Health inspection·December 17, 2021

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. 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 ensure six medication consents that required a physician's signature were signed for one of five sampled residents (16). Residents Affected - Few As a result Resident 16 received medication without proper education. Findings: Resident 16 was admitted to the facility on [DATE] with diagnoses including Dementia (memory loss) and psychosis (a mental disorder characterized by a disconnection from reality) per facility's admission Record. Resident 16's clinical record titled, informed consents for Anxiolytic (medication to reduce anxiety); Hypnotic (medication for sleep); Antipsychotics (medication to treat mental disorder); Antidepressant (medication to treat mood disorder), all dated 9/14/21, was conducted. All the consents for Resident 16 did not have a physician's signature. On 12/17/21 at 4:23 P.M., a concurrent interview and record review of Resident 16's informed consent with LN 20 was conducted. LN 20 acknowledged Resident 16's medication consents, dated 9/14/21, did not have a physician's signature. LN 20 further stated the consents should have a physician's signature. On 12/20/21 at 3:17 P.M., an interview with the DON was conducted. The DON stated her expectation was for the physician to sign the informed consents. The DON further stated the informed consents could not be validated for accuracy if a physician's signature is missing. On 12/20/21 at 5:15 P.M., the DON stated the facility did not have a policy for informed consents. Page 1 of 24 055078 055078 12/17/2021 Parkway Hills Nursing & Rehabilitation 7760 Parkway Drive LA Mesa, CA 91942

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to clarify a Physician's Order for Life Sustaining Treatment (POLST) for one of two sampled residents (19). This failure had the potential for residents to receive inaccurate life sustaining measures during an emergency. Findings: Resident 19 was admitted to the facility on [DATE] with diagnoses which included chronic kidney disease (progressive disease that causes kidney damage) and malignant neoplasm of colon (progressively worsening cancer) per the facility's admission Record. A record review of Resident 19's history and physical notes was conducted. Per the physician's history and physical notes dated 9/28/21, Resident 19 had the capacity to understand and make decisions. Resident 19's clinical record had two POLST forms, both dated 9/28/21. One form was signed by Resident 19, and the other form was signed by a person with an unreadable relationship to the resident. On 12/14/21 at 3:02 P.M. a joint interview and record review with LN 41 was conducted of Resident 19. LN 41 stated she did not know why there were two POLST forms signed by two different people. LN 41 stated both forms contained two different interventions under, Section B. Medical Interventions. In addition, LN 41 stated the POLST should have been clarified with the physician. On 12/14/21 at 3:23 P.M., an interview was conducted with the SSD. The SSD stated there should only be one POLST form in Resident 19's chart in order to avoid confusion. The SSD further stated that the POLST should have been clarified with the physician. On 12/21/21 at 9:43 A.M., an interview was conducted with the DON. The DON stated that Resident 19's POLST should have been reviewed upon admission and clarified with the physician. Per the facility's policy titled Physician Orders for Life Sustaining Treatment (POLST) dated 11/2018, . A legally recognized health care decision-maker may execute, revise, or revoke the POLST form for a resident only if the resident lacks decision-making capacity . 055078 Page 2 of 24 055078 12/17/2021 Parkway Hills Nursing & Rehabilitation 7760 Parkway Drive LA Mesa, CA 91942

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain a safe and home-like environment when; A. Ten of 54 resident rooms (Rooms 5, 6A, 6B, 16, 17, 18, 20, 27, 28A, and 28B) had power strips that were not UL (Underwriters Laboratories, nationally recognized standards for safety) certified and had multiple electrical cords plugged into power strips that were not fastened to the wall or floor, B. Six of 24 resident rooms had a broken window ( Rooms 14, 16, 21, 24, 25, and 26). C. Six of 24 rooms had temperature levels that were not within a comfortable range (Rooms 12, 14, 16, 25, 26, and 27). D. One resident (36) had a space heater that was not UL certified, and E. The facility did not have a permanent generator. These failures to ensure a safe, comfortable and homelike environment may result in power outage, fire or hypothermia (A potentially dangerous drop in body temperature). Findings: A. On 12/15/21 at 8:30 A.M., a concurrent observation and interview was conducted with the MD during a tour of the facility. The MD stated, Power strips should have a sticker with the UL certification and the power strip should be fastened to the wall or the floor. During the tour with MD, the following was observed: room [ROOM NUMBER]- Power strip was not UL certified, room [ROOM NUMBER] A- Power strip was not UL certified, not secured, and had two electrical cords plugged in, room [ROOM NUMBER] B- Power strip was not UL certified, room [ROOM NUMBER]- Power strip was not UL certified, not secured, and had two electrical cords plugged in, room [ROOM NUMBER]- Power strip was not UL certified, not secured and had five electrical cords plugged in, room [ROOM NUMBER]- Power strip was not UL certified and had one electric cord plugged in, room [ROOM NUMBER]- Power strip on floor, not secured, and had two electrical cords plugged in, room [ROOM NUMBER]- Power strip was not UL certified, not secured, and had three electrical cords 055078 Page 3 of 24 055078 12/17/2021 Parkway Hills Nursing & Rehabilitation 7760 Parkway Drive LA Mesa, CA 91942

