Health inspection·September 22, 2022

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure written information regarding formulating an Advance Directive (AD - a written instruction such as a living will, relating to the provision of treatment and services when the individual is unable to make decisions) was provided to the residents and/or the resident's representative (RR), for nine of 10 residents reviewed for Advance Directive (Residents 15, 25, 40, 58, 61, 78, 82, 83, and 284). This failure had the potential for the residents to not be aware of their right to formulate an AD. Findings: On September 22, 2022, Residents 15, 25, 40, 58, 61, 78, 82, 83, and 284's records were reviewed: 1. Resident 15 was admitted to the facility on [DATE], with diagnoses which included orthopedic aftercare (type of care dealing with corrections of the bones and muscles). The Minimum Data Set (MDS - an assessment tool), dated September 9, 2022, indicated Resident 15 had a BIMS (Brief Interview for Mental Status) score of 13 (cognitively intact). The Physician Orders for Life-Sustaining Treatment (POLST - a written medical order from a physician, nurse practitioner, or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness), dated September 12, 2022, did not indicate information regarding formulating an AD was discussed with the resident and/or RR. 2. Resident 25 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (high blood sugar in the body). The POLST, dated December 18, 2018, did not indicate information regarding formulating an AD was discussed with the resident and/or RR. The MDS, dated July 25, 2022, indicated Resident 25 had a BIMS score of 5 (severely impaired). 3. Resident 40 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus. The POLST, dated January 20, 2021, did not indicate information regarding formulating an AD was Page 1 of 13 055954 055954 09/22/2022 National City Post Acute 220 East 24th Street National City, CA 91950

F 0578 discussed with the resident and/or RR. Level of Harm - Minimal harm or potential for actual harm The MDS, dated August 5, 2022, indicated Resident 40 had a BIMS score of 2 (severely impaired). Residents Affected - Some 4. Resident 58 was admitted to the facility on [DATE], with diagnoses which included cerebrovascular insufficiency (loss of blood flow to part of the brain). The MDS, dated July 26, 2022, indicated Resident 58 had a BIMS score of 15 (cognitively intact). The POLST, dated July 26, 2022, did not indicate information regarding formulating an AD was discussed with the resident and/or RR. 5. Resident 61 was admitted to the facility on [DATE], with diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body). The POLST, dated May 5, 2022, did not indicate information regarding formulating an AD was discussed with the resident and/or RR. The MDS, dated July 8, 2022, indicated Resident 61 had a BIMS score of 9 (moderately impaired). 6. Resident 78 was admitted to the facility on [DATE], with diagnoses which included orthopedic aftercare following surgical amputation (surgical removal of a limb). The POLST, dated July 12, 2022, did not indicate information regarding formulating an AD was discussed with the resident and/or RR. The MDS, dated September 2, 2022, indicated Resident 78 had a BIMS score of 14 (cognitively intact). 7. Resident 82 was admitted to the facility on [DATE], with diagnoses which included fracture (broken bone) of the lumbar (lower back). The MDS, dated August 15, 2022, indicated Resident 82 had a BIMS score of 15 (cognitively intact). The POLST, dated August 22, 2022, did not indicate information regarding formulating an AD was discussed with the resident and/or RR. 8. Resident 83 was admitted to the facility on [DATE], with diagnoses which included anemia (low red blood cell in the body). The POLST, dated November 23, 2021, did not indicate information regarding formulating an AD was discussed with the resident and/or RR. The MDS, dated June 23, 2022, indicated Resident 83 had a BIMS score of 15 (cognitively intact). 9. Resident 284 was admitted to the facility on [DATE], with diagnoses which included skin infection. The POLST, dated September 15, 2022, did not indicate information regarding formulating an AD was 055954 Page 2 of 13 055954 09/22/2022 National City Post Acute 220 East 24th Street National City, CA 91950

