Health inspection·July 9, 2021

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. 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 implement a policy to prevent abuse for one resident (Resident 2), when the facility did not follow abuse reporting requirements after the resident reported the incident to the staff. Residents Affected - Few This failure had the potential to compromise resident safety. Findings: Resident 2 was admitted to the facility on [DATE] with diagnoses including cellulitis of right lower limb (skin infection of the right leg), and speech and language development delay (slower to develop) due to hearing loss on per the facility's Resident Face Sheet. On 7/6/21 at 9:55 A.M., an interview was conducted with Resident 2. Resident 2 stated a nurse threw a creamer packet at him about a month ago around 4:30 A.M. Resident 2 stated he did not know the nurse's name, but the alleged nurse was still working to this date. Resident 2 stated he reported the incident to licensed nurse (LN) 31 and was told she would talk to the alleged staff. Resident 2 stated he had not heard any updates from LN 31. On 7/7/21 at 3:13 P.M., an interview was conducted with LN 31. LN 31 stated she recalled Resident 2 telling her about a staff member throwing something at him a couple months ago. LN 31 stated Resident 2 was upset and was not able to describe the alleged staff. LN 31 stated she reported to the previous director of nursing (DON) about the incident but did not follow up with her. LN 31 stated she would report any staff complaints by a resident to the administrator (Admin) or the DON and would document on the progress notes because it could be an abuse case. LN 31 stated she did not document the incident because she was busy passing medications to residents. On 7/7/21 at 3:30 P.M., an interview was conducted with the DON. The DON stated LN 31 just informed her about Resident 31's allegation and would start the investigation. The DON stated all staff were mandated reporters. On 7/8/21 at 1:38 P.M., a joint interview was conducted with the DON and the Admin. The Admin stated he was informed about Resident 2's allegation yesterday. The Admin stated the investigation was in process and no staff were suspended at that time. On 7/9/21 at 3:32 P.M., an interview with the DON was conducted. The DON stated the alleged incident should have been reported and investigated immediately. Page 1 of 25 055335 055335 07/09/2021 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0607 Level of Harm - Minimal harm or potential for actual harm According to the facility's policy, titled Abuse Investigation and Reporting, revised July 2017, All reports of resident abuse. shall be promptly reported to local, state and federal agencies. and thoroughly investigated by facility management. Reporting. 2. An alleged abuse. will be reported immediately, but no later than:. b. two (2) hours if the alleged violation involves abuse. Residents Affected - Few 055335 Page 2 of 25 055335 07/09/2021 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an allegation of abuse was reported in a timely manner for one resident (Resident 2). This failure had the potential to compromise Resident 2 and other residents' safety. Findings: Resident 2 was admitted to the facility on [DATE] with diagnoses including cellulitis of right lower limb (skin infection of the right leg) and speech and language development delay (slower to develop) due to hearing loss per facility's Resident Face Sheet. On 7/6/21 at 9:55 A.M., an interview was conducted with Resident 2. Resident 2 stated a nurse threw a creamer packet at him about a month ago around 4:30 A.M. Resident 2 stated he did not know the nurse's name, but the alleged nurse was still working to this date. Resident 2 stated he reported the incident to licensed nurse (LN) 31 and was told she would talk to the alleged staff. Resident 2 stated he had not heard any updates from LN 31. On 7/7/21 at 3:13 P.M., an interview was conducted with LN 31. LN 31 stated she recalled Resident 2 telling her about a staff member throwing something at him a couple months ago. LN 31 stated Resident 2 was upset and was not able to describe the alleged staff. LN 31 stated she reported to the previous director of nursing (DON) about the incident but did not follow up with her. LN 31 stated the resident's complaint about staff should have been reported to the administrator (Admin) or the DON and documented on the progress notes because it could have been an abuse case. LN 31 stated she did not document the incident because she was busy passing medications to residents. On 7/7/21 at 3:30 P.M., an interview was conducted with the DON. The DON stated LN 31 just informed her about Resident 31's allegation. On 7/7/21, the State Agency received a faxed report from the facility regarding Resident 2's allegation. On 7/8/21 at 1:38 P.M., the Admin was interviewed. The Admin stated once he was notified of an allegation he would report and investigate. On 7/9/21 at 3:32 P.M., an interview with the DON was conducted. The DON stated the alleged incident should have been reported immediately. According to the facility's policy, titled Abuse Investigation and Reporting, revised July 2017, All reports of resident abuse. shall be promptly reported to local, state and federal agencies. and thoroughly investigated by facility management. Reporting. 2. An alleged abuse. will be reported immediately, but no later than:. b. two (2) hours if the alleged violation involves abuse. 055335 Page 3 of 25 055335 07/09/2021 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0610 Respond appropriately to all alleged violations. 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 identify and investigate an alleged abuse violation and protect one resident (Resident 2). Residents Affected - Few This failure had the potential to result in physical and emotional harm for Resident 2 and other residents in the facility. Findings: Resident 2 was admitted to the facility on [DATE] with diagnoses including cellulitis of right lower limb (skin infection of the right leg) and speech and language development delay (slower to develop) due to hearing loss per facility's Resident Face Sheet. On 7/6/21 at 9:55 A.M., an interview was conducted with Resident 2. Resident 2 stated a nurse threw a creamer packet at him about a month ago around 4:30 A.M. Resident 2 stated he did not know the nurse's name, but the alleged nurse was still working to this date. Resident 2 stated he reported the incident to licensed nurse (LN) 31 and was told she would talk to the alleged staff. Resident 2 stated he had not heard any updates from LN 31. On 7/7/21 at 3:13 P.M., an interview was conducted with LN 31. LN 31 stated she recalled Resident 2 telling her about a staff member throwing something at him a couple months ago. LN 31 stated Resident 2 was upset and was not able to describe the alleged staff. LN 31 stated she reported to the previous director of nursing (DON) about the incident but did not follow up with her. LN 31 stated the resident's complaint about staff should have been reported to the administrator (Admin) or the DON and documented on the progress notes because it could have been an abuse case. LN 31 stated she did not document the incident because she was busy passing medications to residents. On 7/7/21 at 3:30 P.M., an interview was conducted with the DON. The DON stated LN 31 just informed her about Resident 31's allegation and the facility would start the investigation. On 7/8/21 at 1:38 P.M., a joint interview was conducted with the DON and the Admin. The Admin stated he was informed about Resident 2's allegation yesterday. The Admin stated the investigation was in process and no staff were suspended at this time. On 7/9/21 at 3:32 P.M., an interview with the DON was conducted. The DON stated the process of investigating abuse allegations included the suspension of the alleged staff until the investigation was completed. The DON stated the alleged incident should have been reported and investigated immediately. According to the facility's policy, titled Abuse Investigation and Reporting, revised July 2017, All reports of resident abuse. shall be promptly reported to local, state and federal agencies. and thoroughly investigated by facility management. 055335 Page 4 of 25 055335 07/09/2021 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

