were five large dumpsters. One large trash dumpster was open with both lids flopped on the side. The DS stated, the lids (dumpster) were normally covered (closed), not sure why one dumpster was left open. The DS stated having the lids which were not closed could attract animals and potentially cause cross-contamination and the spread of bacteria causing disease. During a concurrent observation and interview on 11/28/23 at 10:45 a.m., with the Maintenance Supervisor (MS), at back of facility, there were five large dumpsters. One trash dumpster was left uncovered. The MS stated the trash dumpsters were supposed to be closed. The MS stated that if trash containers/dumpsters were not covered there could be an infestation of flies and rodents in the facility. During an interview on 12/1/23 at 2:42 p.m., with the Infection Prevention (IP), the IP stated it was her expectation for staff to keep the lids to waste containers and dumpsters closed. The IP stated having dumpsters uncovered violated infection control efforts to prevent rodents and pests. During a review of the facility policy and procedure (P&P), titled, Infection Prevention and Control Manual Maintenance, dated 2019, the P&P indicated . Policy The maintenance department provides for maintenance and repair or installation of septic/sewage systems, hazardous waste disposal systems, ice machines, water fountains, and other equipment which is directly or indirectly concerned with infection control . 5. Waste Processing Systems, including Dumpsters, Trash Bins . a. Enforce proper bagging and containment of waste . b. Maintain waste receptacles to prevent leakage . During a review of the FDA (Food and Drug Administration) Food Code dated 2017, retrieved from https://www.fda.gov/food/fda-food-code/food-code-2017, the Food Code indicated . 5-501.113 Covering Receptacles. Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered . 555924 Page 24 of 34 555924 12/01/2023 Bethel Lutheran Home 2280 Dockery Avenue 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** During a review of Resident 26's admission Record (AR), (undated), the AR indicated, . Resident 26 was admitted to the facility on [DATE] . During a review of Resident 26's paper chart the Physician Orders for Life-Sustaining Treatment (POLST), dated [DATE], the POLST indicated, Resident 26 did not have an advanced directive. Resident 26's Health Care Power of Attorney Appointment of Health Care Agent and Proxy document dated [DATE] was located in Resident 26's paper chart. 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 [DATE], the MDS indicated Resident 26's Brief Interview for Mental Status (BIMS - an evaluation of attention, orientation and memory recall) score of 99 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment, score of 99 resident unable to complete the interview), Resident 26 was unable to complete the interview. During a concurrent interview and record review on [DATE] at 10:21 a.m. with Licensed Vocational Nurse (LVN) 5, Resident 26's POLST, dated [DATE] and Health Care Power of Attorney Appointment of Health Care Agent and Proxy dated [DATE] were reviewed. The POLST indicated Resident 26 did not have an advanced directive the Health Care Power of Attorney Appointment of Health Care Agent and Proxy was notarized on [DATE]. LVN 5 stated the POLST should have indicated Resident 26 had an advanced directive. LVN 5 stated the purpose of having an advanced directive was so it could be included in resident's treatment plan. LVN 5 stated it was important to know about the advanced directive for care to be provided based on what the resident wanted. LVN 5 stated the advanced directive indicated the resident's legal decision maker. During a concurrent interview and record review on [DATE] at 9:24 a.m. with the Medical Records (MR), Resident 26's POLST, dated [DATE] was reviewed. The MR stated Resident 26's POLST indicated Resident 26 did not have an advanced directive. The MR stated her role included auditing (official inspection of an organizations accounts) consents, change of conditions and POLST. The MR stated she had not completed a POLST audit. The MR stated all sections of a POLST should be reviewed to make sure each section is completed. The MR stated Resident 26's POLST should have been updated to reflect Resident 26 had an advanced directive because it was not accurate and a new POLST should had been created. During a concurrent interview and record review on [DATE] at 4:24 p.m. with the Administrator (ADM), Resident 26's POLST, dated [DATE] was reviewed. The POLST indicated Resident 26 did not have an advanced directive. The ADM stated at the time of admission the residents were asked if they had an advance directive. The ADM stated if the resident indicated they did not have an advanced directive the facility staff would check no on the POLST. The ADM stated if a resident's advanced directive was brought in after admission, the facility staff should have updated the POLST. The ADM stated it was important to have the updated POLST, so the facility staff knew the status of the resident. The ADM stated Resident 26's POLST was inaccurately filled out because Resident 26 had an advanced directive in her chart. During an interview on [DATE] at 3:21 p.m. with the Director of Nursing (DON), the DON stated she 555924 Page 25 of 34 555924 12/01/2023 Bethel Lutheran Home 2280 Dockery Avenue Selma, CA 93662