F 0578 discussed with the resident and/or RR. Level of Harm - Minimal harm or potential for actual harm The MDS, dated September 20, 2022, indicated Resident 284 had a BIMS score of 14 (cognitively intact). Residents Affected - Some There was no documented evidence information regarding formulating an AD was discussed or offered to resident or RR upon admission for Residents 15, 25, 40, 58, 61, 78, 82, 83, and 284. On September 22, 2022, at 6:30 p.m., an interview with the Social Service Director (SSD) was conducted. She stated AD information was offered to residents upon admission and quarterly thereafter. She stated the documentation about AD information being provided would be either in the resident's POLST and/or the progress notes. The SSD stated information regarding formulating an AD was never provided to the residents or RR if there was no documentation regarding the AD information either on the POLST or the progress notes. The facility's policy and procedure, titled Advance Directive, dated November 2017, was reviewed. The policy indicated, .This facility shall .Provide written information to the resident or resident representative at the time of admission regarding .Their right to accept or refuse medical treatment and the right to formulate an advance directive .Include documentation in the resident's health record at the time of admission that the resident has been provided with written information regarding advance directive and whether the resident has executed such a document . 055954 Page 3 of 13 055954 09/22/2022 National City Post Acute 220 East 24th Street National City, CA 91950

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the PASRR (Preadmission Screening and Resident Review - a federally required document to ensure residents are appropriately placed for services) was coded accurately for diagnosis of mental illness, for one of one resident reviewed for PASRR (Resident 40). Residents Affected - Few This failure had the potential for Resident 40 to not receive the care and necessary services under the appropriate setting. Findings: On September 20, 2022, Resident 40's record was reviewed. Resident 40 was admitted to the facility on [DATE], with diagnoses which included dementia (decline in mental status), depressive disorder (mood disorder), and bipolar disorder (mood disorder). The PASRR, dated November 29, 2021, did not indicate Resident 40 had a diagnosis of mental health disorders. On September 26, 2022, at 12:04 p.m., an interview with the Director of Nursing (DON) was conducted. She stated Resident 40 was admitted with a mental health conditions which included depressive disorder and bipolar disorder. She stated the PASRR should have been coded correctly to reflect Resident 40 had a diagnoses of mental health disorders. The facility's policy and procedure, titled Preadmission SCREENING AND RESIDENT REVIEW (PASRR) Policy, dated August 2022, was reviewed. The policy indicated, .It is the policy of this facility to complete and submit a PASRR screening online for new admission to prevent individuals with Mental Illness (MI) .or other related conditions from being inappropriately placed in nursing homes for long term care . 055954 Page 4 of 13 055954 09/22/2022 National City Post Acute 220 East 24th Street National City, CA 91950

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for oxygen administration, for one of one resident reviewed for oxygen use (Resident 6). This failure had the potential to negatively impact the resident's quality of care and had the potential for staff to not be aware of the resident's care needs and provide appropriate treatment. Finding: On September 19, 2022, at 11:50 a.m., Resident 6 was observed in bed, with oxygen (O2) via nasal cannula (NC - a tube used to deliver oxygen through the nose). Resident 6's oxygen administration was observed at three liters per minute (LPM). In a concurrent interview with Resident 6, she stated she uses O2 continuously due to shortness of breath. Resident 6's record was reviewed. Resident 6 was admitted to the facility on [DATE], with diagnoses which included acute respiratory failure (lung failure). The physician's order, dated August 10, 2021, indicated, .Continuous O2 via NC at 3LPM . On September 22, 2022, at 9:17 a.m., a concurrent interview and record review was conducted with Registered Nurse (RN) 1. RN 1 stated Resident 6 had a physician's order for oxygen. RN 1 stated there was no documentation a comprehensive care plan for oxygen use was initiated for Resident 6. RN 1 stated Resident 6 should have had a comprehensive care plan for oxygen administration. On September 22, 2022, at 9:26 a.m., the Director of Nursing (DON) was interviewed. The DON stated a comprehensive care plan for oxygen administration was not developed for Resident 6. The DON stated a comprehensive care plan for O2 administration should have been developed for Resident 6. The facility policy and procedure titled, Care Plan, Baseline and Comprehensive, revised November 2017, was reviewed. The policy indicated, .A comprehensive, person-centered care plan consistent with residents rights will include measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs .The comprehensive care plan must describe the following .Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . The facility policy and procedure titled, Oxygen, revised November 2012, was reviewed. The policy indicated, .It is the policy of this facility to provide oxygen support via appropriate delivery device, in a safe manner .to maintain adequate oxygenation to the respiratory compromised resident .The use of oxygen will be included on the care plan . 055954 Page 5 of 13 055954 09/22/2022 National City Post Acute 220 East 24th Street National City, CA 91950