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 observation, interview and record review, the facility failed to develop safe discharge planning for one of three residents (Resident 2) reviewed for discharge. Residents Affected - Few This failure had the potential to result in Resident 2 being discharged to a facility that may not be able to meet his needs. Findings: Resident 2 was admitted to the facility on [DATE] with diagnoses that included cellulitis of right lower limb (skin infection of the right leg) per facility's Resident Face Sheet. Per Resident 2's social service (SS) progress note dated 3/20/21 and 6/18/21, the discharge plan was to go to independent living with Regional Center support. Per Resident 2's SS note dated 7/6/21, Resident 2's niece would take the resident home against medical advice (AMA) either today or tomorrow because the resident had been agitated and trying to leave the facility. Per Resident 2's SS progress note dated 7/7/21 at 2:21 P.M., Resident 2 was appropriate for discharge to group home on 7/7/21 per responsible party (RP) request. Per Resident 2's Physician order sheet dated 7/7/21, the resident was to be discharged home on 7/7/21 with medications and home health per responsible party (RP)'s request. On 7/7/21 at 4:15 P.M., an interview with the social service director (SSD) was conducted. The SSD confirmed Resident 2 was getting discharged tonight. The SSD stated Resident 2's niece was responsible in making the decision. The SSD stated the niece felt the resident should get discharged AMA from the facility because the resident was noncompliant with his foot order and had multiple elopement attempts. The SSD stated Resident 2 would be going to a group home he used to reside. However, she did not contact the group home because Resident 2' niece was the RP, and the niece stated the group home was okay for the resident to go. The SSD stated she would talk to the team and decide about Resident 2's discharge plan. On 7/7/21 at 4:53 P.M., an interview with Resident 2 was conducted. Resident 2 stated he was leaving the facility in few hours but wanted to stay until his foot was healed. Resident 2 further stated he told the SSD he was not comfortable with the discharge. However, he was told they could not do anything about it. Resident 2 stated he was not comfortable going to the independent living because he would have to do everything on his own. He added the discharge plan was for him to go back to the independent living when his foot was healed. On 7/7/21 5:10 P.M., Resident 2 was observed to be lying on his bed while the SSD was packing his belongings in the plastic bag. On 7/7/21 at 5:17 P.M., an interview with the SSD was conducted. The SSD stated she talked to the team and decided Resident 2 was leaving AMA. 055335 Page 5 of 25 055335 07/09/2021 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0660 Level of Harm - Minimal harm or potential for actual harm Per Resident 2's Interdisciplinary Team(IDT) note dated 7/7/21 at 4:52 P.M., IDT met to discuss discharge plan for Resident 2. The note indicated, However upon discussion with IDT, we, as a facility are not certain the needs of the resident will be met or whether or not it is safe. Since we are not are of the full extent of the group home and what they can offer, it would be best not to order the discharge, but to leave it AMA and educate per the risks. Conclusion: discharge [dc] will be AMA. Residents Affected - Few On 7/7/21 at 5:20 P.M., Resident 2 wheeled himself in the hallway and stated he was not comfortable with the discharge and he had not talked to his niece. On 7/7/21 at 5:25 P.M., a telephone interview with Resident 2's niece was conducted. The niece stated Resident 2 had repeatedly expressed he wanted to leave the facility to her. She further stated she was tired of the facility constantly calling her about his escape attempts. The niece stated Resident 2 made his own decision, but he told the facility he wanted her to make all the decisions. However, she did not have the legal rights to make the decisions. The niece stated the SSD called her and told her to come and pick up Resident 2 right now. The niece stated she was okay with Resident 2 not leaving against his will. On 7/7/21 at 5:44 P.M., a joint interview with the director of nursing (DON) and the SSD was conducted. The DON stated Resident 2's niece was the decision maker. The SSD stated she documented Resident 2 wanted his niece to make the decision on the face sheet. She further stated she was not looking for a placement for Resident 2 because he was admitted for a short term stay for rehabilitation purposes. Per Resident 2's progress note dated 7/7/21 at 6:18 P.M., discharge was not going to happen today because resident did not want to go. On 7/8/21 at 7:44 A.M., an interview with the medical doctor (MD) 31 was conducted. MD 31 stated Resident 2 did not have the capacity to make his own decision and was unsure who the responsible party for Resident 2. MD 31 stated Resident 2's discharge was sudden, and he was surprised. He further stated Resident 2 had been trying to elope multiple times in the past few weeks. MD 31 stated he was not sure if Resident 2 was getting discharged to an independent living or a boarding home. Per Resident 2's SS progress note, dated 7/8/21 at 6:23 P.M., Resident 2 was updated on the independent living home status and the facility would discuss what level of care resident would need. On 7/9/21 at 8:36 A.M., and interview with the SSD was conducted. The SSD stated there was no discharge plan for Resident 2 at this time. The SSD stated if Resident 2 could not inject Insulin (medication for high blood sugar) himself, he would need a higher level of care. On 7/9/21 at 9:40 A.M., a telephone interview with case manager (CM 31) at Regional center was conducted. CM 31 stated regional center managed Resident 2's social security benefits. She added the independent living the resident used to reside did not provide any medical support. She further stated the facility did not contact her when Resident 2 was getting discharged on 7/7/21. Per Resident 2's progress note dated 7/9/21 at 9:52 A.M., the SSD updated Regional center regarding Resident 2 needing Insulin upon discharge. On 7/9/21 at 4:37 P.M., an interview with the DON was conducted. The DON stated the facility was responsible for safe discharge planning for residents. The DON acknowledged Resident 2's discharge 055335 Page 6 of 25 055335 07/09/2021 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0660 planning process was not safe. Level of Harm - Minimal harm or potential for actual harm The facility's discharge policy did not provide guidance on safe discharge process. Residents Affected - Few 055335 Page 7 of 25 055335 07/09/2021 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 use pressure relieving mattresses as ordered for 4 of 9 residents sampled for pressure related injuries (24, 53, 66, 16). Residents Affected - Some In addition, 1 resident (16) was not repositioned as ordered. As a result, there was the risk of skin breakdown. Findings: 1. Per the facility's Resident Face Sheet, Resident 24 was admitted to the facility on [DATE] with diagnoses to include pressure ulcer (pressure related skin breakdown) of the sacral region (area above the tailbone). Per Resident 24's physician order dated 2/15/21, Treatment: LAL mattress (Low Air Loss mattress, used to relieve pressure). Set mode at alternating, per weight or residents comfort . On 7/7/21 at 8:41 A.M., a concurrent observation and interview was conducted with Resident 24. Resident 24 was lying on an LAL mattress, which was set to 140. Resident 24 stated, she had not asked the facility to adjust the pressure on her mattress. Per Resident 24's clinical record, on 7/5/21 Resident 24 weighed 91 pounds. 