Health inspection·April 26, 2019

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 one of 18 sampled residents (4) was assisted with feeding in a respectful manner. This failure had the potential to negatively impact Resident 4's self-esteem. Findings: Resident 4 was admitted to the facility on [DATE] with diagnoses, which included heart failure and palliative (comfort) care, per the facility's Resident Face Sheet. On 4/24/19 at 7:46 A.M., Resident 4 was observed sitting up in bed with a breakfast tray in front of her. Standing on the left side of the bed, was a staff member feeding the resident with a fork. The staff member was standing over Resident 4, approximately two feet higher than the resident's head and they were not positioned at eye level. On 4/24/19 at 7:48 A.M., an interview was conducted with CNA 23. CNA 23 stated she should not have been standing over Resident 4 while feeding her. CNA 23 stated she needed to be at eye level with the resident and she should have been sitting next to the resident, while feeding. On 4/24/19 at 9:47 A.M., an interview was conducted with the DSD. The DSD stated staff should always be at eye level when assisting residents with meals, and it was a dignity issue. The DSD stated no formal training had been provided to staff over the past year on how to properly assist residents with meals. On 4/25/19 at 8:34 A.M., an interview was conducted with DSDA. The DSDA stated staff needed to be at eye level when assisting residents with meals, because it showed respect to the resident. On 4/25/19 at 9:57 A.M., an interview was conducted with the DON. The DON stated staff should always be at eye level while assisting residents with meals, for dignity purposes. Per the facility's policy, dated August 2009, titled Quality of Life-Dignity, .11. Staff shall promote dignity and assist residents as needed by: .b. Assisting resident with the activities of daily living . Page 1 of 23 055335 055335 04/26/2019 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0685 Assist a resident in gaining access to vision and hearing services. 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 implement the use of a hearing aid for one of three residents (66) with impaired hearing. Residents Affected - Few As a result, there was a potential for Resident 66 to experience decreased socialization and isolation. Findings: Resident 66 was admitted to the facility on [DATE], with chronic obstructive pulmonary disease (a lung disease that affects gas exchange), per the facility's Resident Face Sheet. On 4/23/19 at 2:29 P.M., during the initial tour of the facility, an interview was conducted with LN 21. LN 21 stated Resident 66 was hard of hearing in her right ear. LN 21 stated staff had to speak loudly on Resident 66's left side, to be heard. LN 21 stated the facility was waiting to get hearing aids for the resident. According to Resident 66's quarterly MDS, dated [DATE], Section B, 0200 titled Hearing, was coded as a 1 to indicate Resident 66 had minimal difficulty hearing. According to Resident 66's care plan, dated 4/11/19, titled Communication, .Right hearing aid received 4/11/19 . According to the facility's nursing note, dated 4/12/19 at 11:23 P.M., .hearing aid box empty and hearing aid is not with resident .yesterday a hearing aid was on the floor of the resident's room .hearing aid given to supervisor last night and found in supervisors drawer . On 4/24/19 at 4:25 P.M., an observation and interview was conducted with CNA 24. CNA 24 stated she did not know where Resident 66's right hearing aid was. CNA 24 stated she did not believe Resident 66 had any hearing aids. CNA 24 checked the resident's bedside dresser and no hearing aid container could be located. On 4/24/19 at 4:29 P.M., an interview was conducted with the SSD. The SSD stated she had been keeping Resident 66's hearing aid in her office since 4/12/19, since it was almost lost. The SSD stated she had been trying to figure out how to best introduce the hearing aid to the resident after it was found on the floor. The SSD stated she had not documented or informed anyone that Resident 66's hearing aid was being kept in her office until she could come up with a plan. The SSD further stated she had not discussed any implementation plans with the LNs or the DON on how they could get the resident to use the hearing aid. The SSD stated she should have documented on the Resident 66's care plan where the hearing aid was kept. On 4/24/19 at 4:40 P.M., an interview was conducted with the DON. The DON stated a plan of care should have been initiated to communicate to all staff on the acclimation of Resident 66's hearing aid. The DON stated it should have been documented who would put the device in, for how long, and who would remove the device for safe keeping. 055335 Page 2 of 23 055335 04/26/2019 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0685 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 4/25/19 at 8:23 A.M., an interview was conducted with CNA 24. CNA 24 stated Resident 66 was hard of hearing, so staff needed to speak loudly to her. CNA 24 stated, she was unaware if Resident 66 had hearing aids. On 4/25/19 at 8:30 A.M., an interview was conducted with CNA 25. CNA 25 stated Resident 66 was hard of hearing, so staff needed to be face to face when they spoke with her. CNA 25 stated Resident 66 did not have any hearing aids. On 4/25/19 at 8:35 A.M., an interview was conducted with DSDA. The DSDA stated a hearing aid was important for Resident 66, so she could hear what people were saying and know what was going on around her. According to the facility's policy, dated February 2018, titled Hearing Impaired Resident, Care of, .3. Staff will assist with care and maintenance of hearing devices: a. Assess the resident's .tolerance of wearing a hearing aid . 