F 0584 plugged in; one being another extension cord with an electrical device plugged in, Level of Harm - Minimal harm or potential for actual harm room [ROOM NUMBER] A- Power strip was not UL certified, Residents Affected - Some room [ROOM NUMBER] B- Power strip was UL certified but was on the bedside table and not secured with two electrical cords plugged in. On 12/17/21 at 10 A.M., an interview was conducted with the MA. The MA stated, A low quality power strip could heat up and could be a fire hazard - that's why we check for the UL certification. On 12/20/21 at 4 P.M., a telephone interview was conducted with the MD. The MD stated, There are many electrical devices that do not go through me to get certified because they are usually brought in at admission and I am not told about them. B. On 12/14/21 at 9 AM, an interview was conducted with Resident 37. Resident 37 stated, It's cold in this room. The window on the right side was observed to be open about two inches. The MD stated, The window is broken. It won't shut all the way. On 12/17/21 at 12 noon a concurrent interview and observation was conducted with the MD. All windows in the resident's rooms were observed. MD used a ruler to measure gaps in the windows. The findings were as follows: room [ROOM NUMBER]-the window on the left side was opened 5.5 inches. The MD stated, The handle to open and close the window is broken. room [ROOM NUMBER]- the window was opened about 3 inches wide. The MD stated, The handle to open and close the window is missing. room [ROOM NUMBER] - the window on the left side could not fully close. The window on the right side had blue tape covering a crack on the glass and was able to close all the way but did not lock. The MD stated he did not notice the blue tape on the window and did not know how long it had been there. room [ROOM NUMBER]- the window was opened and did not have a handle to open and close the window. room [ROOM NUMBER]- the glass on the window was separated from the window frame and created a gap, which measured 1 inch wide by 27 inches long. room [ROOM NUMBER]- The window had a gap between the glass and frame on the left side of the window. MD measured the gap to be 1/2 inch by 2.7 inches long. C. On 12/20/21 at 9 A.M., a concurrent interview and observation was conducted with the MA. The MA used the facility's laser thermometer to measure the temperature of the rooms. room [ROOM NUMBER]- Resident 13 was observed in his wheel chair wearing a thick, layered winter coat. Resident 13 stated, It gets very cold in this room. Sometimes I have to sleep with my coat on. The MA measured the temperature of the room, it was 64.9 degrees Fahrenheit. room [ROOM NUMBER]- Resident 38 was observed sitting in his wheelchair wearing a jacket with the 055078 Page 4 of 24 055078 12/17/2021 Parkway Hills Nursing & Rehabilitation 7760 Parkway Drive LA Mesa, CA 91942

F 0584 Level of Harm - Minimal harm or potential for actual harm hood over his head, Resident 38 said. It is very cold in my room, especially at night. Resident 38 stated, I sleep with my jacket on. The MA measured the room temperature. It was 60.1 degrees Fahrenheit. room [ROOM NUMBER]- The MA measured the temperature of room [ROOM NUMBER]. It was 63.7 degrees Fahrenheit. Residents Affected - Some room [ROOM NUMBER]- The MA measured the temperature of room [ROOM NUMBER]. It was 64.8 degrees Fahrenheit. room [ROOM NUMBER]- Resident 37 said, Its still cold in my room. The MA measured the temperature of room [ROOM NUMBER]. It was 68.6 degrees Fahrenheit. On 12/20/21 at 9:45 A.M., The MA acknowledged that the room temperatures were out of range and that the proper temperature range should be 71 degrees Fahrenheit to 81 degrees Fahrenheit. D. On 12/17/21 at 10 A.M., a concurrent observation and interview was conducted with the MD. Resident 36 stated, I've had my space heater since I was admitted in March. Upon observation, a power strip was plugged into the room's wall outlet. The electrical cords for the bed, a fan, and a space heater were all plugged in to the power strip. The MD stated, The power strip is not UL certified and the fan and space heater have not been approved for use in the facility. E. On 12/14/21 at 3: 08 P.M., the facility lights were observed to be flickering. The MD stated, The electricity went out and the generator just kicked on. On 12/14/21 at 3:11 P.M., the MD stated, The electricity is back on now. On 12/17/21 at 9:11 A.M., during an observation in the facility's hallway the lights were flickering. At 9:12 A.M. the lights went out. The MD instructed staff to get extension cords to access power through the red emergency outlets. On 12/17/21 at 9: 14 A.M. during observations and interviews, it was observed that the extension cords plugged into the red emergency outlets were not providing electricity to the lights and other devices requiring electric power such as oxygen concentrators which were in use by Residents 6, 22, and 34 and Low Air Loss mattresses which were in use by Residents 1, 2, 4, 15, 18, 27, 34, 39 and 40. At 9:14 A.M. the MD stated, I don't know why the generator did not turn on this time. The MD further stated, I contacted the company we rent the generator from. They are sending someone to see what went wrong. LNs were observed providing oxygen tanks to Residents 6, 22 and 34. CNAs, LNs, PT, OT and Activities staff were observed assisting residents on to wheelchairs as the Low Air Loss Mattresses were deflating. Food from two refrigerators were disposed of when the refrigerator's internal temperatures went out of safe range. It was observed that the facility did not have electrical power for approximately 57 minutes. The generator kicked on at 10:10 A.M. after the rental company arrived to fix it. According to the facility's policy titled, Emergency Generator or Alternate Energy Source, revised April 2019, .10. Permanent generator will be used in accordance with NFP 110 and Life Safety Code requirement, including location, testing, fuel storage and maintenance. 055078 Page 5 of 24 055078 12/17/2021 Parkway Hills Nursing & Rehabilitation 7760 Parkway Drive LA Mesa, CA 91942