F 0842 Level of Harm - Minimal harm or potential for actual harm expected the POLST to be accurately completed upon admission. The DON stated a resident's POLST should had been redone if it had inaccurate information. During a review of the facility's policy and procedure (P&P) titled, Charting Errors and/or Omissions, dated [DATE], the P&P indicated, . Accurate medical records shall be maintained by this facility . Residents Affected - Some During a review of Resident 34's AR, dated [DATE], the AR indicated Resident 34 was admitted on [DATE] with diagnoses which included, hemiplegia (paralysis [the loss of the ability to move and sometimes to feel anything] of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), anxiety disorder. During a concurrent interview and record review on [DATE] at 10:09 a.m. with LVN 4, Resident 34's POLST form dated [DATE] was reviewed. LVN 4 stated the POLST was not completed for Resident 34. During a concurrent interview and record review on [DATE] at 11:16 a.m. with the DON, Resident 34's POLST form dated [DATE] was reviewed. The DON stated Resident 34's POLST was not completed. The DON stated the POLST was needed to be completed so staff knew who it was discussed with and who completed the form. During a professional reference retrieved from https://capolst.org/ titled POLST California, dated 2023, the reference indicated, . Physician Orders for Life-Sustaining Treatment (POLST) is a form that gives seriously-ill patients more control over their end-of-life care, including medical treatment, extraordinary measures (such as a ventilator or feeding tube) and CPR. Printed on bright pink paper, and signed by both a patient and physician, nurse practitioner or physician assistant, POLST can prevent unwanted or ineffective treatments, reduce patient and family suffering, and ensure that a patient's wishes are honored . Based on interview and record review, the facility failed to maintain complete and accurate medical records consistent with professional standards of practice for 6 of 18 sampled residents (Residents 24, 35, 46, 453, 26 and 34) when the Physician Orders for Life-Sustaining Treatment (POLST - a legal document that specifies the type of treatment and services a resident would like in an emergency life threatening medical situation) form was incomplete and readily available in the residents' medical records for Resident 24, 35, 46, 453, 26 and 34. This failure had the potential risk for end-of-life care decisions to not be followed for Residents 24, 35, 46, 453, 26 and 34. Findings: During a review of Resident 24's admission Record (AR), undated, the AR indicated, Resident 24 was admitted to the facility on [DATE] with diagnoses which included, encounter for palliative care (specialized medical care for people living with a serious illness), Alzheimer's Disease (progressive mental deterioration), protein calorie malnutrition (lack of sufficient nutrients in the body), type 2 diabetes mellitus (A chronic condition that affects the way the body processes blood sugar) and heart failure (a chronic condition when the heart cannot pump enough blood). During a review of Resident 35's AR, undated, the AR indicated, Resident 35 was admitted to the 555924 Page 26 of 34 555924 12/01/2023 Bethel Lutheran Home 2280 Dockery Avenue Selma, CA 93662

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility on [DATE] with diagnoses which included, muscle wasting and atrophy (loss of muscle mass), anxiety disorder (intense, excessive worry and fear), protein-calorie malnutrition, dementia (loss of memory, language and other abilities which interferes with daily living), and hypertensive heart failure (heart failure caused by high blood pressure). During a review of Resident 46's AR, undated, the AR indicated, Resident 46 was admitted to the facility on [DATE] with diagnoses which included, enterocolitis (inflammation of the intestine [long, tube-like organ that completes digestion]) due to clostridium difficile (bacteria causing infection of the colon [longest part of large intestine]), atrial fibrillation (an abnormal heartbeat which can lead to blood clots in the heart), anemia (lower than normal healthy red blood cells), muscle weakness, protein-calorie malnutrition and adult failure to thrive (a decline of health and ability in older adults). During a review of Resident 453's AR, undated, the AR indicated, Resident 453 was admitted to the facility on [DATE] with diagnoses which included, nontraumatic intracerebral hemorrhage (bleeding in the brain without trauma), ataxia (loss of full control of bodily movements), atrial fibrillation and muscle weakness. During a concurrent interview and record review on [DATE] at 9:59 a.m. with Licensed Vocational Nurse (LVN) 4, Residents 35, 46 and 453's POLST was reviewed. LVN 4 stated the POLST was a document which indicated the treatment the resident would want in case of an emergency. LVN 4 stated the POLST was an important document because it traveled with the resident when they were transferred to the hospital. LVN 4 stated the POLST for Residents 35, 46 and 453 should have been completed. During a concurrent interview and record review on [DATE] at 10:33 a.m. with Medical Records (MR), the POLST for Residents 24, 35, 46 and 453 were reviewed. MR stated the POLSTs for Residents 24, 35, 46, and 453 were missing information and incomplete. MR stated it was important for the POLST to be completed accurately because they contained information regarding resuscitation and medical decisions if a resident were unable to make decisions for themselves. MR stated it was her responsibility to perform chart audits and verify the POLSTs were complete. During a concurrent interview and record review on [DATE] at 11:17 a.m. with the Director of Nursing (DON), the POLST for Residents 24, 35, 46 and 453 were reviewed. The DON stated the POLST was a document which indicated a resident's life sustaining decisions in an emergency, including CPR. The DON reviewed the POLSTs and stated they were incomplete. The DON stated the entire POLST had to be completed, otherwise the document would not be legal. The DON stated Medical Records was responsible to audit the POLSTs and she or the Assistant Director of Nursing (ADON) would review the audit to follow up. During a review of the facility's policy and procedure (P&P) titled, Advanced Directives, dated 7/2019, the P&P indicated, . It is the policy of this facility to comply with state and federal law . Upon admission or as soon as practicable thereafter, the resident and/or his/her legal representative or surrogate decision maker will be provided with information regarding preferred intensity of care . The resident or his/her legal representative or surrogate shall complete this form as he/she desires which may include a POLST form . A physician, NP [nurse practitioner] or PA [physician's assistant] signature is required on the POLST form. In the event of an emergency before the physician's signature is obtained, the resident's status will remain a full code . this form shall be copied and the copy will be carried with the resident when he or she is transferred out of the facility . 555924 Page 27 of 34 555924 12/01/2023 Bethel Lutheran Home 2280 Dockery Avenue Selma, CA 93662