055335 Page 3 of 23 055335 04/26/2019 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 accurately assess the skin for one of 18 sampled residents (42). Residents Affected - Few In addition, Resident 42's care plan was not revised when the resident's skin was reassessed by the physician and the skin issue was resolved. This inaccurate skin assessment and failure to revise the resident's care plan had the potential for confusion and miscommunication among staff and affect Resident 42's care. Findings: Resident 42 was admitted to the facility on [DATE] with diagnoses, which included colostomy (a surgical procedure that brings the large intestine out via the abdomen for bowel waste), and obstructive reflux uropathy (instead of flowing into the bladder the urine flows back to the kidneys), per the facility's Resident Face Sheet. This document also indicated Resident 42 was her own responsible party. During an interview with Resident 42 on 4/23/19 at 9:13 A.M., the resident stated she had a surgical wound on her abdomen that had been slow to heal, and she received daily wound treatments. During an interview with WN 1 on 4/23/19 at 12 P.M., WN 1 stated Resident 42 had a dehisced surgical wound (an opening of a surgical wound), that was nearly healed, but had no pressure ulcers. During a wound treatment observation on 4/23/19 at 3:34 P.M., a round pink wound that measured approximately two by three centimeters was observed on Resident 42's lower abdomen. A colostomy bag was secured in place on Resident 42's left upper abdomen, a clean and intact dressing was in place over the left nephrostomy tube (a tube coming out of the kidney) on the resident's left flank, draining yellow urine into the collection bag. Resident 42's coccyx (tail bone) and sacral area (area above the tail bone) was covered with a brief and was not observed. 1. According to Resident 42's nursing progress note, dated 3/16/19, the resident was noted to have a Stage III wound (pressure ulcer where there is full thickness skin loss with fat visible) on her coccyx and a deep tissue injury (DTI), maroon in color on her sacrum. According to Resident 42's nursing progress note titled Skin Note, dated 3/18/19, the resident was assessed by the wound physician. This note indicated, .Sacral wound was diagnosed with shearing sacral wound vs (versus) pressure ulcer . discolored slightly north of the wound which is also part of the skin shearing (when layers of skin rub together or skin remains stationary and underlying tissue moves or tears blood vessels and causes tissue damage) . According to two separate nursing progress notes, dated 3/19/19, .tx (treatment) to Coccyx/sacrum DTI area . According to an IDT progress note, dated 4/9/19, Resident 42's coccyx and left buttock shearing wound was showing signs of healing. According to an IDT Skin Note, dated 4/17/19, .Shearing wound to coccyx and sacrum . Continues to 055335 Page 4 of 23 055335 04/26/2019 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0686 improve this past week . Level of Harm - Minimal harm or potential for actual harm During an interview with WN 2 on 4/25/19 at 1:46 P.M., WN 2 stated she identified a wound on Resident 42's coccyx and sacrum on 3/16/19 while providing care. WN 2 stated she documented the wound as a Stage III pressure ulcer on the coccyx and a DTI above it on the sacrum. WN 2 stated the wound physician assessed the resident on 3/18/19 and diagnosed the wounds as skin shearing. WN 2 stated the observation event she created when she identified the wound should have been updated to reflect the diagnosis of skin shearing that was made by the physician on 3/18/19, in order to accurately reflect Resident 42's wound. Residents Affected - Few During an interview with the DON on 4/25/19 at 2:23 P.M., the DON stated it was crucial to identify skin breakdown by describing it accurately, so that treatments were appropriate and current for the care of the resident. 2. A review of Resident 42's records, indicated two active care plans related to the resident's coccyx and sacral wounds. According to one of Resident 42's care plan, dated 3/19/19, .Has a pressure ulcer site: sacrum DTI . According to another of the resident's care plan, dated 3/19/19, .Resident was noted with skin shearing to her coccyx area . During an interview with WN 2 on 4/25/19 at 1:46 P.M., WN 2 stated both of the care plans should have been resolved. WN 2 stated the care plan that indicated Resident 42 had a DTI should have been revised to reflect the updated assessment and diagnoses of the wound physician on 3/18/19. WN 2 further stated Resident 42's wound had healed last week and the care plan should have been resolved once the wound was healed. During an interview with the DON on 4/25/19 at 2:23 P.M., the DON stated care plans needed to be accurate to reflect the actual care of the residents. The DON stated Resident 42's care plan should have been revised when the diagnosis was changed. The DON further stated it was important for care plans to be revised as the resident's wound changed and should have been resolved when the wound was healed. According to the facility's policy titled Pressure Ulcer/Injury Risk Assessment, dated 7/17, .Steps in the Procedure: .4. Conduct a comprehensive skin assessment: .c. If a new skin alteration is noted, it will be documented in the medical record. 5. Develop the resident-centered care plan and interventions based on . the condition of the skin . c. The care plan must be modified as the resident's condition changes . According to the facility's policy titled Care Plans, Comprehensive Person-Centered, dated December 2016, .Policy Interpretation and Implementation: 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . 055335 Page 5 of 23 055335 04/26/2019 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide proper supervision during a shower for one of 18 sampled residents (41). This failure resulted in Resident 41 falling from a shower chair and hitting his head. Findings: Resident 41 was admitted to the facility on [DATE] with diagnoses, which included dementia (a loss of mental abilities that leads to impairments in memory, reasoning, planning, and behavior), per the facility's Resident Face Sheet. According to Resident 41's MDS assessment, dated 2/28/19, the resident's cognitive skills were severely impaired. This assessment also indicated Resident 41 was totally dependent with bathing, requiring two-person assistance. On 4/23/19 at 8:55 A.M., Resident 41 was observed lying on his right side in bed. The resident's bed was in the lowest position. During an interview with Resident 41's family member (FM) on 4/23/19 at 9:09 A.M., the FM stated the resident fell while in the shower a few months ago. Resident 41's FM stated she heard a crash in the shower, and when the staff let her in she saw the resident on the shower room floor with the shower chair across the room from where Resident 41 was lying on the floor. According to Resident 41's care plan, dated 12/18/15, the resident was at risk for falls. During an interview with CNA 10 on 4/25/19 at 9:40 A.M., CNA 10 stated she worked as the shower aide doing resident showers, and as a CNA on the unit. CNA 