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Per the facility's policy titled, Electrical Safety for Residents, dated January 2011 indicated, . 2. Inspect electrical outlets, extension cords, power strips and electrical devices as part of routine fire safety and maintenance inspections .3. Portable space heaters are not permitted in the facility. Per the facility's policy titled, Supervision, Maintenance Services, revised May 2008, .1. The day-to-day maintenance operation is under the supervision of the Maintenance Director .3. Duties and responsibilities of the Maintenance Director are outlined in his/her job description. Per the Director of Maintenance job description, . Ensure the safe and proper functioning of the environment and equipment that are necessary to care for the resident population in the facility. 055078 Page 6 of 24 055078 12/17/2021 Parkway Hills Nursing & Rehabilitation 7760 Parkway Drive LA Mesa, CA 91942

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor and clarify with the physician the use of physical restraint (any device that the individual cannot remove easily which restricts freedom of a person's bodily movement) for one of one sampled resident (23). As a result, Resident 23 complained of hand and shoulder pain. Findings: Resident 23 was admitted to the facility on [DATE] with diagnoses which included muscle weakness, cognitive (thinking) communication deficit, and hemiplegia and hemiparesis (one side of the body paralyzed) per the facility's admission Record. During the initial tour of the facility on 12/14/21, Resident 23 was heard screaming, Help, help, somebody please. Resident 23 was observed laying on her bed with her right arm raised. Resident 23's right hand was observed to have a white colored mitten. Resident 23 stated she had the mitten for, Five months, I'm not sure why they put it on me. Resident 23 stated she could only move her right arm and staff fed her for meals. Resident 23 was observed on 12/17/21 at 10:15 A.M. Resident 23 was screaming for help and stated she had pain on her right arm. Resident 23's right hand mitten was observed to have a white colored tape wrapped around the wrist area. On 12/17/21 at 11:15 A.M., a joint observation and interview was conducted of Resident 23 with the DON. The DON observed Resident 23's mitten and attempted to remove the white tape. The DON stated, This is not right, they are not suppose to tape the hand mittens on a resident. The DON further stated that the tape was tight and was difficult to remove. While the DON was removing the tape on the hand mitten, Resident 23 stated, My arm and shoulder hurts. Resident 23's clinical record was reviewed. Per the Nurse Practitioner's order dated 3/20/20 at 17:48 (5:48 P.M.), Mittens/socks on both hands . Per the facility's care plan dated 3/20/20, [Resident 23] have behavioral problem and the care plan did not include a time frame for the hand mitten use under the section, Interventions. On 12/17/21 at 4:46 P.M., an interview was conducted with the SSD. The SSD stated Resident 23's hand mittens should not have been taped because it was considered as an abuse. On 12/21/21 at 9:43 A.M., an interview was conducted with the DON. The DON stated she was not sure how often the restraint should be reordered. The DON stated that there should have been a reassessment of the hand mitten restraint use. In addition, the DON stated the hand mitten order should have been clarified with the physician especially the duration. Per the facility's policy titled Use of Restraints, dated 4/2017, . 2 .IF the resident cannot 055078 Page 7 of 24 055078 12/17/2021 Parkway Hills Nursing & Rehabilitation 7760 Parkway Drive LA Mesa, CA 91942

F 0600 Level of Harm - Minimal harm or potential for actual harm remove a device in the same manner in which the staff applied it given that resident's physical condition . and this restricts his/her typical ability to change position or place, that device is considered a restraint . 9 . The order shall include the following . c. The type of restraint, and period of time for the use of restraint . 16. Restrained individuals shall be reviewed regularly . Residents Affected - Few 055078 Page 8 of 24 055078 12/17/2021 Parkway Hills Nursing & Rehabilitation 7760 Parkway Drive LA Mesa, CA 91942

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. 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 reevaluate the use of a hand mitten physical restraint (any device that the individual cannot remove easily which restricts freedom of a person's bodily movement) for one of one sampled resident (23). Residents Affected - Few Failure to reassess the need of a physical restraint have the potential for residents to be placed for injury and affect their quality of life. Findings: Resident 23 was admitted to the facility on [DATE] with diagnoses which included muscle weakness, cognitive (thinking) communication deficit, and hemiplegia and hemiparesis (one side of the body paralyzed) per the facility's admission Record. Resident 23's clinical record was reviewed. Per the Nurse Practitioner's order dated 3/20/2020 at 17:48 (5:48 P.M.), Mittens/socks on both hands . Per the facility's care plan dated 3/20/2020, [Resident 23] have behavioral problem and the care plan had no time frame for the hand mitten use under the section, Interventions. Resident 23's Treatment Administration Record (TAR) from September through December 2021 indicated that Resident 23 was using hand mittens. On 12/21/21 9:43 A.M., an interview was conducted with the DON. The DON stated she was not sure how often the restraint should be ordered. In addition, the DON stated the hand mitten order should have been clarified with the physician especially the duration. Per the facility's policy titled Use of Restraints dated 4/2017, . 9 . The order shall include the following . c. The type of restraint, and period of time for the use of restraint . 16. Restrained individuals shall be reviewed regularly . 055078 Page 9 of 24 055078 12/17/2021 Parkway Hills Nursing & Rehabilitation 7760 Parkway Drive LA Mesa, CA 91942

