Inspection·December 2, 2021

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of clinical records and facility documents, the facility failed to ensure one resident (Resident 68) maintained acceptable parameters of nutritional status when the facility did not carry out the recommendations from the IDT meeting. Residents Affected - Few This failure had the potential to result in the resident not maintaining her weight which can further compromise her nutritional and medical status. Findings: Weight loss in nursing home residents is linked to poor out comes, including higher rates of hospitalization and death (American Journal of Nursing, 2008). Centers for Medicare/Medicaid (CMS) suggest the following parameters for evaluating undesired weight loss. A loss of 5% (percent) after 1 month; 7.5% within 3 months and 10% within 6 months is considered significant. Weight loss greater than the described parameters are suggestive of severe weight loss (Centers for Medicaid/Medicare (CMS), Appendix PP, 2017). Additionally, insidious weight loss is defined as a gradual, unintended, progressive weight loss over time (CMS, Appendix PP, 2008). During a review of Nutrition Care of the Older Adult from the Academy of Nutrition and Dietetics, dated 2016, indicated the goal of Medical Nutrition Therapy is to maintain or restore the individual's usual body weight. During a review of facility policy and procedure titled Tracking Weight Changes, dated 2014, indicated the care team will review and document on all insidious and significant weight changes with appropriate referrals to the physician and RD. The RD will make referrals and take actions as necessary. During a review of facility Policy on fortification, dated February 2020, indicated the use of a fortification program to maintain or enhance the nutritional status of residents determined to be at risk by a qualified individual. It further indicated the facility will ensure a fortification program is initiated when there is a nutritional problem to increase caloric intake and better meet individual nutritional needs. During a lunch dining observation on 11/29 at 1:10 pm, and concurrent review of Resident 68's lunch tray ticket showed the resident was on SB6 Fort (Small & bite sized fortified) diet and a house supplement. Resident 68 stated she did not like the food provided however had not informed any staff at the facility. Surveyor observed Resident 68 ate 50% of the lunch meal. During a review of Resident 68's clinical record indicated: Resident 68 was admitted on [DATE] with diagnoses that included Urinary Tract Infection (an infection in any part of your urinary system - kidneys, ureters, bladder and urethra) and chronic kidney disease (kidneys are damaged and can't filter blood the way they should). admission diet order was a regular diet. admission weight was 146 pounds. Weight dated 2/1/21 was 151 pounds. Physician's orders dated 2/12/21 initiated a fortification, regular diet. A Comprehensive Nutrition assessment dated [DATE], RD 2 documented Resident 68's estimated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055079 If continuation sheet Page 2 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055079 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission View Health Center 1425 Woodside Drive San Luis Obispo, CA 93401 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nutritional needs as 1715 calories and 54 to 68 grams of protein. RD 2 documented current body weight as 151 pounds, with an average oral intake of 56% of the fortified diet, in addition to occasional snacks. RD 2 documented intakes were meeting estimated needs as evidenced by stable weight, intact skin, and no edema (swelling caused by excess fluid in the tissues). Based on the nutritional analysis of the facility's meal fortification plan, Resident 68 would need to eat approximately 70% of her meals to meet her estimated nutritional needs. Review of Resident 68's weight record dated 3/1/21 documented a weight of 139 pounds, a loss of 12 pounds (7.9%) in one month which is considered severe. From 3/8 through 8/2/21, Resident 68's weight fluctuated between 131 and 138 pounds. On 9/6/21 Resident 68's weight was documented as 128 pounds, a decrease of 4 pounds. Resident 68 continued to have a gradual continual monthly decline. On 11/1 the weight was documented as 122 pounds for a total weight loss of 29 pounds (19%) in nine months, and 15 pounds (10.9%) in six months, which is considered significant. Cross Reference F641. During Weight and Skin Committee Reviews dated 3/4 and 4/8, the Interdisciplinary Team (IDT) documented recommendations for Resident 68 to receive a house supplement (liquid nutrition supplement) twice a day