10 stated when giving a shower to a resident, she always assembled the supplies she needed in the shower room and placed them within reach, prior to taking the resident to the shower. CNA 10 stated she always faced the resident and did not turn away from the resident any time during the shower. During an interview with CNA 11 on 4/25/19 at 4:02 P.M., CNA 11 stated he would never leave a resident or turn away from them while in the shower room. CNA 11 stated if he forgot something, or if it was not in reach he would call for help. According to Resident 41's IDT Notes, dated 2/2/19, the resident was at risk for falls and was found on the floor of the shower room on 2/2/19. This document also indicated the resident was sitting in the shower chair prior to the fall, and when the CNA turned to reach for a towel Resident 41 leaned forward and fell, hitting his head against the wall. During an interview with CNA 12 on 4/26/19 at 9 A.M., CNA 12 stated if a resident was aggressive or they were concerned about falls, they would have two CNAs during the shower. CNA 12 stated she always faced the resident during a shower, gathered all needed supplies, and put them within reach, prior to bringing any resident into the shower room. CNA 12 stated if she forgot something she would call for help. 055335 Page 6 of 23 055335 04/26/2019 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with the DSDA on 4/26/19 at 9:17 AM, the DSDA stated she shared responsibility for training staff with the DSD. The DSDA stated CNAs were trained to have all the supplies they needed for the shower before the resident was taken to the shower room, so that they did not have to leave the resident. The DSDA also stated the CNAs were instructed to call for help if they forgot something and to always stay in front of the resident and face them to ensure they did not fall. The DSDA stated she did one-on-one training regarding shower safety with the CNA (13) caring for Resident 41 when he fell. The DSDA stated Resident 41's fall was avoidable because CNA 13 had told her she had turned away from the resident to get a towel when Resident 41 fell. During an interview with the DON on 4/26/19 at 10:36 A.M., the DON stated he expected staff to keep residents safe during showers. The DON stated he expected CNAs to be trained in resident safety and to stay present with residents and to call for help when needed. During an interview with CNA 13 on 4/26/19 at 2:34 P.M., CNA 13 stated after she finished Resident 41's shower, she turned her back to the resident to grab the towel. CNA 13 stated Resident 41 fell out of the shower chair while her back was turned. CNA 13 stated she called for help once the resident was on the floor. CNA 13 stated, It was a mistake, I should have put it (towel) on another shower chair or somewhere I didn't have to reach for it. According to a document titled, Corrective/Disciplinary Action Form, dated 2/6/19, .on 2/2 (CNA 13) was giving a resident a shower, she could not reach the towel so she walked away from the patient to grab it. At this time the patient fell hitting his head and knees . During an interview with the DON on 4/26/19 at 2:45 P.M., the DON stated the CNA should have been educated on shower safety prior to the incident to avoid the resident's fall. According to the facility's policy titled Falls and Fall Risk, Managing, dated 3/18, Policy Statement: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling . According to the facility's policy titled Shower, dated May 2018, .General Guidelines: .3. Stay with the resident throughout the bath. Never leave the resident unattended in the shower. 4. Use the emergency call signal to summon assistance, if needed . 055335 Page 7 of 23 055335 04/26/2019 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on interview and record review, the facility failed to provide evidence of nursing staff competencies (evidence the nursing staff had the knowledge and skills required for their role) for three of three LNs (1, 2, and 3). As a result, there was the potential for resident care to be compromised due to the lack of knowledge and skills of the nursing staff. Findings: On 4/24/19 at 4:30 P.M., an interview was conducted with LN 1. LN 1 was unable to demonstrate he had the knowledge to care for a resident returning from dialysis. On 4/25/19 at 3:37 P.M., an interview was conducted with LN 2. LN 2 was unaware of her responsibilities for the care of a resident returning from dialysis. According to LN 1's employee file, LN 1 was hired on 10/10/17. Per the New Employee Orientation Checklist, the box for LN Skills Checklist was blank. There was no evidence of nursing competencies within LN 1's employee file. According to LN 2's employee file, LN 2 was hired on 5/17/16. Per the New Employee Orientation Checklist, the box for LN Skills Checklist was blank. There was no evidence of nursing competencies within LN 2's employee file. According to LN 3's employee file, LN 3 was hired on 6/28/18. Per the New Employee Orientation Checklist, the box for LN Skills Checklist was blank. There was no evidence of nursing competencies within LN 3's employee file. On 4/26/19 at 10:05 A.M., an interview was conducted with the DON. The DON stated, before LNs were permitted to care for residents, they were given competency training or testing to ensure they were competent. The DON stated, all LNs were expected to know what to do when a resident returned from dialysis. On 4/26/19 at 10:53 A.M., an interview was conducted with the DSDA. The DSDA stated, nursing competencies were kept in each employee's file, and LN 1's skills checklist should have been completed, but the facility was behind on checking off nursing competencies. The DSDA stated, LN 2's skills checklist was not completed and her competencies were not up to date. On 4/26/19 at 1:21 P.M., an interview was conducted with the DON. The DON stated, he was unable to locate nursing competencies for LN 1, LN 2, or LN 3. According to the facility's policy, titled Competency of Nursing Staff, revised October 2017, . licensed nurses . employed (or contracted) by the facility will: . b. demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents .5. Facility and resident-specific competency evaluations will be conducted upon hire within 90 days, annually and as deemed necessary based on the facility assessment 055335 Page 8 of 23 055335 04/26/2019 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0760 Ensure that residents are free from significant medication errors. 