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a resident centered care plan for antipsychotic medications (medication to treat mental illness) for two of five sampled residents (2, 32). This failure had the potential for the staff not to recognize behavioral changes and possible side/adverse effects in Resident 2 and 32. Findings: A. Resident 2 was admitted to the facility on [DATE] with diagnoses including anxiety disorder (excessive, and persistent worry and fear about everyday situations) and psychosis (a mental disorder characterized by a disconnection from reality) per facility's admission Record. Per Resident 2's Order Summary Report, dated 12/21/21, QUEtiapine Fumarate, an antipsychotic medication, was ordered on 3/15/21. Resident 2 did not have a care plan for this antipsychotic medication. B. Resident 32 was admitted to the facility on [DATE] with diagnoses including schizophrenia (mental disorder in which people interpret reality abnormally) per facility's admission Record. Per Resident 32's Order Summary Report, dated 12/21/21, QUEtiapine Fumarate, an antipsychotic medication was ordered on 11/11/21. Resident 32 did not have a care plan for this antipsychotic medication. On 12/20/21 at 4:01 P.M., a concurrent interview and record review of Resident 2's care plan was conducted with LN 21. LN 21 acknowledged there was no care plan for Resident 2's antipsychotic medication. LN 21 further stated care plan for antipsychotic medication should have been created. On 12/20/21 at 4:25 P.M., an interview with the DON was conducted. The DON stated she expected an antipsychotic medication care plan to be initiated for Resident 2 and 32. The DON further stated it was important to have a care plan to know the interventions and goals of the medication treatment. According to the facility's policy titled Care Plans, Comprehensive Person-Centered, revised December 2016, .A comprehensive, person-centered care plan that includes measurable objects and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 055078 Page 10 of 24 055078 12/17/2021 Parkway Hills Nursing & Rehabilitation 7760 Parkway Drive LA Mesa, CA 91942

F 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and closed record reviews, the facility failed to develop a discharge plan for one of two sampled residents (49). Resident 49 left the facility against medical advice (AMA- leaving the facility without a doctor's approval) thirteen days after his admission date. Residents Affected - Few This failure had the potential for Resident 49 to not receive appropriate coordination of care upon discharge. Findings: Resident 49 was admitted to the facility on [DATE] with diagnoses to include hypertensive urgency (high blood pressure with minimal to no symptoms and no signs or symptoms of organ damage) per the admission Record. A record review of Resident 49's clinical record was conducted. Resident 49's Nursing Note, dated 10/21/2021, indicated Resident 49 approached facility staff and, .will be leaving today to be picked up by his friend. Resident 49's progress notes did not show any documentation related to discharge planning. Resident 49 did not have a care plan focused on discharge planning. Resident 49's Physician Discharge Summary, signed and dated by the physician on 11/20/2021, indicated resident was discharged on 10/21/2021 AMA. On 12/17/2021 at 3:55 P.M., an interview was conducted with the DON. The DON stated all residents should have a discharge plan developed at least within three days of admission to the facility by the interdisciplinary team, along with a care plan related to discharge. According to the facility's policy titled, Discharge Summary and Plan, revised December 2016, .4. Every resident will be evaluated for his or her discharge needs and will have an individualized post-discharge plan. 055078 Page 11 of 24 055078 12/17/2021 Parkway Hills Nursing & Rehabilitation 7760 Parkway Drive LA Mesa, CA 91942

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 coordinate a scheduled hospice visit and plan of care for one of two hospice residents reviewed for hospice care (39). Residents Affected - Few This failure had the potential for miscommunication among health care givers. Findings: Resident 39 was admitted to the facility on [DATE] with diagnoses which included malignant neoplasm (progressively worsening cancer) of right lung, neoplasm of bone and spinal cord. Resident 39's clinical record was reviewed. The following information was obtained from the facility's hospice binder: A. November 2021 [Hospice] Personalized Visit Schedule calendar with signatures on 11/4, 11/5, and 11/12/21. B. An [unknown month] Personalized Visit Schedule Calendar with one signature on unknown month/13/unknown year. C. Two Interdisciplinary Plan of Care Revision/Physician Orders dated 11/12/21 and 12/2/21. On 12/20/21 at 9:30 A.M., an interview was conducted with the SC. The SC stated hospice visited the residents three times a week. The SC stated hospice came and saw the resident but was not sure if they documented their visits. On 12/20/21 at 3:49 P.M., a joint interview and record review was conducted of Resident 39 with the SSD. The SSD stated facility staff knew Resident 39 was a hospice resident, but was not sure if they knew the resident's overall hospice condition. In addition, the SSD stated she was not sure how often the hospice staff visited the residents. The SSD reviewed the hospice's Personalized Visit Schedule form then stated that Resident 39 was only visited three times last November. The SSD further stated she was not sure how many times Resident 39 was visited for the month of December because there was, Inconsistent documentation. On 12/21/21 at 10 A.M., an interview was conducted with the DON. The DON stated that the hospice calendar was inconsistent and did not matched the date on the progress notes. The DON stated the expectation was for the facility staff to communicate with the hospice nurse about the plan of care of the resident. Per the facility's policy titled Hospice Program - [Facility Name] 2021, .10 . it is the responsibility of the facility to meet the resident's personal care and nursing needs .These include: d. Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed . 13. Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility . 055078 Page 12 of 24 055078 12/17/2021 Parkway Hills Nursing & Rehabilitation 7760 Parkway Drive LA Mesa, CA 91942