2. Per the facility's Resident Face Sheet, Resident 53 was admitted to the facility on [DATE] with diagnoses to include hemiplegia (inability to move one side of the body). On 7/7/21 at 8:18 A.M., an observation and interview was conducted with Resident 53. Resident 53 was lying on an LAL mattress, which was set to 300. Resident 53 stated, her bed was uncomfortable and felt lumpy. Per Resident 53's clinical record, on 7/4/21 Resident 53 weighed 126 pounds. 3. Per the facility's Resident Face Sheet, Resident 66 was admitted to the facility on [DATE] with diagnoses to include pressure ulcer. Per Resident 66's physician order dated 6/14/21, LAL mattress per weight or residents comfort . On 7/7/21 at 8:32 A.M., an observation was conducted of Resident 66. Resident 66 was lying on an LAL mattress. The LAL mattress pump read 270, and was a different brand than the LAL mattress it was attached to. Per Resident 66's clinical record, on 7/5/21 Resident 66 weighed 182 pounds. On 7/9/21 at 10:18 A.M., an interview was conducted with the DON. The DON stated, the settings for an LAL mattress should be based on a resident's weight. The DON further stated, if a resident requested a different pressure setting for their mattress, it would have been documented in the order. 055335 Page 8 of 25 055335 07/09/2021 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0686 Level of Harm - Minimal harm or potential for actual harm 4. Per the facility's Resident Face Sheet, Resident 16 was admitted to the facility on [DATE] with diagnoses to include dysphasia following cerebral infarction (stroke). Per the facility's Minimum Data Set (MDS - an assessment tool), dated 11/19/20, Resident 16's Brief Interview of Mental Status (BIMS - a cognitive assessment tool) score was 3 (severe impairment). Residents Affected - Some Per the facility's MDS, dated [DATE], Resident 16 required extensive assist with bed mobility (unable to move and reposition self independently). Per Resident 16's physician order dated 3/9/20, LAL mattress per weight or residents comfort . On 7/6/21, at 10:20 A.M., an observation was conducted. Resident 16 was lying on her back on an LAL mattress with her eyes closed. The LAL mattress pump read 320 pounds. Per Resident 16's clinical record, on 7/4/21 Resident 16 weighed 146 pounds. On 7/6/21, at 11:20 A.M., 11:53 A.M., 3:00 P.M., and 4:11 P.M., Resident 16 was observed lying on her back, with her eyes closed. On 7/7/21, at 8:37 A.M., 9:36 A.M., 11:23 A.M., and 4:55 P.M., Resident 16 was observed lying on her back. The LAL mattress pump read 320. On 7/8/21, at 8:05 A.M., 10:12 A.M., and 1:52 P.M., Resident 16 was observed lying on her back, with her eyes closed. On 7/9/21, at 8:07 A.M., a concurrent interview and record review was conducted with LN 2. Per Resident 16's Skin Care Plan, initiated on 5/27/17, LAL mattress was to be set per weight or resident's comfort. LN 2 stated the facility standard was to turn residents every 2 hours and as needed. Per Resident 16's clinical record, on 7/4/21 Resident 16 weighed 146 pounds. LN 2 stated LAL should have been programmed to 146 pounds. On 7/9/21, at 8:36 AM., a subsequent interview and observation was conducted with LN 2. LN 2 stated Resident 16's LAL mattress was set to 320 pounds. LN 2 stated the weight setting was wrong. LN 2 stated residents must be turned regularly to prevent skin breakdowns. On 7/9/21, at 8:43 A.M., an interview was conducted with the DON. The DON stated, it was important to turn residents frequently and to have correct LAL settings to prevent skin breakdowns. According to the facility's policy titled, Prevention of Pressure Ulcers/Injuries, dated July 2017, .2. At least every hour, reposition residents who are .bed-bound . According to the [LAL pump brand name] Low Air Loss and Alternating Pressure Mattress Replacement System User's Manual, .4.1 General Operation .5. According to the weight and height of the patient, adjust the pressure setting to the most comfortable level . 055335 Page 9 of 25 055335 07/09/2021 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure fall safety interventions for two of six residents (Resident 35 and Resident 23) reviewed for accidents were provided when: Resident 35's chair/bed silent alarm (an alarm used to help warn staff when a resident is changing position or getting up) was not implemented consistently; In addition, Resident 35's falls were not thoroughly investigated to ensure that all fall preventative measures were implemented. Resident 23's wheechair was placed in an area that was not within the resident's reach. In addition, the facility was not secured during the night when a visitor's entrance was left open and unlocked. As a result, Resident 35 fell eight times while at the facility. One of Resident 35's fall resulted in a laceration on the forehead which required suturing. Resident 23 had the potential to fall and become injured. Furthermore, not securing the facility from potential intruders put the safety of all residents's at risk. Findings: Resident 35 was admitted to the facility on [DATE] with diagnoses that included heart failure per the undated Resident Face Sheet. A review of Resident 35's Fall Risk Assessment, dated 2/11/2021, indicated Resident 35 was At Risk for falls. A review of Resident 35's physician orders, dated 2/21/2021, indicated an order for Silent bed alarm to wheelchair/bed to alert staff of solo transfers. A joint observation of Resident 35 was conducted with the Assistant Director of Nursing (ADON) on 5/26/2021 at 3:30 P.M. Resident 35 sat on her wheelchair without a silent alarm. A review of Resident 35's nursing progress notes from February 2021 thru May 2021 indicated that Resident 35 fell on 2/14, 2/15, 2/26, 4/8, 4/10, 4/24, 5/13, and 5/21/2021. The nursing progress notes indicated the following: On 2/14/2021 at 8:50 P.M., Resident 35 was found on the floor. According to the record, CNA (certified nursing assistant) heard yelling from the room and went to check, found resident on the floor . The progress note also indicated Resident 35 was asked what she was trying to do and the resident replied, I wanted to use the wheelchair. On 2/15/2021 at 10:29 P.M., Resident 35 was found sitting on the bathroom floor. According to the progress note, CNA found her (Resident 35) sitting on the floor leaning to the BR (bathroom) door. On 2/26/2021 at 4:15 P.M., Resident 35 was found on the floor on the right side of the bed with the resident's foot caught on the wheelchair. According to the record, Resident 35 sustained a skin 055335 Page 10 of 25 055335 07/09/2021 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0689 tear on the right knee measuring 3 centimeters (cm.) by 3 cm. Per the progress note, Resident 35 could not describe what she was doing prior to the fall. Level of Harm - Actual harm Residents Affected - Few On 4/8/2021 at 9:43 A.M., Resident 35 was found on the floor in the bathroom of room [ROOM NUMBER]. According to the record, Resident 35 was sitting on the floor next to the toilet. Per the progress note, Resident 35 sustained a skin tear on the right leg. On 4/10/2021 at 8:10 P.M., Resident 35 fell to the floor from the wheelchair in front of the nurse's station. On 4/24/2021 at 6:57 P.M., Resident 35 was found on the floor by the reception area and nurse's station. Per the progress note, Resident 35 was asked what happened and resident replied, I slid from the wheelchair when I'm trying to move myself. The progress note indicated Resident 35 sustained a skin tear on her right index finger (second finger). On 