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 administer a PRN (as needed) medication for constipation per the physician's order for one of two residents (4), reviewed for constipation. Residents Affected - Few As a result, Resident 4 experienced abdominal discomfort and an episode of fecal impaction (hardened stool stuck in the rectum) one month prior. This failure also had the potential to cause a bowel obstruction (a blockage of the intestines). Findings: Resident 4 was admitted to the facility on [DATE], with diagnoses which included heart failure and palliative (comfort) care, per the facility's Resident Face Sheet. According to Resident 4's progress notes, dated 3/13/19 at 10:34 P.M., .tried to manually disimpact (removal of feces) pt (patient) as ordered .one, small hard marble-like stool. Noted w/ (with) high impaction. Pt given soap suds enema at this time . According to Resident 4's physician orders, dated 10/8/18, an order for magnesium hydroxide (an oral laxative - a medication to stimulate a bowel movement) once a day, prn for constipation prevention. Bisacodyl suppository (a laxative medication inserted rectally) once a day, prn if magnesium hydroxide ineffective. Enema once a day, prn if suppository ineffective. On 4/25/19 at 1:39 P.M., an observation and interview was conducted with Resident 4. Resident 4 was in bed and an unidentified CNA was at the bedside, preparing to perform personal care. Resident 4 stated she did not feel good and touched her abdomen and stated she had pain. According to Resident 4's Vital Report for bowel movements (BMs), Resident 4 had a small BM on 4/20/19 at 8:15 P.M. As of 4/25/19 at 6:43 A.M., no further BMs were documented. Resident 4's care plan, titled Constipation, dated 10/9/18, Goal: .BM every 1-2 days .Approach: .Administer medications per MD order . According to Resident 4's MAR, oral laxative was administered on 4/22/18 at 6:01 A.M. One suppository was administered on 4/23/19 at 5:51 A.M. The MAR contained no documented evidence an enema was ever administered. According to Resident 4's MAR, Resident 4 verbalized pain on 4/23 and 4/24/19, rating the pain between 3-5 (pain scale 1-10, with 10 being the worst pain). On 4/25/19 at 2:39 P.M., an interview was conducted with LN 21. LN 21 stated Resident 4's last BM was five days ago. LN 21 stated residents should have bowel movements every one to three days and if no BM, then constipation medication should be administered. On 4/25/19 at 2:57 P.M., an interview was conducted with the DSDA. The DSDA stated CNAs were expected to document resident BMs every shift, and inform LNs if the BMs were abnormal. The DSDA stated LNs were expected to administer constipation medication as ordered by their physician. The DSDA stated constipation could cause pain to the resident or possible infection. 055335 Page 9 of 23 055335 04/26/2019 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 4/25/19 at 3:14 P.M., an interview was conducted with the DON. The DON stated a better system was needed to monitor BMs. The DON stated staff were expected to communicate with each other if a resident did not have a BM for two to three days. The DON stated LNs should have administered an enema to Resident 4, after the resident had no BM from the oral laxative or the suppository. On 4/25/19 at 3:37 P.M., a joint interview and record review of Resident 4's MAR was conducted with LN 20. LN 20 stated the oral laxative was administered on day two and a suppository was administered on day three with no BM results. LN 20 stated she did not know why an enema was not administered. On 4/25/19 at 3:47 P.M., an interview was conducted with CNA 26. CNA 26 stated it was important to document and monitor BMs. CNA 26 stated if a resident went two days without a BM, nurses should be notified so medications could be administered. Per the facility's policy, dated September 2017, titled Bowel (lower Gastrointestinal Tract) Management-Clinical Protocol, .3. Bowel management record shall be reviewed .to ensure residents have a bowel movement every 2-3 days 5. Bowel management shall be documented in the medication administration record . 055335 Page 10 of 23 055335 04/26/2019 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on dietetic services staff observation, interviews, and document reviews the facility failed to ensure safe and effective Dietetic Services oversight in accordance with the facility contract. Failure to ensure effective oversight of day to day dietetic services operations could place 88 residents at nutritional risk, and in turn, further compromise their medical status. Findings: During the annual recertification survey from 4/23/19-4/26/19, multiple issues pertaining to dietetic services were unmet and identified in relation to: 1. the evaluation of dietary staff competency (cross reference F802), 2. the oversight and delivery of sanitation, food safety, and food storage in the kitchen (cross reference

F802, 803, 812), and; 3. the overall evaluation of food production in relation to therapeutic diets and menu compliance (cross reference F803). 1. On 4/23/19 at 7:52 A.M., during the initial kitchen tour, an observation and interview was conducted with DSW 1 and DSS. DSW 1 incorrectly demonstrated the method to test sanitizer strength in the red buckets. DSW 1 stated he worked at the facility for a few months. The DSS stated DSW 1 was trained on the correct sanitizer testing process. The in-service records on sanitizer testing in the red buckets were requested for the DSW 1 but not provided. The DSS stated she worked at the facility as the Food service manager for 3 years. On 4/25/19 at 9:00 A.M., an observation and interview was conducted of the dish machine with DSW 1 and DSS. DSW 1 incorrectly demonstrated how to test the correct sanitation level of the dish machine when he dipped a sanitizer test strip in the front drain tank solution, and checked the color. Then DSW 1 dipped another strip inside the machine's middle compartment solution, while it was running, and checked the color strip. DSW 1 then stated the machine was a low temperature machine and wash/rinse temperatures should be between 120 or 130 degrees. DSW 1 further stated he tested the dish machine sanitizer after the breakfast and lunch meals. The DSS stated DSW 1 did not correctly test the sanitizer strength of the machine because he should have used a plate to run the strip through the machine. The DSS further stated the wash/rinse temperature ranges should be 120-150 degrees each. The dish machine manufacturer's guidelines were requested but not provided. 