F 0725 Level of Harm - Minimal harm or potential for actual harm Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on interview, and record review, the facility failed to ensure there was enough staff coverage to meet the residents' needs. Residents Affected - Few This failure had the potential to affect the quality of care and life of all the residents in the facility. Findings: During the survey entrance on 12/14/21 at 8:47 A.M., the ADM and the DON was not present in the facility. Subsequently, the ADM was not in the facility on 12/15, 12/16, and 12/17/21. On 12/20/21 at 7:11 A.M., an interview and record review with LN 44 was conducted of the facility's staffing schedule. The night shift schedule for CNAs dated 12/19/21 indicated there were three CNAs scheduled to work. LN 44 stated there was one CNA left in the building from night shift and the two CNAs, Just left. On 12/20/21 at 7:14 A.M., an interview was conducted with CNA 42. CNA 42 stated his shift started at 11 at night and ended at 7:30 in the morning. CNA 42 stated that staff should finish their full eight hour shift to make sure residents' needs were met. On 12/20/21 at 7:29 A.M., an interview was conducted with the SC. The SC stated staff who worked in the facility were all 8 hour shifts and they should clock out once they finished their 8 hour shift. On 12/21/21 at 9:43 A.M., an interview was conducted with the DON. The DON stated staff should never clock out early and not finish their 8 hour shift. During the QAPI meeting on 12/21/21 at 12:00 P.M., the ADM stated clocking out early was not a best practice and needed to be addressed. The ADM further stated that staff leaving early could affect the coverage for the residents and did not meet the facility's expectations. Per the facility's undated policy titled Daily Work Assignments- [Facility Name], . 6. Change in work assignments may not be made for personal reasons . 055078 Page 13 of 24 055078 12/17/2021 Parkway Hills Nursing & Rehabilitation 7760 Parkway Drive LA Mesa, CA 91942

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a medication that required titration(gradually lowering a drug's dosage over a prolonged period) as ordered by a physician for one of three sampled residents (2). As a result Resident 2 did not receive the full benefits of the drug treatment. Findings: Resident 2 was admitted to the facility on [DATE] with diagnoses including ulcerative colitis (inflammation in the digestive tract) per facility's admission Record. On 12/20/21 at 9:46 A.M., a medication administration observation was conducted with LN 19. LN 19 stated Resident 2 had a scheduled dose of prednisone (a medication to reduce inflammation). LN 19 was observed searching for Resident 2's prednisone in the medication cart. LN 19 stated she needed to contact the pharmacy because Resident 2's prednisone was out of stock. Per Resident 2's Order Summary Report, dated 12/20/21, .prednisone 20 mg give 1 tablet by mouth one time a day for COLITIS . Per Resident 2's MAR, dated December 2021, Resident 2 was given prednisone 40 mg from 12/11/21 to 12/16/21. Consequently, Resident 2 was scheduled to take prednisone 20 mg from 12/17/21 to 12/21/21. This document indicated prednisone was not given on 12/18/21, 12/19/21, and 12/20/21. Per Resident 2's Progress Notes, dated 12/18, 12/19/21, a LN documented, pharmacy delivery was pending for prednisone. Per Resident 2's Progress Notes, dated 12/20/21, a LN documented prednisone was not available. On 12/20/21 at 2:07 P.M., an interview with the PC was conducted. The PC stated it was important for the nurses to follow the tapering dosage (gradually lowering a drug's dosage over a prolonged period) for prednisone. On 12/20/21 at 3:17 P.M., an interview with the DON was conducted. The DON stated she expected the nurses to give the medication according to the physician's order. According to the facility's policy, titled Administering Medications, revised April 2019, .4. Medications are administered in accordance with prescriber orders, including any required time frame .7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified . 055078 Page 14 of 24 055078 12/17/2021 Parkway Hills Nursing & Rehabilitation 7760 Parkway Drive LA Mesa, CA 91942