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, for one of one resident reviewed for falls (Resident 25), the facility failed to ensure: 1. Adequate supervision and close monitoring were provided; and 2. Effectiveness of interventions were evaluated, and new interventions were implemented to address resident's behavior of getting up unassisted and prevent further falls. These failures resulted to Resident 25 to have five repeated falls in 2022 while at the facility. The resident's 5th incident of fall on September 20, 2022, resulted in Resident 25 sustaining left hip fracture (broken bones), and was transferred out to acute hospital for further evaluation and surgery. Findings: On September 20, 2022, at approximately 1:05 p.m., Resident 25 was observed standing near the foot of her bed and was trying to ambulate. Resident 25 was observed to have difficulty standing and keeping her balance. There were no staff observed near Resident 25's room nor the hallway to monitor Resident 25. On September 20, 2022, at 1:10 p.m., the Administrator (ADM) was informed of Resident 25 needing assistance. The ADM was observed to walk to Resident 25's room and found the resident on the floor. Resident 25 was observed on the floor laying on her left side with both arms and legs flexed. On September 20, 2022, Resident 25's record was reviewed. The admission Record, indicated Resident 25 was admitted to the facility on [DATE], with diagnoses which included disorders of bone density and structure (bone disease), unsteadiness on feet, Alzheimer's disease (mental health condition with memory loss), and dementia with behavioral disturbance (mental health condition with memory loss). A review of the untitled care plan, dated December 16, 2018, indicated, . (name of resident) has impaired cognitive function/dementia or impaired thought process r/t (related to) Alzheimer's (sic), Dementia, Difficulty making decisions .Interventions .Engage the resident in simple, structured activities that avoid overly demanding tasks . A review of Resident 25's record indicated a bowel toileting program was initiated since April 4, 2019, and indicated the resident to be assisted to the bathroom before and after meals and at bedtime. A review of the untitled care plan, initiated January 20, 2022, indicated, (Resident's name) is risk for falls r/t poor safety awareness .fall risk assessment 26 (high) .dementia .Alzheimer's disease . A review of the document titled, Progress Notes, dated January 20, 2022, at 4:20 p.m., indicated, .Around 4PM (4 p.m.) CNA (Certified Nursing Assistant) called the writer that (resident's name) found on the floor, face down and nose bleeding .According to her she's trying to gets-up (sic) by 055954 Page 6 of 13 055954 09/22/2022 National City Post Acute 220 East 24th Street National City, CA 91950

F 0689 Level of Harm - Actual harm Residents Affected - Few herself, tries to transfer herself to bed without calling for assistance, was out of balance and landed on the floor .Noted L (left) forehead bump, bruising and swollen, L (left) eye is red and nose stops bleeding with redness/bruising also. Resident verbalized pain on the affected area (L forehead bump) .Noticed vomits when incident happens. Noted resident confused, trying to get up most of the time, thinking she can be able to walk without assistance and saying wanna (want to) go home to Mexico .Called (physician's name) to send to ER (emergency room) for further eval . A review of the document titled, Progress Notes, dated January 20, 2022, at 4:10 p.m., indicated the following interventions were placed after the fall incident on January 20, 2022: - Landing mat (a soft mat placed at the side of the bed used when the resident falls out of bed); - Call light within reach; - Closely monitoring for safety and comfort; and - Keep resident clean and dry. A review of the document titled, admission Record, indicated Resident 25 was readmitted back to the facility from the acute hospital on January 23, 2022. A review of the document titled, Fall Risk Assessment, dated January 23, 2022, indicated, .History of Falls within last six months .Multiple Falls .Agitated Behavior in Last Seven Days .Behavior occurred daily or more .Gait Analysis .Unable to independently come to a standing position .Exhibits loss of balance while standing .Strays off the straight path of walking .Requires hands-on assistance to move from place to place . A review of the document titled, Progress Notes, dated February 2, 2022, at 10:09 p.m., indicated, .Resident had unwitnessed fall. Staff found resident sitting on the floor mat by bedside . A review of the document titled, FSI-Fall Scene Investigation Report, dated February 2, 2022, indicated lowering and locking the bed as new intervention recommended. A review of the Minimum Data Set (MDS- an assessment tool), dated July 12, 2022, indicated the following information on Resident 25: - BIMS (Brief Interview for Mental Status) score of 2 (severely impaired); - Required one-person extensive assistance with transfer; - With unsteady balance requiring staff assistance with moving from seated to standing position and transferring between bed and wheelchair; - Always incontinence (involuntary leakage) of the bladder and frequent incontinence of the bowel; and - On a toileting program to address bowel continence. A review of the document titled, Progress Notes, dated July 27, 2022, at 2 p.m., indicated, .At 055954 Page 7 of 13 055954 09/22/2022 National City Post Acute 220 East 24th Street National City, CA 91950