5/13/2021 at 8:47 P.M., Resident 35 attempted to stand up and slid out of her wheelchair onto the floor. Per the progress note, Resident 35 stated, Had to go pee. On 5/21/2021 at 9: 51 P.M., Resident 35 was found on the floor in her room. According to the progress note, Resident 35 sustained a laceration to the forehead measures approximately 3 cm. x (by) 0.3 cm. with moderate amount of blood noted on forehead and floor. Resident reports pain only to her head. On 5/21/2021 at 10:23 P.M., Resident 35 was transferred to the hospital via 911. On 5/22/2021 at 9:10 A.M., Resident 35 returned to the facility from the hospital. According to the progress note, the hospital impression was, fall, Head Trauma (head injury), Staples. A review of Resident 35's care plan related to the fall incidents was conducted. According to Resident 35's fall care plan, the following fall prevention interventions were initiated after each fall incidents: After the fall on 2/14/2021 (found on the floor), fall interventions were initiated on 2/15/2021, one day after the fall, which included Room change to A bed to more visible to staff and RNA (restorative nursing assistant - strengthening exercises) program. After the fall on 2/15/2021 (found on the floor in the bathroom), a fall intervention was initiated on 2/18/2021, three days after the fall, which indicated, Silent bed/wheelchair alarm to alert staff of solo transfers (regular alarm until silent alarm arrives a t the facility). After the fall on 2/26/2021 (found on the floor), there was no new fall preventative intervention written on Resident 35's care plan. After the fall on 4/8/2021 (found on the bathroom floor in room [ROOM NUMBER]), a fall intervention was initiated on 4/9/2021, one day after the fall, which indicated, Move resident to A bed to be more visible to staff. After the fall on 4/10/2021 (fell at the nurse's station), a fall intervention was initiated on 4/13/2021, three days after the fall, which indicated, (Brand of non-skid mat) to wheelchair to reduce 055335 Page 11 of 25 055335 07/09/2021 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0689 risk for falls. Level of Harm - Actual harm After the fall on 4/24/2021 (found on the floor by the reception area and nurses' station), a fall intervention was initiated on 4/27/2021, three days after the fall, which indicated, (Brand of non-skid mat) on top of wheelchair pad to reduce risk for falls. Residents Affected - Few After the fall on 5/13/2021 (got up needing to use the bathroom), a fall intervention was initiated on 5/18/2021, five days after the fall, which indicated, Encourage resident to go to bed before 8 P.M. to prevent falls h/o (history of) falls after 8 P.M. and encourage resident to use restroom before going to bed. After the fall on 5/21/2021 (found on the floor with laceration on the forehead), fall interventions were initiated on 5/25/2021, four days after the fall with injury, which included Place mattress on the right side of the bed. Allow resident to sleep on the mattress on the floor and Place resident in supervised area and continue to redirect. An interview with CNA 50 was conducted on 5/26/2021 at 3:10 P.M., to discuss Resident 35's fall incident on 5/21/2021. CNA 50 stated she passed by Resident 35's room and saw the resident on the floor. CNA 50 stated she saw blood on Resident 35's head. A telephone interview with the Assistant Director of Nursing (ADON) was conducted on 6/1/2021 at 11 A.M. to discuss Resident 35's fall incident on 4/8/2021. The ADON stated she was at the nurse's station when she heard Resident 35 yelled for help from room [ROOM NUMBER]. The ADON stated the box for Resident 35's chair alarm was at the nurse's station and that she could not recall whether the silent alarm went off when Resident 35 fell in room [ROOM NUMBER]. An observation of Resident 35 was conducted on 7/8/2021 at 5:30 A.M. Resident 35 sat on her wheelchair without the silent chair alarm. An interview with CNA 51 was conducted on 7/8/2021 at 7:09 A.M. CNA 51 stated Resident 35 was a fall risk. CNA 51 stated Resident 35 did not use any device to help prevent the resident from falling. An interview with licensed nurse (LN) 50 was conducted on 7/8/2021 at 3:10 P.M. to discuss Resident 35's fall incident on 5/21/2021. LN 50 stated she was in the A Hall when she was informed by a CNA that Resident 35 was found on the floor in her room. LN 50 stated the box for Resident 35's silent alarm was placed on top of her medication cart. LN 50 stated she did not hear the alarm go off. Resident 35's silent alarm was checked and it was set on the lowest volume setting. When the silent alarm was tested under the low volume setting, the sound was not easily heard when the environment was noisy. The silent alarm's volume setting was changed to the loudest setting. The sound was loud and easily heard. LN 50 stated, I did not hear that sound. An interview and joint record review with the Director of Nursing (DON) was conducted on 7/9/2021 at 10:31 A.M. The DON reviewed Resident 35's nursing progress notes, care plans and the Interdisciplinary (IDT - team members from different disciplines working collaboratively) notes related to the fall incidents. The DON confirmed that Resident 35 had eight falls from 2/14/2021 thru 5/21/2021. The DON stated Resident 35's fall on 5/21/2021 resulted in a laceration on the forehead, which required staples. The DON stated the IDT met after each of Resident 35's fall incident to find out the cause of the fall and to ensure appropriate fall preventative interventions were initiated. The DON acknowledged that the Post Fall IDT notes did not indicate that the IDT questioned whether the silent 055335 Page 12 of 25 055335 07/09/2021 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0689 Level of Harm - Actual harm Residents Affected - Few chair/bed alarm was used when Resident 35 fell repeatedly. The DON reviewed the nursing progress notes and confirmed that the nursing progress notes related to Resident 35' falls did not indicate that an audible sound or alarm were heard prior to finding Resident 35 on the floor. The DON acknowledged that to initiate an appropriate fall preventative intervention, a thorough root cause of the fall should be conducted. The interviews with CNA 1, the ADON, and LN 1 were shared with the DON. The DON could not explain why CNA 1, the ADON, and LN 1 did not hear the alarm go off prior to finding Resident 35 on the floor. The DON could not explain why the IDT did not question the use of the silent alarm during their discussion of Resident 35's repeated falls. The DON stated that fall preventative interventions should be consistently implemented to help prevent falls. A review of the facility's policy and procedure titled Falls and Fall Risk, Managing, revised on March 20218, was conducted. The policy indicated, 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 and to try to minimize complications from falling.Resident-Centered Approaches to Managing Falls and Fall Risk .6. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant.9. Position-change alarms will not be used as the primary or sole intervention to prevent falls, but rather will be used to assist the staff in identifying patterns and routine of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner. 2. Resident 23 was readmitted to the facility on [DATE] with diagnoses to include hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following nontraumatic intracerebral hemorrhage (brain bleed/stroke) affecting left non-dominant side, per the facility's Resident Face Sheet. A review of Resident 23's clinical record was conducted. The resident's clinical record indicated Resident 23 had been found on the floor on 2/16, 2/17, and 2/26/21. The three incidents of being found on the floor had been classified as falls. The IDT (interdisciplinary team) note dated 2/26/21 , indicated, .