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 two emergency kits (Ekits) were locked, secured, and accounted for. Failure to secure Ekits had the potential for drug diversion and inappropriate medication use. Findings: On 12/16/21 at 11:07 A.M., a joint observation and interview was conducted with the ICP in the facility's medication storage. Inside the medication room were a total of six Ekits, one of which was not sealed, and the other was partially sealed with a string tie. In addition, there was a medium-sized container that contained multiple bubble packs that had medications with resident names. Inside the medication refrigerator were two opened vials of medication labeled Daptomycin (an antibiotic) that both contained approximately 1/3 of yellow-tan colored fluid inside. Per the ICP, when a medication was taken out of the Ekit, the seal should be replaced and the medications should be reordered from the pharmacy. The ICP further stated she was not sure why the Ekits were not sealed properly, and what medications were taken out. On 12/16/21 at 11:50 A.M., an interview and record review was conducted with the DON. The DON stated the Ekits should always be sealed and, This was not an acceptable practice. The DON further stated that one medication was taken out of the Ekit on 11/9/21. The DON stated, Whoever removed the medication should have sealed the Ekit correctly, and called the pharmacy for a refill. The DON stated all discontinued medications should have been placed in the incinerator bins for disposal, and to not leave them exposed in the container. On 12/20/21 at 2:07 P.M., an interview was conducted with the facility's PC. The PC stated she was not aware that the Ekits were opened because, The facility did not send a request for refill. In addition, the PC stated that Ekits should always be kept sealed all the time for safety purposes. Per the facility's policy titled Storage of Medications revised 4/2019, . 5. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed . The facility did not provide a policy about proper storage and safety of Ekits. 055078 Page 15 of 24 055078 12/17/2021 Parkway Hills Nursing & Rehabilitation 7760 Parkway Drive LA Mesa, CA 91942

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and review of facility documents the facility failed to ensure food was stored in accordance with professional standards of food service safety when: Residents Affected - Few A. multiple food items were in the refrigerator or freezer with no dates and not properly sealed; B. staff's personal items were stored in the kitchen next to the refrigerator; C. a window sill in the food storage room was not clean; and D. two dented cans. These failures to ensure effective food and nutrition service operations may result in placing residents at risk for food borne illness and the growth of harmful organisms. Findings: A. On 12/14/2021 at 9:20 A.M., a joint observation and interview was conducted with the Cook. There were three trays holding plastic cups filled with white, red, and amber colored fluid with no labels with date and description. Upon observation of the freezer, was a blue plastic bag with frozen carrots with no label. In the same freezer, was an open box with an open plastic bag of beef patties. The [NAME] stated the bag of carrots and beef patties should have been put into a new resealable bag and dated. Upon observation of the refrigerator, was an unsealed bag of grated cheese, filled halfway, with no label. The [NAME] stated the cheese should be in a sealed plastic bag and dated. B. On 12/14/21 at 9:25 A.M., a black sweater was observed hanging on a chair between the refrigerator and food prep counter. On 12/15/21 at 9 A.M., a sweater was observed again, hanging on a chair between the refrigerator and food prep counter. The [NAME] stated, It's my sweater, it shouldn't be there but there was no where else to put it. C. On 12/14/21 at 9:40 A.M., a window next to the coffee cart was observed to have multiple black, fuzzy particles. On 12/14/21 at 9:45 A.M., the MA was interviewed. The MA stated the particles were dust balls. The MA stated he did not know who was responsible for cleaning the window. On 12/14/21 at 10:10 A.M., the MD was interviewed. The MD stated, I don't know who is responsible for cleaning the window in the food storage room. On 12/20/21 at 4 P.M., the ADM was interviewed. The ADM stated, Since food is stored in that storage room, the kitchen staff is responsible for keeping it clean. D. On 12/14/21 at 10:15 A.M., a concurrent observation and interview was conducted of the back food storage room. Two dented cans were observed on the food shelf in the storage room. The [NAME] 055078 Page 16 of 24 055078 12/17/2021 Parkway Hills Nursing & Rehabilitation 7760 Parkway Drive LA Mesa, CA 91942

F 0812 Level of Harm - Minimal harm or potential for actual harm stated, These cans shouldn't be here. Dented cans should be on a separate cart with a Do not use sign. The [NAME] further stated, We're supposed to return them or throw them out. There is a chance the food in dented cans are contaminated. The 2017 Federal FDA Food Code reference was reviewed. The reference stated the following: Residents Affected - Few Storage of personal items: 6-305.11 (B)-Lockers or other suitable facilities are to be provided for the storage of employee personal possessions. Dented cans: 3-1-1.11 Food is to be safe and unadulterated. 3-101.11 (Annex)- According to the FDA, dented, pitted, and rusted cans can potentially be a serious hazard. 3-202.15 (Annex)- damaged cans may allow the entry of bacteria or other contaminants and must be returned. 3-202.15- Food packages are to be in good condition and protect the integrity of the food and not exposed to adulteration or potential contaminants. Ready-to-Eat food storage: 3-302.11- Food is to be protected from cross contamination by separating raw animal foods during storage preparation, holding and displaying from ready-to-eat food (raw and cooked). 055078 Page 17 of 24 055078 12/17/2021 Parkway Hills Nursing & Rehabilitation 7760 Parkway Drive LA Mesa, CA 91942