with meals, and HCMP (High Calorie Med Pass - 2 calories per ml oral nutrition supplement) two ounces (60 ml) twice a day, respectively. Quarterly Nutrition assessment dated [DATE], RD 2 documented Resident 68's current weight as 137 pounds with estimated needs of 1557 to 1869 calories and 62 to 74 grams (g) protein. RD 2 re-estimated Resident 68's nutrition needs based on current weight rather than her usual body weight. RD 2 documented to continue with current plan of care with goal of weight maintenance, rather than to regain lost weight. A Weight and Skin Committee Review dated 6/10/21, RD 1 documented current weight as 132 pounds a five pound/3.6% weight loss for one month. RD 1 documented there was a new open area under the resident's breast from scratching and wound was nonhealing so far. RD 1 recommended to increase HCMP to three ounces (90 ml) three times a day and to start a Multivitamin (MVI) for healing. Review of physician's orders dated 6/9/21, indicated HCMP 90 ml oral twice a day. Although the HCMP order was increased in quantity it was not increased in frequency as recommended by RD 1 during the Weight and Skin Committee Review notes. Weight and Skin Committee Reviews dated 6/17, 6/24, 7/1 and Quarterly Nutrition assessment dated 8/9 and 11/3/21, there was no documentation to indicate the error was identified. During an interview with RD 1 and RD 2 on 12/01/21 at 11:10 AM, RD 1 and 2 stated they see residents who trigger for weight loss of 5% or 5 pounds monthly, 2.5% weekly weights, 7.5% weight for 3 months, and 10% for 6 months. RD 1 stated the order on 6/10/21 should have been for HCMP three times a day not twice a day. RD 1 stated we usually double check the order in the system to ensure it is consistent with what we recommended. RD 1 confirmed that order was missed on Resident 68. During an interview with RD 1, RD 2, and RD3 on 12/01/21 at 2:38 PM, RD 2 stated they follow up with the monthly weight and if does not trigger for significant weight loss then they think the intervention is working. RD 2 stated if the weight is triggered again then they will check the chart to see how the intervention is working. The RD's practice of not monitoring insidious weight loss was not in accordance with the facility weight tracking policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055079 If continuation sheet Page 3 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055079 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission View Health Center 1425 Woodside Drive San Luis Obispo, CA 93401 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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. Based on interview and record review, the facility failed to ensure one of 5 sampled residents (Resident 6), documentation on the informed consent for psychotropic medication included the specific medication name, dosage, route, and diagnosis/reason for use. For Resident 6, this facility failure resulted in their representative consenting to an unspecified treatment on their behalf. Findings: During a review of the facility's policy and procedure (P&P) titled, [Facility name] Verification of Informed Consent for Psychotherapeutic Medication or Physical Restraint, (undated), the P&P indicated, .the facility has verified that the following material information has been reviewed with the resident and/or the resident's responsible party or legal representative .medication name, dosage, route and diagnosis/reason for use . During a review of Resident 6's Physician Order Sheet (Orders), dated November 2021, the Orders indicated, Quetiapine (antipsychotic medication) 50 mg (milligram) tablet (50mg) TABLET Oral (by mouth) .One time daily . During a concurrent interview and record review on 11/30/21, at 9:26 a.m., with a licensed nurse (LN1), Resident 6's [Facility name] Verification of Informed Consent for Psychotherapeutic Medication or Physical Restraint (Consent), dated 5/14/21 was reviewed. The Consent indicated, on 5/14/21, at 3:44 p.m., the consent was obtained and verified with Resident 6's Representative. The Consent also indicated, the Physician's Order for the specific medication, dosage, route, and diagnosis/reason for use was not documented on the form. LN1 stated, The medication, dosage, and route should be identified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055079 If continuation sheet Page 4 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055079 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission View Health Center 1425 Woodside Drive San Luis Obispo, CA 93401 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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 expired medications were not stored and available for staff use, in one of four medication carts inspected. These failures had the potential for unsafe and ineffective medication administration that can cause harm to the residents. Findings: During a concurrent interview, and inspection of the facility's medication carts, on 11/30/2021 at 3:30 p.m., with the Director of Nursing (DON) and the Director in Training (DIT), the following items were observed: 1. Fiber therapy, dietary fiber supplement, 52 teaspoon doses, net weight (wt) 13 ounces (oz), 368 grams (g), with an expiration date of 10/21. 