[Resident 23] fall on 2/22/21 . Resident was found on the bathroom floor on his right side . Resident states that he didn't have his wheelchair so he crawled to the bathroom . New interventions implemented .wheelchair next to resident so resident can assist himself to restroom PRN [as needed] A review of Resident 23's physician orders dated 2/26/21, indicated, Keep wheelchair open, locked, and in reach of resident at all times for resident to assist himself to bathroom. Special Instructions: (Fall prevention/safety) Every shift On 7/7/21 at 8:39 A.M. a joint observation and interview was conducted with Resident 23 inside the resident's room. Three residents resided in the room. Resident 23 was in Bed A located nearest to the door. A wheelchair was not observed at Resident 23's bedside. Resident 23 stated he could usually assist himself to the wheelchair if it were placed on the right side of his bed nearest to the door. On 7/7/21 at 9:16 A.M., an observation was conducted of Resident 23 inside the resident's room. Resident 23 was observed in bed. A wheelchair was not observed at Resident 23's bedside. On 7/7/21 at 3:15 P.M., an observation was conducted of Resident 23 inside the resident's room. Resident 23 was observed in bed. A wheelchair was not observed at Resident 23's bedside. 055335 Page 13 of 25 055335 07/09/2021 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0689 On 7/7/21 at 4:47 P.M. an observation was conducted of Resident 23 inside the resident's room. Resident 23 was observed in bed. A wheelchair was not observed at Resident 23's bedside. Level of Harm - Actual harm Residents Affected - Few On 7/7/21 at 5:29 P.M., a joint observation, interview, and record review was conducted with LN 22. LN 22 reviewed Resident 23's physician order dated 2/26/21 for the resident's wheelchair to be open, locked, and within the resident's reach. LN 22 then observed Resident 23 in bed in his room and the resident's wheelchair folded and placed against the wall. LN 22 stated Resident 23's wheelchair had not been open, locked, and within the resident's reach. LN 22 stated the physician order to prevent further falls had not been followed. LN 22 stated Resident 23 could get injured trying to get to the bathroom without his wheelchair. On 7/9/21 at 9:43 A.M., an interview was conducted with the director of nursing (DON). The DON stated the physician order for Resident 23's wheelchair to be kept open, locked and within the resident's reach had not been followed. The DON stated the physician order was first, a fall prevention measure and second, to facilitate the resident being able to access the bathroom. The DON stated it was her expectation for Resident 23's fall prevention intervention to be in place at all times. The facility's policy titled Falls and Fall Risk, Managing revised March 2018, indicated, .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 and to try to minimize complications from falling .1. The staff, with input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls 3. On 7/8/21 at 3:58 A.M., an observation was conducted of the main entrance to the facility. The double door main entrance was closed. A sliding glass door, adjacent to the double door main entry, was opened approximately three inches. This led into an open room used for visitors and from there into the whole building. Four surveyors entered the facility through the sliding glass door of the visitors' room, and were able to access different areas of the building. The four surveyors were not immediately noticed by staff. On 7/8/21 at 4:03 A.M., an interview was conducted with licensed nurse (LN) 4. LN 4 stated all points of entry into the facility should have been checked at the start of the night shift (11 P.M.). LN 4 stated this was to be done to keep the residents safe. LN 4 stated the room used for visits adjacent to the double door main entry should have been checked and locked after 5 P.M. the night before. On 7/8/21 at 7:22 A.M., an interview was conducted with LN 30. LN 30 stated as the charge nurse for the night shift, it was her responsibility to check the points of entry to the facility at the start of the shift and to make sure they were locked. LN 30 stated she did check the points of entry to ensure they were locked at the start of her shift. LN 30 stated she had not checked the entrance to the visiting room that was adjacent to the double door main entry. LN 30 stated, I should have checked. LN 30 stated having an unsecured point of entry into the facility at night was not safe. On 7/9/21 at 9:15 A.M., an interview was conducted with the director of nursing (DON). The DON stated it was her expectation for all points of entry into the facility to be secured at night so that unauthorized persons could not enter. The DON stated staff who worked nights were trained on how and when to check that the building was secured and that included the visitor entrance adjacent to the main double door. The DON further stated there was no policy that addressed securing the facility entrances. 055335 Page 14 of 25 055335 07/09/2021 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident 41 was readmitted to the facility on [DATE], per the facility's Resident Face Sheet. Residents Affected - Some On 7/6/21 at 11 A.M., an interview was conducted with Resident 41. Resident 41 stated it took a long time to get help after she activated her call light. Resident 41 stated it sometimes took an hour to get her brief changed when she was soiled. 5. Resident 222 was admitted to the facility on [DATE] with diagnoses to include fracture of the pelvis and lower end of the left radius (forearm), difficulty walking, and a history of falling, per the facility's Resident Face Sheet. On 7/6/21 at 3:01 P.M. an interview was conducted with Resident 222. Resident 222 stated he had been in the facility for about a week. Resident 222 stated staff seemed to respond very slowly when he activated his call light. Resident 222 stated waiting 20 minutes for staff to help was his limit when he needed to use the bathroom. Resident 222 stated after waiting for 20 minutes, he would take himself to the bathroom. Resident 222 stated he was not supposed to do that alone. Resident 222 stated, I don't want an accident [urine or feces] that would be a mess. 6. Resident 71 was admitted to the facility on [DATE], per the facility's Resident Face Sheet. On 7/6/21 at 4:06 P.M., an interview was conducted with Resident 71. Resident 71 stated she got a slow staff response when she needed help to the bathroom. Resident 71 stated when she activated her call light to get help, someone would come in and turn it off and tell her they would go get her CNA. Resident 71 stated she would press her call light again as soon as they leave the room, because help would not come after asking for it the first time. 7. Resident 23 was readmitted to the facility on [DATE] with diagnoses to include hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following nontraumatic intracerebral hemorrhage (brain bleed/stroke) affecting left non-dominant side, per the facility's Resident Face Sheet. On 7/7/21 at 3:19 P.M., an interview was conducted with Resident 23. Resident 23 stated he did not consistently get help when he needed it. Resident 23 stated on more that one occasion, he had to lower himself from bed to the floor and crawl to the bathroom because no one would help him when he activated his call light. Resident 23 stated after waiting 30 minutes for help he would not be able to hold it any longer and had to go. Resident 23 stated he did not want to defecate in his clothing or on the bed and would crawl to the bathroom if staff did not provide assistance. A review of Resident 23's MDS Assessment (Minimum Data Set, an assessment tool) dated 4/20/21, indicated the resident required the assistance of one staff for toileting activities. A review of Resident 23's progress notes dated 2/16/21 at 11:45 P.M., indicated, Called to