F 0689 0915 (9:15 a.m.) Resident found sitting on the floor with both flexed and right hand holding on the sink and left hand holding the toilet seat . Level of Harm - Actual harm Residents Affected - Few A review of the document titled, FSI-Fall Scene Investigation Report, dated July 27, 2022, indicated Resident 25 was left alone in the bathroom and was trying to get up. A review of the untitled care plan, initiated on July 28, 2022, indicated, .IDT (Interdisciplinary Team - a group of healthcare professionals) Fall Review: Recommending staff remain with patient for direct supervision during toileting program to reduce risk for falls . A review of the document titled, Progress Notes, dated August 7, 2022, at 2:39 p.m., indicated .At 13:25 (1:25 p.m.) Resident found sitting on the floor, leaning backward against the wheelchair, both foot rest on axilla (underarm), both legs are extended with soiled adult brief . A review of the document titled, FSI-Fall Scene Investigation Report, dated August 8, 2022, indicated Resident 25 was trying to stand up prior to the fall and was last toileted at 9 a.m. (Resident 25 should have been toileted before and after lunch according to the toileting program initiated on April 4, 2019). The document also included interventions to implement toileting schedule, and ensure the resident was placed in high visibility area when out of bed. OT (occupational therapy) was also recommended to assess for fall preventions to maximize safety and decrease risk of falls. A review of the physician's order, dated August 9, 2022, indicated, .Patient will receive skilled OT services 3x/wk (three times a week) for 4 (four) weeks for self-care, there (therapeutic) ex (exercise), there act (activities), wheel chair management, group therapy, and patient/caregiver education in order to maximize safety and decrease risk for falls .related to UNSTEADINESS ON FEET .for 30 days. A review of the document titled, OT Evaluation & Plan of Treatment, dated August 9, 2022, indicated, .Clinical Impressions: Pt (patient) .with decreased safety awareness and cognitive deficits, decreased strength, balance and endurance that raise a concerns (sic) for safety with functional transfers, mobility and ADLs (Activities of Daily Living) . A review of the document titled, Occupational Therapy Discharge Summary, dated September 13, 2022, indicated Resident 25 received OT services from August 9 to September 13, 2022. The document included the following: - Short term goal for Resident 25 was to complete toilet/commode transfers with minimal assist and occasional verbal cues for safety awareness. Resident 25 required maximum assistance and 90% of verbal cuing upon discharge from OT services (goal not met); - Long term goal to decrease risk for falls as evidence by scoring of more than 6 (six); Resident 25 scored 1 (one) upon discharge from OT services (goal not met); and - Recommendation to continue with restorative nursing program. There were no further interventions initiated to address Resident 25's behavior of getting up unassisted after completing OT services on September 13, 2022. A review of the document titled, Progress Notes, dated September 20, 2022, at 3:56 p.m., indicated 055954 Page 8 of 13 055954 09/22/2022 National City Post Acute 220 East 24th Street National City, CA 91950