2. Geri-Lanta, regular strength antacid, anti-gas, 12 fluid (FL) ounces (oz), 355 milliliters (ml), with an expiration date of 9/21. 3. Hydroco/apap (medication to treat pain) tablets 5-325 milligrams(mg) pack, with an expiration date of 11/4/2021. During the concurrent interview with the DIT, the expired items were shown to him. The DIT stated, Yes they are expired. The items were then shown to the DON. The DON stated, Yes they are expired. We should of caught the expired medications prior to the expiration and removed them. During a review of the facility's policy and procedures (P&P), titled, Disposal of Medications, undated, the P&P indicated, in part, Outdated, contaminated, discontinued or deteriorated medications, and the contents of containers with no label shall be destroyed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055079 If continuation sheet Page 5 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055079 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission View Health Center 1425 Woodside Drive San Luis Obispo, CA 93401 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interviews and review of facility documents the facility failed to maintain kitchen equipment in safe operating condition when the reach in refrigerator door contained a torn gasket and there was no air gap on the food preparation sink when the pipe was directly plummed into the wall. Residents Affected - Some These failures have the potential for the refrigerator to not maintain a safe temperature for food as a torn gasket can allow warm air to get into the refrigerator and lack of an air gap can lead to a backflow of sewage into the food preparation sink. The facility census was 93. Findings: 1. During the inital kitchen tour on 11/19/21 starting at 9:16 AM, an observation of the reach-in refrigerator was 42 degrees Fahrenheit (F) and on the center refrigerator door the gasket was torn. During an observation and concurrent interview with the Maintanence Director (MD) on 11/29/21 at 3:19 PM, the reach-in refrigerator door with torn gasket was shown to the MD. MD stated once a month he cleans the condensing coils however not routine to check gaskets on the doors. MD stated he relies on Kitchen staff to tell him if gaskets need to be replaced. During an interview on 12/01/21 at 11:10 AM with Registered Dietitians (RD 1, RD 2, RD 3), RD 1 stated she conducts kitchen audits on Fridays. RD 1 stated she does monthly in-depth kitchen inspections and explained the items on the inspections. RD 1 stated she has not checked gaskets on the refrigerator doors during her inspections. 2. During an observation and concurrent interview with the Maintanence Director (MD) on 11/29/21 at 3:19 PM, the food preparation sink showed the pipe was directly plummed into the wall. MD confirmed there was no air gap for this sink and that is directly plumbed into the wall. According to standards of practice within the foodservice industry, an air gap between the water supply inlet (drain pipe) and the flood level rim of the plumbing fixture (floor sink drain), equipment or non-food equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch. During periods of extraordinary demand, drinking water systems may develop negative pressure in portions of the system. If a connection exists between the system and a source of contaminated water during times of negative pressure, contaminated water may be drawn into and foul the entire system. (2017 FDA Food Code) According to the 2017 Food and Drug Administration (FDA) Food Code, Section 5-202.13 Backflow Prevention, Air Gap, indicated an air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonFood equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch). During the review of the facility policy and procedure titled Maintenance, undated, indicated the policy was established to ensure the facility provides a safe, functional, sanitary and comfortable environment for residents, staff and the public. It indicated the Administrator and Maintenance Supervisor will inspect facility and equipment monthly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055079 If continuation sheet Page 6 of 6