room by CNA who stated pt [patient] was sitting on floor in bathroom A review of Resident 23's progress notes dated 2/17/21 at 8:07 P.M., indicated, Writer responded to res [resident] calling out for help. Found res sitting on BR [bathroom] floor . Res stated he did 055335 Page 15 of 25 055335 07/09/2021 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some not fall. He said that he crawled down from bed onto floor to go to the BR for BM [bowel movement] but needs assistance to sit on the toilet .Call light was activated. Res stated that he needed to crawl because nobody came to help. Explained to res that at times help can't come right away d/t [due to] staffs [sic] are occupied w/ other residents . Res replied that more staff is needed A review of Resident 23's progress notes dated 2/22/21 at 11:06 P.M., indicated, . At 1510 [3:10 P.M.] CNA informed writer that resident is on the BR floor on his R [right] side his L [left] arm pulling the emergency call button 8. On 7/7/21 at 5:07 P.M., a joint interview and record review was conducted with LN 22. LN 22 reviewed Resident 23's progress notes on 2/17/21 and stated she had found the resident on the bathroom floor. LN 22 stated she heard the resident yelling and noticed that the call light had been activated. LN 22 stated it would be nice if staff could help residents right away. LN 22 acknowledged residents' feeling the urge to have a BM could not wait for help for an extended period of time. A confidential staff (CS) interview was conducted with CS 21. CS 21 stated it was hard to meet the needs of their assigned residents. CS 21 stated the facility had a staffing problem. A CS interview was conducted with CS 22. CS 22 stated the facility did not assign enough staff to meet the needs of the residents. A CS interview was conducted with CS 23. CS 23 stated evening and night shifts were the worst when it came to having enough staff. CS 23 stated if staff were sick, they had to find their own replacement and usually they did not find a replacement. CS 23 stated they had not heard of a licensed nurse being used to cover the work of a CNA who called out. A review of Resident Council Meeting minutes on 5/20/2021 and 6/30/2021, indicated call lights were not being answered in a timely matter. A review of Resident Council Department Feedback dated 5/20/21, indicated that staff would be in-serviced regarding call light response. A CS interview was conducted with CS 24. CS 24 stated there was a big staffing problem. CS 24 stated they did not feel the residents' acuity levels (the amount of nursing care residents required) were factored in when making staff assignments. CS 24 stated if staff called-out sick they were often not replaced. CS 24 stated she did not think staff in-services about call light response were helpful. CS 24 stated staff wanted to answer call lights and help the residents, but there often was not enough staff to accomplish that. A CS interview was conducted with CS 25. CS 25 stated I think we need more help. CS 25 stated they considered staffing to be an issue. CS 25 stated they had not received an in-service about responding to residents' call lights. CS 25 stated the problem was having enough staff onboard to meet the residents' needs. On 7/9/21 at 5:02 P.M., an interview was conducted with the director of nursing and administrator (ADM). The ADM acknowledged the resident council had raised the issue of call light response in the May and June 2021 meetings. The ADM stated the residents' perception of the call light situation was not going to match the facility's perception. When asked about the decision to respond to the resident council's concerns by in-servicing staff for call light response on 5/20/21, the ADM stated, Well they're the ones answering the call light, right? The ADM stated staffing would continue to be an ongoing issue. 055335 Page 16 of 25 055335 07/09/2021 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The facility's policy titled Staffing revised October 2017, indicated, .Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents 3. On 7/6/21 at 10:57 A.M., an interview was conducted with Resident 13. Resident 13 stated, it could take up to two hours for someone to answer the call light when she needed help because the facility did not have enough certified nursing assistants (CNAs). On 7/6/21 at 10:03 A.M., an interview was conducted with Resident 53. Resident 53 stated, when she activated her call light because she needed someone to change her after soiling her brief, it sometimes took two to three hours. Based on interview and record review, the facility failed to answer call lights in a timely manner to meet the needs of the residents for 6 out of 10 confidential residents (A, B, C, D, E, and F) and 6 of 22 sampled residents (13, 53, 23, 41, and 71) and 1 unsampled resident (222). This failure had the potential to result in residents not receiving needed services timely and efficiently. Findings: 1. A review of Resident Council Meeting minutes on 5/20/21 and 6/30/21, indicated call lights were not being answered in a timely matter. On 7/7/21 at 10:02 A.M., a group interview with confidential residents was conducted. During the confidential group interview, five out of nine residents raised concerns regarding delay in answering call lights and having insufficient staff to provide care for all the residents. a) Resident A stated call light issues were always ongoing, especially at nighttime. Resident A further stated sometimes when the call light was on, the staff walked by their room without answering the light. Resident A stated they pressed the call light because they were in pain and had to wait 2 hours for the call light to be answered. When the light was answered, the staff stated they were the only one working that hallway and could not do everything. b) Resident B stated the call light was not answered in a timely manner. c) Resident C stated the longest wait was 45 minutes. d) Resident D stated the longest wait was 45 minutes. Resident D also stated the longest wait times were at nighttime because they were understaffed. e) Resident C agreed to Resident D's statement. f) Resident E agreed to Resident D's statement. 2. A confidential interview was conducted with Resident F. Resident F stated they have had to wait two hours after requesting help to use the bathroom and after requesting pain medication. Resident F 055335 Page 17 of 25 055335 07/09/2021 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0725 stated it took forever for staff to help them. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 055335 Page 18 of 25 055335 07/09/2021 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

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 ensure a physician ordered medication (a laxative -medication to promote bowel movements) was administered to one of three residents (Resident 28) during the medication administration observation. This deficient practice had the potential for Resident 28 to experience constipation (bowel movements that were difficult to pass). Findings: Resident 28 was readmitted to the facility on [DATE], per the facility's Resident Face Sheet. On 7/8/21 at 10:12 A.M., a medication administration observation was conducted with licensed nurse (LN) 21. LN 21 was observed preparing medications for Resident 28. LN 21 prepared Resident 28's polyethylene glycol 3350 (a laxative in powder form) by mixing it into a glass filled with approximately 8 ounces of water. The mixture was colorless and had the appearance of water. A review of Resident 28's physician orders dated 1/8/21, indicated, . (polyethylene glycol 3350) .powder . Special Instructions: to prevent constipation ., mix with 8 oz [ounces] of water or juice once a day On 7/8/21 at 10:18 A.M., a medication administration observation was conducted with LN 21 at Resident 28's bedside. Resident 28 was administered her oral medications in pill