2. On 4/23/19 at 10:51 A.M., during the initial kitchen tour and observation of the walk-in refrigerator, a couple of rotten onions had multiple spots resembling mold were discovered. The DSS stated It's mold, growing referring to the onions. The DSS then stated, Oh, but we could just cut those parts off because they (the onions) could still be used. On 4/23/19 at 3:27 P.M., an interview was conducted with RD 1. RD 1 acknowledged the onions were rotten, and if mold appeared to be growing, they needed to be thrown away. RD 1 stated the onions could have contaminated other food if they were used and residents could have gotten sick. 055335 Page 11 of 23 055335 04/26/2019 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0801 Level of Harm - Minimal harm or potential for actual harm On 4/23/19 at 3:34 PM, during an observation of the dry storage room, several large bags of food items were found with different dates on them including rice and toasted oats cereal. The toasted oats had two open dates on them, 3/24/19 and 4/12/19. The DSS stated the staff had been trained on the dating system and the dates written on food products should have been an open date and use by date. The DSS acknowledged the inconsistent dates on the food items. Residents Affected - Some The food items on the emergency plan menu was reviewed. Food items including cases of three ounce-canned tuna was listed, however the tuna in five ounce pouches were stored in addition to the canned tuna cases. The DSS did not have accurate calculations for a three-day food supply of non-perishable foods listed on the emergency menu. Per facility's document dated July 2017, titled Water and Food Supplies, Emergency, .Food .emergency food supply needed is calculated; 3 days worth .emergency menus . During the kitchen visit on 4/23/19 at 3:34 P.M., dirty utensils were stored with clean utensils in a drawer and wet dishes were stored in dish machine racks underneath a food preparation counter. The DSS further stated she had been working on a more comprehensive cleaning schedule that would identify the employee and task to be completed on a daily basis. 3. On 4/23/19 at 11:31 A.M., an observation and interview was conducted of lunch trayline with CK 1 and the DSS. CK 1 described how she prepared 10 pureed diet servings for the entrée, which did not follow the recipe for the regular lunch entrée of [NAME] Beef Stew. CK 1 stated she worked for the facility for 13 years. DSS acknowledged CK 1 did not follow the recipe for pureed meals. Additionally, during lunch trayline on 4/23/19, 22 residents did not receive appropriate food items for fortified diets. On 4/24/19 at 11:46 A.M., during an observation of lunch tray line, the vegetables on the tray line station were spinach and carrots. In an interview with CK 1, CK 1 stated those were the only vegetables prepared for lunch that day. When the therapeutic menu spreadsheet was reviewed, green beans were listed for the renal diets. There was a resident on a renal diet who received carrots and not green beans for lunch. During an interview with the DSS and RD 2 at 12:46 P.M., the DSS stated she was unaware green beans were on the menu for the day so they were not ordered. The RD stated the green beans should have been served to the residents on a renal diet because they were on the menu. The RD further stated the carrots were an appropriate substitution for the green beans. A review of the RD monthly kitchen sanitation inspection reports for January-March 2019 did not indicate issues or concerns with any of the identified areas including evaluation of kitchen employee competence in foodservice tasks, overall food safety, sanitation, and storage, or adherence to therapeutic menu and recipe guidance. On 4/24/19 at 4:56 P.M., Registered Dietitian (RD 2) was interviewed about her oversight of and involvement in dietetic services operations. RD 2 stated she worked in the facility two days per week and spent about 95 percent of time on clinical nutrition care including new admits and reassessments, and the other five percent on other issues in the dietary department as needed. RD 2 stated RD 1 and the DSS completed the staff in-services, she does them as needed. On 4/26/19 at 11:01 A.M., RD 1 was interviewed about her oversight of and involvement in dietetic services operations. RD 1 stated she worked part-time about three days per week and her typical day involved reviewing weekly weights, attending weekly weight committee meetings, responding to new 055335 Page 12 of 23 055335 04/26/2019 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some admission inquiries, reviewing tube feeding assessments, providing nutritional recommendations to the DON, and completing nutrition consults. The RD stated her primary role was clinical with occasional foodservice operation involvement of about 10-15 minutes during her work day, if time permitted. RD 1 stated her foodservice involvement was limited and mainly included completing the kitchen sanitation checks. RD 1 also stated the kitchen sanitation checks were not reviewed with the Admin. Neither RD 1 or RD 2 mentioned completing a comprehensive evaluation or assessment of foodservice operations including food palatability and meal production, or staff competency assessment audits. Furthermore, when asked about trends of quality assurance controls that have been identified and tracked in the kitchen, RD 1 stated the floors are cracked and needed to be replaced, which was listed on each of the monthly kitchen sanitation reports. RD 2 stated she was unaware of any trends and couldn't think of anything specifically when asked the same question of performance improvement activities. 