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain accurate physician's progress notes for one of one sampled resident (23). This failure had the potential for Resident 23 to receive inaccurate treatments and wrong medical information. Findings: Resident 23 was admitted to the facility on [DATE] with diagnoses which included muscle weakness, cognitive (thinking) communication deficit, and hemiplegia and hemiparesis (one side of the body paralyzed) per the facility's admission Record. Resident 23's clinical record was reviewed. Resident 23's three pages of physician's progress notes dated April 2021 indicated a different resident's name on the first two pages. The progress notes contained resident's history of present illness, review of systems, exam, and data review. In addition, the physician progress notes contained assessment, plans, and goals. On 12/20/21 at 10:34 A.M., a joint interview was conducted with the ICP and the RMRC. The ICP stated the physician's progress notes were in Resident 23's chart and did not know how long it had been there. The ICP stated the first two pages were for the wrong resident and it should not have been placed in Resident 23's chart. The RMRC stated she did not know how it happened and was not sure who was responsible for checking the resident charts. On 12/20/21 at 11:30 A.M., an interview was conducted with the DON. The DON stated nurses should be checking the documents as part of their routine chart checks. The DON stated no one was assigned to do chart audits because they don't have someone in medical records. 055078 Page 18 of 24 055078 12/17/2021 Parkway Hills Nursing & Rehabilitation 7760 Parkway Drive LA Mesa, CA 91942

F 0867 Level of Harm - Minimal harm or potential for actual harm Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on observation, interview, and record review, the facility failed to identify and consistently maintain a QAPI plan when: Residents Affected - Some A. Current Infection control practice standards were not followed during medication administration and staff screening for COVID-19 (a highly contagious respiratory disease that could affect the entire body); B. Resident room windows were broken and not repaired, non certified for safe use power extension cords were used, and facility generator did not function during power outage; C. Facility staffing coverage not monitored and; D. Two emergency medication kits were not properly secured and accounted for. This failure had the potential to affect the safety, quality of life and care of all the residents in the facility. See F880, F584, F725, and F761. Findings: On 12/21/21 at 7:45 A.M., an interview was conducted with the SSD. The SSD stated she was not aware of any QAPI projects in the facility. The SSD stated, I was handed a paper yesterday indicating I was the project lead for anti-psychotic medication. On 12/21/21 at 8:19 A.M., an interview was conducted with LN 41. LN 41 stated she did not know what QAPI meant. On 12/21/21 at 8:30 A.M., an interview was conducted with CNA 43. CNA 43 stated she did not know what QAPI meant or knew of any projects that the facility was doing. On 12/21/21 at 8:43 A.M., an interview was conducted with the HSK. The HSK stated she had never heard of QAPI or attended any meeting. On 12/21/21 at 8:58 A.M., an interview was conducted with the OT. The OT stated there were no current QAPI projects at the facility. On 12/21/21 at 9:01 A.M., an interview was conducted with the COTA. The COTA stated he did not heard of any QAPI projects since he started working in the facility, 8 months ago. On 12/21/21 at 12:05 P.M., a joint interview and record review of the facility's QAPI plan was conducted with the ADM, DON, ICP, and facility's Regional Consultant. The ADM stated the QAPI committee included himself, the Medical Director, DON, the facility's department directors and they met every month and quarterly. The facility's QAPI binder contained meeting minutes from April, May, June, July, and November 2021 055078 Page 19 of 24 055078 12/17/2021 Parkway Hills Nursing & Rehabilitation 7760 Parkway Drive LA Mesa, CA 91942

F 0867 and did not address the issues stated above. Level of Harm - Minimal harm or potential for actual harm The facility's document titled Quality Assurance Performance Improvement Plan indicated, . The facility leadership team, including the administrator and director of nurses are responsible and accountable for developing, leading, and closely monitoring the QAPI program . The Committee maintains a QAPI manual that contains meeting minutes, PIP's (Performance Improvement Projects), and data analysis reports. Residents Affected - Some The facility's document titled Quality Assurance Performance Improvement Plan indicated, . The plan was established on October 2021. The Plan will be reviewed in an annual basis and as needed . 055078 Page 20 of 24 055078 12/17/2021 Parkway Hills Nursing & Rehabilitation 7760 Parkway Drive LA Mesa, CA 91942

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility did not maintain proper infection control practices based on current standards when: Residents Affected - Some A. Two staff members (CNA 11, CNA12) did not screen for COVID-19 prior to clocking in for work; B. Staff did not properly sanitize medical equipment and did not perform hand hygiene between residents during medication administration (LN 19, LN 41, LN 44). These failures to ensure proper infection control practices based on current standards had the potential to spread infection in the facility. Findings: A. Upon entering the front entrance of the facility on 12/14/2021 at 8:47 A.M., instructions were given by facility staff to check temperature and answer screening questions on an electronic tablet. On 12/15/2021 at 7:20 A.M., two staff members were observed entering a side gate of the facility from the parking lot, instead of the front entrance. On 12/16/2021 at 8:30 A.M., an interview was conducted with the ICP. The ICP stated all staff members are required to screen for COVID-19 at the front entrance of the facility prior to clocking into work. The ICP stated an in service on the screening process was given to staff members on 12/15/2021. On 12/17/2021 at 7 A.M., CNA 11 was observed entering the side gate of the facility from the parking lot. On 12/17/2021 at 7:07 A.M., CNA 12 was observed entering the side gate of the facility from the parking lot. On 12/17/2021 at 2:10 P.M., an interview was conducted with CNA 12. CNA 12 stated she clocks into work and then screens. CNA 12 stated the screening process started a few months ago but cannot recall if there was an in service. She stated someone from the company who set up the tablet showed her how to use it. On 12/17/2021 at 2:55 P.M., an interview was conducted with CNA 11. CNA 11 stated she screens at the front entrance and then clocks in. She stated she was in serviced on how to use the tablet by the people who installed it. A review of the facility's screening sheets, and time adjustment request forms dated 12/17/2021 was conducted. According to CNA 11's time adjustment request form, CNA 11 clocked in at 7 A.M. and screened at 7:05 A.M. According to CNA 12's time adjustment request form, CNA 12 clocked in at 7 A.M., the screening sheet did not list CNA 12's name. 055078 Page 21 of 24 055078 12/17/2021 Parkway Hills Nursing & Rehabilitation 7760 Parkway Drive LA Mesa, CA 91942