F 0842 During a review of the facility's P&P titled, Charting Errors and/or Omissions, dated [DATE], the P&P indicated, . Accurate medical records shall be maintained by this facility . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 555924 Page 28 of 34 555924 12/01/2023 Bethel Lutheran Home 2280 Dockery Avenue Selma, CA 93662

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 maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of infections when: Residents Affected - Few 1. One of three sampled resident's (Resident 4) foley catheter (indwelling urinary catheter - a thin tube placed in the bladder to drain urine into a bag) tubing was lying the floor on two separate occasions. This failure placed Resident 4 at risk for catheter contamination and a urinary tract infection (UTI- an infection in any part of the urinary system [kidneys, ureters, bladder]). 2. Two of two non-kitchen staff (staff position unknown and Maintenance Director [MS])entered the kitchen area without wearing proper hair covering and washing their hands. This failure had the potential to cause cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and spread of infection. Findings: During a concurrent observation and interview on 11/27/23 at 11:17 a.m. with Resident 4, Resident 4 was sitting in his wheelchair at bedside. Resident 4's catheter tubing was under his wheelchair lying on the floor which was dirty with crumblike debris. Resident 4 stated he had a history of urinary tract infections. During a review of Resident 4's admission Record (AR-a document containing resident medical and personal information), undated, the AR indicated, Resident 4 was admitted to the facility on [DATE] with diagnoses which included neuromuscular dysfunction of bladder (lack of bladder control due to brain, spinal cord or nerve problems), benign prostatic hyperplasia (BPH-enlarged prostate [gland at the base of the bladder]) and retention of urine (difficulty emptying the bladder completely). During a review of Residents 4's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 4's Brief Interview of Mental Status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 15 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 4 was cognitively intact. During a concurrent observation and interview on 11/27/23 at 11:25 a.m. with Certified Nursing Assistant (CNA) 3 in Resident 4's room, Resident 4 was sitting in his wheelchair with the catheter tubing lying on the floor. CNA 3 stated the catheter tubing should not touch the floor because it was an infection control issue. During an observation on 11/27/23 at 12:38 p.m. in Resident 4's room, Resident 4 was sitting in his wheelchair at bedside with the catheter tubing lying on the floor. During an interview on 11/29/23 at 10:12 a.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 stated the catheter tubing being on the floor was an infection control issue and the catheter tubing should not touch the floor. LVN 4 stated Resident 4 could have easily stepped on the tubing and dislodged (knocked out of position) the catheter causing further issues. LVN 4 stated having a foley catheter 555924 Page 29 of 34 555924 12/01/2023 Bethel Lutheran Home 2280 Dockery Avenue Selma, CA 93662