055335 Page 13 of 23 055335 04/26/2019 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0802 Level of Harm - Minimal harm or potential for actual harm Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and record review, the facility failed to ensure staff for the food and nutrition services department competently carried out kitchen duties in a safe, and sanitary manner when: Residents Affected - Few 1. A staff member was unable to verbalize and demonstrate correct techniques related to testing sanitizer buckets; and 2. A staff member was unable to demonstrate the correct technique for testing the sanitation level on the dishwasher. These practices had the potential for residents to be exposed to food borne illness, due to lack of staff training and monitoring of their duties. Cross reference 801 Findings: 1. On 4/23/19 at 7:50 A.M., an observation and interview was conducted with DSW. DSW demonstrated the testing of a sanitizing solution inside a red bucket. DSW dipped the test strip in the bucket solution for approximately 1-2 seconds. The test strip turned green which indicated the sanitizer solution was at the appropriate level. DSW stated if the test strip turned green, it indicated the sanitizing solution was dirty and it needed to be changed. DSW stated the strip should turn orange-brown. An orange-brown coloring indicated the test strip ranged between 100-200 ppm (parts per million, the concentration of a solution). On 4/23/19 at 7:52 A.M., an interview was conducted with the DSS. The DSS stated she trained DSW on how to test the sanitizer buckets. The DSS stated the correct technique was to hold the test strip in the solution for 10 seconds. The DSS stated the test strip should turn green which indicted 200-300 ppm, which was the correct concentration for the sanitizing solution. On 4/23/19 at 3:34 P.M., a subsequent interview was conducted with the DSS. The DSS stated she could not provide any documented evidence that DSW was trained on the testing of sanitation bucket solutions. Per the facility's policy, dated 2018, titled Sanitation, .2. The FNS (Food and Nutritional Services) Director is responsible for instructing .personnel in the use of equipment. Each employee shall know how to operate and clean all equipment in his specific work area . 2. On 4/25/19 at 9 A.M., an observation and interview was conducted with DSW. DSW demonstrated how to test the dishwasher for the correct sanitation level. DSW stated the water temperature needed to reach 120 degrees Fahrenheit during the sanitation test. DSW dipped a test strip in the solution drain tank in the front of the machine. DSW stated the strip was light purple, which indicated 50-100 ppm, which was, okay. DSW then dipped a test strip inside the machine while it was running. DSW stated the color again was light purple, which meant the sanitation was good. The DSW did not verbalize or demonstrate the test strip should be run through the machine on a plate or other item when testing the sanitizer. 055335 Page 14 of 23 055335 04/26/2019 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few DSW stated he tests the sanitation level after he washed all the dishes and he wrote the water temperatures in a log. The temperature log was reviewed and temperatures for the lunch hours had already been documented along with the breakfast temperatures. On 4/25/19 at 9:15 A.M., an interview was conducted with the DSS. The DSS stated the dishwasher rinse cycle temperature needed to be between 120-150 degrees Fahrenheit. The sanitizer test strip should have been put on a plate or another object during the rinse cycle and not held in the solution. The DSS further stated the sanitation test should be performed before the dishes were washed, to confirm the sanitizer solution was at the correct level. The DSS stated DSW did not use the correct method to test the sanitation levels. The DSS stated DSW should not have recorded the lunch temperatures in the log book, since it was still breakfast time. Per the facility's policy, dated 2018, titled Sanitation, .2. The FNS (Food and Nutritional Services) Director is responsible for instructing .personnel in the use of equipment. Each employee shall know how to operate and clean all equipment in his specific work area . 055335 Page 15 of 23 055335 04/26/2019 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure: Residents Affected - Some 1. The pureed (food blended to the consistency of applesauce or milkshake thick liquid) diet recipe was followed for nine residents; 2. The fortified diet was followed for 22 residents; and, 3. The therapeutic menu was followed for a renal diet. These failures had the potential to provide meals that did not meet the nutritional needs of residents who received puree, fortified, and renal diets and further compromise their health status. Cross reference 801 Findings: 1. On 4/23/19 at 11:31 A.M., an interview was conducted with CK 1, during lunch tray preparation. CK 1 stated the lunch entree being served was beef stew and corn bread. CK 1 stated she prepared 10 pureed servings for the entrée by using a pureed meat recipe and not the recipe for [NAME] Beef Stew. CK 1 stated instant mashed potatoes flakes and gravy were used as a thickener in the pureed meal preparation. On 4/23/19 at 11:33 A.M., an interview was conducted with the DSS. The DSS stated CK 1 should have used actual portions of the beef stew when preparing the pureed stew. The DSS stated CK 1 did not prepare the pureed entrée correctly. The DSS stated mashed potatoes were also served on the puree lunch meal trays, so residents were not served the correct amount of starch, since potato flakes had been added to the puree as a thickener. Per the facility's undated recipe, titled [NAME] BEEF STEW, .Ingredients: margarine or oil, stew beef, onion, garlic cloves, diced tomatoes, potatoes, green or red bell peppers, zucchini, oregano, red pepper flakes, cumin .; .PUREEDS: Puree and serve 1 cup . Per the facility's policy, dated 2018, titled Food Preparation, .Recipes are specific as to portion yield, method of preparation, amounts of ingredients, and time and temperature guide . 2. On 4/23/19 at 11:31 A.M., during the lunch tray line, an observation and interview was conducted with DA 1. There were 22 resident tray cards labeled as fortified (a diet with additional calories). DA 1 stated the fortified item for the day was, Extra butter .2 or 3 on the tray. On 4/23/19 at 12:08 P.M., an interview was conducted with the DSS about fortified diets. The DSS stated the fortified items for the day were an eight ounce carton of milk, or a four ounce cup of ice cream. The DSS acknowledged DA 1 had incorrectly served butter instead of the fortified items identified for the day. Per the facility's policy, dated 2018, titled Fortification of Food: Increasing Calories and /or 055335 Page 16 of 23 055335 04/26/2019 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Protein in the Diet, .The Dietitian or FNS (Food and Nutrition Service) Director will select the fortification method from the list provided .Food and Nutrition staff will be familiar with the fortification process for each item chosen to be used . 