form with a liquid nutritional supplement. LN 21 then gave Resident 28 the polyethylene glycol 3350. Resident 28 stated, I don't want the water. LN 21 disposed of the polyethylene glycol 3350. LN 21 did not inform Resident 28 that there was a medication mixed in with the water. LN 21 did not explain the risks of refusal to Resident 28. On 7/8/21 at 10:24 A.M., an interview was conducted with Resident 28. Resident 28 stated she did not know there had been a medication mixed in with the 8 oz of water. Resident 28 stated she would have taken the medication if she had been informed. On 7/8/21 at 10:28 A.M., an interview was conducted with LN 21. LN 21 stated she should have made Resident 28 aware there had been a medication mixed in with the water before disposing of it. LN 21 stated she should have educated Resident 28 on the risks of refusing the medication. On 7/9/21 at 8:10 A.M., an interview was conducted with the director of nursing (DON). The DON stated LN 21 should have informed Resident 28 there was a medication mixed in with the water before disposing of it. The DON stated it was her expectation that LNs provided residents with information regarding their medications during the medication administration, and educated residents on the risks of medication refusals. The facility's policy titled Administering Medications, revised April 2019, did not provide guidance related to resident medication refusals and providing resident medication education. 055335 Page 19 of 25 055335 07/09/2021 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the use of as needed psychotropic medication (a medication which effects the mind) was limited to 14 days for 1 of 5 residents sampled for unnecessary medications (Resident 13.) As a result, there was the risk of Resident 13 receiving unnecessary medication. Findings: Per the facility's Resident Face Sheet, Resident 13 was admitted to the facility on [DATE] with diagnoses to include dementia (a mental and physical decline), and anxiety. Per the facility's Prescription Order, on 3/23/21 the physician wrote an order for Resident 13 for a psychotropic medication to treat anxiety. The end date read, Open Ended. Per the Consultant Pharmacist's Recommendation To Inter-Disciplinary Team (IDT) between 6/1/21 and 6/16/21, the Pharmacist wrote, Please evaluate if the order(s) can be discontinued, or document the clinical justification for extending beyond 14 days (and specify the duration beyond 14 days) to keep the facility in compliance with regulations . The facility's response, signed by the IDT on 6/20/21, was NP (Nurse Practitioner) to write justification for PRN (use as needed) to extend over 14 days . On 7/9/21 at 10:58 A.M., a telephone interview was conducted with the Pharmacist. The Pharmacist stated, psychotropic medications should not be ordered as needed for more than 14 days. The Pharmacist further stated, if a resident needed a psychotropic medication to be used as needed beyond the initial 14 days, a physician had to reevaluate the resident to determine if the medication was still appropriate. On 7/9/21 at 11:20 A.M., an interview was conducted with the DON. The DON stated, when a psychotropic medication was ordered to be used as needed, the order should not be for longer than 14 days. The DON further stated, if a physician or NP ordered an as needed psychotropic medication for more than 14 days, the facility needed the physician to document their justification. On 7/9/21 at 4:15 P.M., a subsequent interview was conducted with the DON. The DON stated, she was not able to find evidence of a physician documenting justification for the order of Resident 13's psychotropic medication as needed for more than 14 days. 055335 Page 20 of 25 055335 07/09/2021 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

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 interview and record review, the facility failed to accurately document the decision maker for one of 22 residents (Resident 2) reviewed for medical record accuracy. This failure resulted in confusion among facility's staff and had the potential for delay in medical treatment. Findings: Resident 2 was admitted to the facility on [DATE] with diagnoses that included cellulitis of right lower limb (skin infection of the right leg), and speech and language development delay (slower to develop) due to hearing loss per facility's Resident Face Sheet. Per Resident 2's History and Physical (H&P) dated 3/15/21, Resident 2 did not have the capacity to understand and make decisions. Further noted the decision maker was Resident 2's brother. Per Resident 2's Physician's order started on 3/15/21, Resident 2 was capable of understanding rights, responsibilities, and informed consent. On 7/7/21 at 4:15 P.M., an interview with the social service director (SSD) was conducted. The SSD stated Resident 2's niece was responsible for making the decision for the resident. On 7/7/21 at 5:25 P.M., a telephone interview with Resident 2's niece was conducted. The niece stated Resident 2 made his own decisions. The niece further stated Resident 2 wanted her to make all the decisions, but she did not legally have the rights. On 7/7/21 at 5:44 P.M., a joint interview with the director of nursing (DON) and the SSD was conducted. The DON stated the niece was the decision maker for Resident 2. The SSD stated the responsible party was documented first on the face sheet's contact lists. The SSD further stated she wrote Resident 2 wanted his niece to make the decision on his face sheet. The SSD was unsure if Resident 2 was able to make his own decision. Per Resident 2's face sheet, Resident 2's niece was documented as a responsible party of the resident and the resident preferred his niece to be informed on everything and sign all documents. Further noted no Durable Power of Attorney for Health Care (legal document allowing to let someone else make medical decision) provided. Per Resident 2's progress note dated 7/7/21, the note indicated the order of Resident 2 had the capacity to make his own decision was discontinued. On 7/8/21 at 7:44 A.M., an interview with the medical doctor (MD) 31 was conducted. MD 31 stated Resident 2 did not have the capacity to make his own decision. MD 31 further stated he was unsure who the responsible party was for this resident. On 7/8/21 at 10:10 A.M., a concurrent interview and record review with licensed nurse (LN) 31 was conducted. LN 31 stated Resident 2 and his niece made the decisions together, but Resident 2 had the 055335 Page 21 of 25 055335 07/09/2021 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few final say. LN 31 reviewed Resident 2's face sheet and stated Resident 2's niece would be making the decision according to the document. On 7/9/21 at 8:21 A.M., an interview with LN 32 was conducted. LN 32 stated Resident 2 made his own decisions. She further stated the decision maker was the first person listed on the face sheet under contacts. On 7/9/21 at 8:36 A.M., an interview with the SSD was conducted. The SSD stated Resident 2 and his niece agreed for his niece to become the responsible party during the interdisciplinary team meeting yesterday. The SSD stated Resident 2 could make basic decisions, but not medical decision. Per Resident 31's social service progress note dated 7/8/21, physician clarified Resident 2 could not make his own decisions. Further noted, Resident 2's niece accepted to be the responsible party per Resident 2's request. On 7/9/21 at 3:32 P.M., an interview with the DON was conducted. The DON confirmed Resident 2's niece became the responsible party for Resident 2. The DON stated delay in treatment process could have happened if the residents' decision maker was unclear. According to the facility's policy, titled Charting and Documentation revised July 2017, . 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate . 055335 Page 22 of 25 055335 07/09/2021 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and record review the facility's Quality Assurance Performance Improvement (QAPI) committee failed to thoroughly and completely identify and implement areas of their fall prevention program. This resulted in findings of multiple falls for Resident 35, including a fall with injury. See F656, and F689. Findings: During an interview with the facility's administrator (admin) on 7/9/21 at 5:02 P.M., the admin stated the facility started looking at falls last spring. The admin stated the necessary room changes that were required for infection control during the pandemic, required the facility to look at how to best deal with resident falls, since residents could not always be placed near the nursing station. The admin stated they implemented a falling star program, identifying residents whose doors would remain open with frequent visual checks. The admin stated they talked about falls daily at stand up meeting and with the Interdisciplinary Team (IDT). The admin stated they have seen some improvement in the number and trends of falls after adjusting their Performance Improvement Plans (PIP). The admin acknowledged that Resident 35 did have a fall with injury, with a couple of subsequent falls. The admin stated they were looking at any way to prevent falls and that not all falls were preventable. According to a review of the facility's policy titled Fall 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 risk and causes to try to prevent the resident from falling and to try to minimize complications from falling . Resdient-Centered Approaches to Managing Falls and Fall Risk: .7. In conjunsction with the attending physician, staff will identify and implement relevant interventions . to try to minimize serious consequences of falling. 8. Position-change alarms will not be used as the primary or sole intervention to prevent falls, but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner . Monitoring Subsequent Falls and Fall Risk: . 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. 4. The staff and/or physician will document the basis for consulsions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls . According to a review of the facility's Quality Assurance Performance Improvement Plan, dated 11/17, .Scope: . b. Our QAPI Plan addresses opportunities for improvement in patient care process with our committees/subcommittees. i. Clinical Care- . Using the available data the committee develops plans to identify and promote quality improvement for identified facility Focus Areas (falls, falls with injury .) . Systematic Analysis and Systemic Action: . b. The QAPI worksheet process and Root Cause Analysis (RCA) are used to identify improvement opportunities and to understand how to improve them . c. The QAPI Committee monitors progress to ensure that interventions or actions are implemented and effective in achieving and sustaining improvements . 055335 Page 23 of 25 055335 07/09/2021 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure transmission-based precautions (measures used to prevent spread of infection) were appropriately implemented per infection control standards, for 4 of 6 residents (Residents 19, 475, 477, & 478), when: Residents Affected - Few 1. Resident 19 and Resident 475 were placed together in one room while each resident required a different type of transmission-based precautions. 2. Three residents on transmission-based precautions had the doors open. These failures had the potential to increase the risk of infection for other residents and staff in the facility. Findings: 1. Resident 19 was admitted to the facility on [DATE] with diagnoses, which include acute cystitis (bladder infection), malignant neoplasm of prostate (prostate cancer), per the facility's Resident Face Sheet. According to Resident 19's progress notes, dated 6/30/21, the resident received antibiotics due to a Methicillin-resistant Staphylococcus aureus (MRSA- a bacteria resistant to some common antibiotics) urinary tract infection (UTI). According to Resident 19's Infection Control-Infection Report, dated 7/1/21, the resident received antibiotics for a UTI and required TBP (Contact Precautions- for infections that can be transmitted by direct or indirect contact with an infected person.) On 7/6/21 at 9:35 A.M., there were signs on Resident 19's door which indicated the room was in isolation for unknown COVID-19 status. An interview was conducted with licensed nurse (LN) 2 on 7/8/21 at 2:15 P.M. LN 2 stated Resident 19 was on contact precautions and antibiotics for MRSA in his urine. LN 2 further stated Resident 19's roommate (Resident 475) was on TBP because he was partially vaccinated and had an unknown COVID-19 status. During an interview with the Infection Preventionist (IP) on 7/9/21 at 1:57 P.M., the IP stated Resident 19 was on contact precautions due to a MRSA UTI and his roommate (Resident 475) was on TBP because he was only partially vaccinated for COVID-19. The IP stated Resident 475 was recently moved into the room with Resident 19. The IP stated, That was a mistake. The IP stated she was only notified of the room change after the fact. The IP further stated placing residents appropriately was important to contain infections and avoid outbreaks. During an interview with the director of nursing (DON) on 7/9/21 at 4:33 P.M., the DON stated she expected residents on TBP to be placed together per infection control standards to avoid cross-transmission of infections. 2. On 7/6/21 at 9:31 A.M., four rooms on the facility's A Hallway indicated those residents were on 055335 Page 24 of 25 055335 07/09/2021 LA Paloma Healthcare Center 3232 Thunder Drive Oceanside, CA 92056

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few transmission-based precautions (TBP). Two of the four rooms had the door to the hallway closed; the other two rooms had open doors. On 7/6/21 between 12:51 P.M. and 1:03 P.M., the same two rooms on TBP observed earlier had the doors open to the hallway. During an observation on 7/8/21 at 4:13 A.M. and 4:55 A.M., three of five rooms on TBP had the doors open to the hallway. During an interview with certified nursing assistant (CNA) 3 on 7/8/21 at 5:28 A.M., CNA 3 stated rooms on TBP needed to be closed to the hallway unless the resident was a fall risk. CNA 3 stated the residents in those TBP rooms with open doors were not fall risks. During an interview with licensed nurse (LN) 4 on 7/8/21 at 7:30 A.M., LN 4 stated the doors to rooms on TBP should remain closed unless the resident was a fall risk or they stated a preference to have the door open. During an interview with the Infection Preventionist (IP) on 7/9/21 at 2:11 P.M., the IP stated doors should remain closed in rooms on TBP. The IP stated some residents feel isolated and prefer the doors open, but in those instances, the resident's medical record and care plan should indicate the resident's preference for open doors. During a concurrent interview and record review at 2:15 P.M., the IP stated there was no preference for open doors documentation in Resident 477's or Resident 478's medical record. During an interview with the director of nursing (DON) on 7/9/21 at 4:23 P.M., the DON stated she expected the staff to follow TBP infection control standards, while also meeting the needs of the residents. The DON stated if they deviated from those standards due to safety or resident preferences, she expected documentation in the residents' care plans. According to a review of the facility's policy titled Infection Prevention and Control Program, dated 10/18, .An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Policy Interpretation and Implementation: .2. The program is based on accepted national infection prevention and control standards . 11. Prevention of Infection: A. Important facets of infection prevention include: . (7) Implementing appropriate isolation precautions when necessary . 055335 Page 25 of 25