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 12/21/2021 at 1:25 P.M., an interview was conducted with the DON. The DON stated all staff members need to screen first before going to the back of the facility to clock in. The DON stated, It's important to screen first because a staff might have symptoms that they were not aware of. Per the facility's policy titled, Coronavirus Disease 2019 (COVID-19) Plan for [name of facility] dated, September 2021 was reviewed. The policy indicated, Due to the higher risk of severe illness and death from COVID-19 among elderly persons and those with chronic medical conditions, the facility has developed policies for the safe care and treatment of residents with COVID-19 .Infection Prevention and Control . The facility screens, including temperature checks, and documents every individual entering the facility (including staff) for COVID-19 symptoms. B. On 12/16/21 at 8:34 A.M., a medication administration observation was conducted with LN 41. LN 41 was observed not doing a hand hygiene before and after administering medications to a resident. LN 41 was observed using a wrist blood pressure (BP) monitor on a resident without sanitizing the equipment before and after use. LN 41 was interrupted before proceeding with the medication administration. On 12/16/21 at 8:59 A.M., an interview was conducted with LN 41. LN 41 stated she forgot to do hand hygiene and sanitize the BP monitor. The BP monitor was observed in LN 41's front scrub pocket. On 12/16/21 at 9:15 A.M., a medication administration observation was conducted with LN 44. LN 44 was observed dispensing medications without performing hand hygiene. LN 44 then proceeded to enter a resident's room with a BP monitor without sanitizing the equipment. LN 44 was interrupted before proceeding with the medication administration. LN 44 stated she forgot to sanitize her hands then stated, I should have. LN 44 further stated that she did not sanitized the BP cuff and only did it, Every two residents. On 12/16/21 at 9:33 A.M., an interview was conducted with the ICP. The ICP stated that LNs are expected to do hand hygiene before and after medication administration. The ICP further stated that BP monitors should be sanitized before and after resident use. B. On 12/20/21 at 9:46 A.M., a medication administration observation was conducted with LN 19. LN 19 was observed to be placing a wrist BP monitor on Resident 19's wrist in the resident's room. LN 19 placed the wrist BP monitor on the medication cart without sanitizing. On 12/20/21 at 9:46 A.M., an interview with LN 19 was conducted. LN 19 stated she did not wipe the wrist BP monitor with every resident use because she did not want the BP monitor to get wet. On 12/20/21 at 3:17 P.M., an interview with the DON was conducted. The DON stated she expected the nurse to clean and sanitize the BP monitor between each resident use. The facility's policy titled, Infection Prevention Quality Control Program, revised February 2021,was reviewed. The policy indicated, 1. The infection prevention and control program is developed to address the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment .The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures/surveillance, data analysis prevention infection and employee health and safety .d. the committee meets regularly at least quarterly, 055078 Page 22 of 24 055078 12/17/2021 Parkway Hills Nursing & Rehabilitation 7760 Parkway Drive LA Mesa, CA 91942

F 0880 and consists of team members across disciplines. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 055078 Page 23 of 24 055078 12/17/2021 Parkway Hills Nursing & Rehabilitation 7760 Parkway Drive LA Mesa, CA 91942

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some 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 and review of the Client Accommodations Analysis (document with measurements of the square footage of the useable living space of individual resident rooms and approved capacities), the facility failed to provide the minimum of 80 square feet (sq. ft.) per resident in 4 of 28 resident rooms. Findings: The facility's Analysis of Accommodations was reviewed. Resident rooms [ROOM NUMBERS] each accommodated two resident occupancy providing 143 total square feet of space per room. Each room provided 71.5 of sq. ft. per resident. Resident room [ROOM NUMBER] accommodated three residents, providing a total of 221 sq. ft. of room space with 73.66 sq. ft. of room space per resident. Resident room [ROOM NUMBER] accommodated four resident occupancy providing a total 304 sq. ft. per room with 76 sq. ft. per resident. The variations in room size requirements are not observed to adversely affect the resident's health, safety, quality of care or quality of life during the survey. The Department recommends continuance of the room size variance/waiver for Rooms 2, 4, 6 and 21. 055078 Page 24 of 24