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few placed Resident 4 at a high risk for a urinary tract infection which could cause confusion and decreased physical functioning. During an interview on 11/29/23 at 2:24 p.m. with the Director of Nursing (DON), the DON stated the catheter tubing lying on the floor could be a source of infection. The DON stated the tubing lying on the floor close to Resident 4's foot placed the catheter at risk for dislodgement if it got stepped on. The DON stated Resident 4 used the catheter long term which could cause an infection leading to sepsis (the body's life-threatening response to an infection). During a concurrent interview and record review on 11/30/23 at 3:44 p.m. with the DON, the facility's policy and procedure (P&P) titled, Catheter Care, Indwelling, dated November 2013, was reviewed. The P&P indicated . It is the policy of this facility to provide catheter care to reduce the risk of infections . Keep the collecting Bag below the level of of[sic] the bladder at all times and do not rest the bag on the floor . The DON stated CDC guidelines were to be followed for catheter care. The DON stated the P&P was not followed. During a review of a professional reference retrieved from https://www.cdc.gov/infectioncontrol/guidelines/cauti/recommendations.html titled Catheter-Associated Urinary Tract Infections, dated 11/5/2015, the reference indicated, . Guideline for Prevention of Catheter-Associated Urinary Tract Infections . Proper Techniques for Urinary Catheter Maintenance . maintain unobstructed urine flow . Keep the catheter and collecting tube free from kinking . Keep the collecting bag below the level of the bladder at all times. Do rest the bag on the floor . 2. During an observation on 11/27/23 at 8:50 a.m., in the kitchen, a non-kitchen staff member (position unknown) entered the kitchen without putting on a hair net or washing hands at the handwashing sink. During a concurrent observation and interview on 11/28/23 at 10:45 a.m., in the kitchen, the Maintenance Supervisor (MS) entered the kitchen area without applying a beard net or washing hands at handwashing sink station. The MS stated he was not aware he needed to wear a beard net and needed to wash his hands before entering the kitchen areas. The MS stated body hair should have been covered to keep hair from food. The MS stated dirty hands could cause contamination and spread of infection to residents. During an interview on 11/28/23 at 10:50 a.m., in the kitchen, with the DS, the DS stated non-kitchen employee should have worn a hairnet. The DS stated the MS should have worn a beard net. The DS stated, We don't have them [beard nets]. The DS stated the non-kitchen staff and MS should have washed their hands with soap and water at the handwashing sink. The DS stated everyone entering the kitchen food preparation area was expected to wear a hairnet and to wash their hands at the sink first. During an interview on 12/1/23 at 2:42 p.m., with Infection Preventionist (IP), the IP stated hand sanitizers were not placed in the kitchen to promote handwashing. 555924 Page 30 of 34 555924 12/01/2023 Bethel Lutheran Home 2280 Dockery Avenue 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, during the survey period of 11/27/2023 to 12/1/23, the facility failed to provide the minimum of at least 80 square feet per resident in multiple resident rooms (Rooms 27, 28, 29, 31, 32, 33, 34, 35, 36, 47, 48, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59 and 60). This failure had the potential for residents to not have reasonable accommodations for privacy or adequate space for care to be rendered. Findings: During a concurrent observation and interview on 11/30/23 at 9:38 a.m. with the Maintenance Supervisor (MS), an environmental tour was conducted. The MS measured 22 resident rooms as follows: Room Number Square Feet Number of Residents 27 154 2 28 154 2 29 154 2 31 154 2 32 154 2 33 555924 Page 31 of 34 555924 12/01/2023 Bethel Lutheran Home 2280 Dockery Avenue Selma, CA 93662

F 0912 154 Level of Harm - Potential for minimal harm 2 34 Residents Affected - Many 154 2 35 154 2 36 154 2 47 154 2 48 154 2 50 154 2 51 154 2 52 154 555924 Page 32 of 34 555924 12/01/2023 Bethel Lutheran Home 2280 Dockery Avenue Selma, CA 93662

F 0912 2 Level of Harm - Potential for minimal harm 53 154 Residents Affected - Many 2 54 154 2 55 154 2 56 154 2 57 154 2 58 154 2 59 154 2 60 154 2 555924 Page 33 of 34 555924 12/01/2023 Bethel Lutheran Home 2280 Dockery Avenue Selma, CA 93662

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Many During an interview on 12/1/23 at 2:55 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she had worked at the facility for two years and the resident room sizes had not been an issue. CNA 1 stated there was enough room for resident care and storage. CNA 1 stated she had received any resident complaints regarding their room size. During an interview on 12/1/23, at 3:05 p.m., with Resident 4, in room [ROOM NUMBER], Resident 4 sat in his wheelchair at bedside. Resident 4 stated he had no issues with the size of his room. Resident 4 stated he had enough privacy and room for storage. During the observations made from 11/27/23 to 12/1/23, 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 continue in effect. ________________________________________________ Health Facility Evaluator Supervisor Signature & Date Request waiver continue in effect. _______________________________ Administrator Signature & Date 555924 Page 34 of 34