3. On 4/24/19 at 11:46 A.M., an observation and interview of the lunch tray line was conducted. The vegetables on the tray line station were spinach and carrots. CK 1 stated those were the only vegetables prepared to be served to residents for lunch that day. There were no alternate vegetables prepared for lunch. On 4/24/19 at 12:46 P.M., an interview was conducted with the DSS. The DSS stated green beans were not served to the residents on a renal diet because she was unaware green beans were listed on the menu for the day. The DSS further stated there were no green beans in the kitchen because they had not been ordered. The RD stated the green beans should have been served to the residents on a renal diet because they were on the menu. Per the facility's therapeutic menu spreadsheet, dated 2019, titled SPRING MENUS Week 3- 4/24/19, Renal Diets .Lunch: Garden fresh meatloaf with gravy, Wheat pasta with margarine, Seasoned green beans, and garlic bread . 055335 Page 17 of 23 055335 04/26/2019 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

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 record review, the facility failed to ensure sanitary conditions were maintained during food storage when: Residents Affected - Some 1. Two of 14 onions which had black discoloration were not discarded; 2. Two of seven dried cereal bowls were not discarded 24 hours after being prepared and one was not discarded 48 hours after being prepared; 3. Three serving scoops were dirty with green and brown crusted substances and were stored with clean serving utensils; 4. Sixteen plastic bowls were stored wet underneath a food prep counter; and, 5. Three light bulb panels directly above the food preparation area and tray line station were exposed and uncovered. These failures had the potential to cause widespread food borne illness among residents who consume food from the kitchen. Cross reference 801 Findings: 1. On 4/23/19 at 10:51 A.M., an observation and interview was conducted with the DSS inside the walk-in refrigerator. On a shelf in the back of the refrigerator, there was a large clear rubber bin containing approximately 14 onions. Two onions inside the bin contained a dark colored substance with multiple spots resembling mold. The DSS stated, It's mold, growing. The DSS stated she or the staff inspected the produce upon delivery and the last delivery was on 4/19/19. The DSS stated kitchen staff used the FIFO (First in, first out) method, and staff must have missed those two onions. The DSS then stated, Oh, we could just cut those parts off because they could still be used. On 4/23/19 at 3:27 P.M., an interview was conducted with RD 1. RD 1 stated the onions were rotten, and if mold appeared to be growing, they needed to be thrown away. The RD 1 stated the onions could have contaminated food if they were used and residents could have gotten sick. Per the facility's policy dated 2018, titled General Receiving of Delivery of Food and Supplies, .Food deliveries will be inspected to assure high quality food .they are to be received in proper condition .Carefully inspect deliveries for .appearance . Per the facility's policy, dated 2018, titled Storing Produce, . 1. Check boxes of fruit and vegetables for rotten, spoiled items. One rotten tomato, apple or potato in a box can cause the rest .to spoil faster. Throw away all spoiled items . Per the facility's policy, dated 2018, titled Procedure for Refrigerated Storage, .15. Produce will be .rotated in the order it is delivered to assure fresh produce is used, free of wilting or spoilage. 055335 Page 18 of 23 055335 04/26/2019 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. On 4/24/19 at 8 A.M., an observation and interview was conducted with the DSS of the dry storage room. On a shelve to the right, was a food tray which contained seven pre-made bowls of dry cereal. The lids on the cereal bowls were dated. One lid was dated 4/22/19, two bowls were dated 4/23/19 and four bowels were dated 4/24/19. The DSS stated the dates on the lids were when the cereal was put in the bowls. The DSS further stated she and the staff checked the storage room every day for outdated food items. The DSS stated they do not have daily assignments for who was responsible for checking the dates of the food in the dry storage, and that, All staff were responsible for checking food dates. On 4/24/19 at 8:03 A.M., an interview was conducted with CK 1. CK 1 stated cereal should have been only been stored in the bowls for one day. 3. On 4/23/19 at 3:34 P.M., an observation and interview was conducted with CK 2 and the DSS. Inside a drawer underneath the tray line station, there were three serving scoops with dried crusted green and brown substances on them stored with clean utensils. The drawers were also dirty with crumbs and brown stains throughout the inside. CK 2 stated the serving utensils and the drawers were cleaned every night after the CK's shift. The DSS acknowledged the drawer and serving scoops were dirty and stated they should have been cleaned by the CK's. Per the facility's policy, dated 2018, titled Sanitation, .All utensils, counters, shelves and equipment shall be cleaned, maintained in good repair . According to the 2017 Federal Food Code, section titled Cleaning of Equipment and Utensils. 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, stated Equipment Food-Contact Surfaces and Utensils shall be clean to sight and touch .must be cleaned on a routine basis to prevent the development of .soil residues that may contribute to an accumulation of microorganisms . 4. On 4/23/19 at 3:36 P.M., during the observation and interview with the DSS, 12 dish machine racks were stacked beneath the food preparation counter. The racks contained plastic bowls, cups, and utensils. Two racks had 16 wet plastic soup bowls with water puddles on top of them. Water dripped down on top of the dishes stored underneath them. The DSS stated the dish machine racks with clean cups, bowls, and other dishes were stored in the racks underneath the prep counter because they could be dried there and the kitchen had, space issues. Per facility's policy dated 2018, titled Dish Washing, .5. Dishes are to be air dried in racks before stacking and storing . According to the 2017 Federal FDA Food Code, section 4-901.11, titled Equipment and Utensils, Air-Drying Required, Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow . 5. On 4/23/19 at 10:58 A.M., an observation was conducted of the ceiling light panels in the kitchen. There were three uncovered light bulb panels directly above the food preparation area and tray line station. The DSS stated the light bulb panels had been exposed for a while because the facility could not find covers to fit them. 055335 Page 19 of 23 055335 04/26/2019 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0812 Level of Harm - Minimal harm or potential for actual harm On 4/24/19 at 8:30 A.M., an interview was conducted with the Admin. The Admin stated the maintenance director had searched for a light cover for the ceiling light panels, but could not locate any. Per the facility's policy, dated 2018, titled Kitchen Safety, OPEN BULBS OVER STOVES AND TABLES SHOULD BE ENCLOSED . Residents Affected - Some According to the 2017 Federal FDA Food Code, Cleanability, part 6-201.11 Floors, Walls, and Ceilings, section .floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable . 055335 Page 20 of 23 055335 04/26/2019 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure safe and sanitary practices were implemented for resident's food brought in from the outside. Residents Affected - Few Failure to ensure safe food storage and reheating procedures for residents' food brought in from the outside had the potential to result in foodborne illness. Cross reference 801 Findings: On 4/23/19 at 3:14 P.M., an interview was conducted with CNA 20. CNA 20 stated resident food brought in from the outside was stored in the nurse's station refrigerator for a certain amount of days, but she did not know how many days. CNA 20 stated the facility could not store resident fast food overnight in the refrigerator. On 4/24/19 at 8:55 A.M., an interview was conducted with LN 23. LN 23 stated resident food from the outside was, Good for 48 hours and stored in the refrigerator inside the med room. LN 23 further stated the LNs checked the food before it was given to residents and she did not know about reheating procedures. On 4/24/19 at 9:32 A.M., an interview was conducted with CNA 21. CNA 21 stated resident food was stored in the patient refrigerator, located in the medication room. CNA 21 stated the food needed to be labeled with the resident's name and room number. CNA 21 stated she was unsure of how long food was allowed to be stored. On 4/24/19 at 9:35 A.M., an observation and interview was conducted with LN 20 of the patient refrigerator located inside the medication room. LN 20 stated the charge nurses inspected the refrigerator during their shift and threw away any resident food stored for more than three days. LN 20 stated she had checked the refrigerator for labels and dates earlier that morning. Stored in the refrigerator was a package of Land of Lakes Butter, dated 11/16/18, and labeled with a resident's name. The pre-printed expiration on the butter container was 4/10/19. LN 20 stated she did not notice the expiration date on the container and the butter should have been thrown away on 4/10/19. LN 20 stated LNs were responsible for checking the dates of the refrigerator items, as well as, the temperature while housekeeping was responsible for cleaning it. On 4/24/19 at 9:44 A.M., an interview was conducted with CNA 22. CNA 22 stated resident food brought in by family or friends was heated in the microwave located in the staff break room. CNA 22 stated they heated the food for about one minute, but they did not test the temperature because they, just know when the food was heated correctly. On 4/24/19 at 9:47 A.M., an interview was conducted with the DSD. The DSD stated staff were aware resident food was only to be stored for three days. The DSD stated food was heated in the staff break room, and heating time depended on the type of food being heated. The DSD did not know if a reference was available to staff for the amount of heating time. The DSD stated over the past year, staff had not been in-serviced on proper procedures for storing and reheating resident food brought in from the outside. 055335 Page 21 of 23 055335 04/26/2019 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0813 Level of Harm - Minimal harm or potential for actual harm Per the facility's policy, dated October 2017, titled Foods Brought by Family/Visitors, .5. All personnel involved in preparing, handling, serving or assisting the resident with outside meals or snacks will be trained in safe handling practices . The nursing staff will discard perishable foods on or before the 'use by' date . The policy did not provide guidance on reheating foods. Residents Affected - Few 055335 Page 22 of 23 055335 04/26/2019 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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 administer a vaccine in a timely manner for one of 10 sampled residents (74). Residents Affected - Few As a result, Resident 74 was not vaccinated for influenza (flu) during influenza season, and had the potential to contract and spread influenza. Findings: Per the facility's Resident Face Sheet, Resident 74 was admitted to the facility on [DATE] with diagnoses to include, altered mental status and dementia (cognitive decline). On 4/24/19 at 3:03 P.M., a concurrent interview and record review was conducted with the DSD. The DSD was unable to find documentation to indicate the facility administered an influenza vaccine to Resident 74. On 4/24/19 at 3:29 P.M., an interview was conducted with the DSDA. The DSDA stated, the facility was still giving influenza vaccines through the end of April 2019 per the CDC recommendation. According to Resident 74's Consents - Informed Consent - Influenza Vaccine form, the form was signed by Resident 74's responsible party (person who made medical decisions for the resident) without a date. On 4/24/19 at 4:25 P.M., an interview was conducted with the DSD. The DSD stated, Resident 74 was admitted to the facility on [DATE], the Consents - Informed Consent - Influenza Vaccine form, was signed by the responsible party on 3/26/19, but the facility did not administer the vaccine. On 4/26/19 at 1:28 P.M., an interview was conducted with the DON. The DON stated, when a new resident was admitted to the facility during influenza season, the facility obtained consent for the influenza vaccine, and would administer the influenza vaccine on the day the consent was signed. Per the facility's policy, titled Influenza Vaccine, revised August 2016, All residents and employees who have no medical contraindications (a reason to withhold treatment) to the vaccine will be offered the influenza vaccine annually . 055335 Page 23 of 23