F 0689 Level of Harm - Actual harm .Around 1310 (1:10 p.m.) CN (charge nurse) was notified by business personnel patient had an (sic) fall. CN then went to the room and found patient lying on the floor on her left side. Both feet legs flexed and both arms on her side .Patient complained of pain on L (left) hip and L (left) lower leg, unable to move .MD (physician) was notified with order to send to ER (emergency room) for eval (evaluation) . Residents Affected - Few A review of the document titled, FSI-Fall Scene Investigation Report, dated September 20, 2022, indicated Resident 25 was trying to stand up prior to the fall. There were no new interventions recommended after this fall incident. A review of the document titled, Progress Notes, dated September 21, 2022, at 8:54 a.m., indicated F/U (follow up) call (name of hospital) .Resident is admitted for left hip fracture and going for surgery today at 11AM (11 a.m.) . There were no documented evidence specific interventions were implemented to provide close supervision and monitoring for Resident 25 to address the resident's behavior of getting up unassisted after each fall incident on January 20, February 2, July 27, August 7, and September 20, 2022. On September 22, 2022, at 11:51 a.m., Registered Nurse (RN) 3 was interviewed. She stated Resident 25 had the tendency to get up from her wheelchair unassisted. She stated Resident 25 was confused at most times and required redirections. On September 22, 2022, at 12 p.m., an interview with CNA 1 was conducted. She stated Resident 25 should be taken to the restroom before and after each meal (breakfast and lunch during morning shift). She further stated Resident 25 had tendency to get out of bed unassisted. On September 22, 2022, at 1:27 p.m., during an interview with CNA 2, he stated Resident 25 had to be closely monitored for episodes of getting out of bed without asking staff for help. He stated Resident 25 was often confused and have poor safety awareness. He stated he usually would bring Resident 25 to the nursing station or the receptionist area after the resident went to the bathroom before and after meals for close monitoring. On September 22, at 1:42 p.m., during an interview, CNA 3 stated she was the CNA assigned to Resident 25 on September 20, 2022. She stated she assisted Resident 25 to the bathroom at around 1 p.m. and put resident back to bed. She stated she left Resident 25 in the room and went to pick up meal trays. On September 22, 2022, at 3:40 p.m., the Occupational Therapy Program Manager (OTPM) was interviewed. She stated Resident 25 received OT services from August 9 to September 13, 2022. She stated they mostly worked on the resident's safety and muscle strengthening to improve balance and prevent fall. She stated Resident 25's response to OT treatment varied depending on her cognitive status. She stated OT services were discontinued as Resident 25 had reached the maximum potential based on her cognitive status. On September 22, 2022, at 6:45 p.m., an interview with the Director of Nursing (DON) was conducted. She stated Resident 25 had multiple falls prior to the last fall on September 20, 2022 (which resulted in a left hip fracture). The DON stated Resident 25 was confused and required redirections. She stated Resident 25 required close supervision and monitoring from staff due to her episodes of getting out of bed unassisted. She stated if the nursing staff were not able to monitor Resident 25, the 055954 Page 9 of 13 055954 09/22/2022 National City Post Acute 220 East 24th Street National City, CA 91950

F 0689 resident would be brought either at the nursing station, receptionist area, or to the activities to be monitored closely by the staff. Level of Harm - Actual harm Residents Affected - Few During the interview with the DON, she stated she was not sure why Resident 25 was in bed after being toileted during the last fall incident on September 20, 2022. She stated Resident 25 should have been brought to the activities or at the nursing station after toilet use. She stated Resident 25 should always be within eye sight from staff. The DON also stated Resident 25 continued to get out of bed due to her current cognitive status and sustained multiple falls despite interventions implemented for the resident. The DON stated she was not sure as to why Resident 25's behavior of getting out of bed was not evaluated or addressed after each fall incident. She was also not sure as to why effectiveness of the interventions were not evaluated after each fall incident for Resident 25. The DON stated the fall incidents in July and August of 2022 were due to Resident 25 getting out of bed to use the restroom. She stated OT referral was initiated after Resident 25 fell on August 7, 2022, to help the resident gain strength and balance while standing. She was not sure as to why OT therapy was not initiated or evaluated earlier for Resident 25 after the fall incident on July 27, 2022. The DON further stated starting OT services earlier than August 9, 2022, would have been beneficial for Resident 25. In addition, the DON further stated a fall alarm could have helped to prevent falls for Resident 25. She stated the facility currently discouraged the use of fall alarm on residents who were high risk for fall. The facility policy and procedure titled, Falls Management, dated November 2012, was reviewed. The policy indicated, .It is the policy of this facility that our physical environment remains as free of accident hazards as possible .Residents will be assessed for fall risk and interventions will be implemented to reduce the risk of falls .Resident who have sustained a fall, will be placed on the facility's heightened awareness program, which includes visual identifier, (i.e. Falling Star), designed to alert staff of a resident who has actively fallen in the presence of standard fall prevention interventions that have been outline on the care plan .Recent falls will be reviewed daily by the designated fall team, to evaluate cause, determine additional strategies as needed to prevent recurrence for each resident and further revise the care plan if needed .General incident and accident trending will be complied and reviewed no less often than quarterly by the Quality Assessment and Assurance Committee. The review will include identification of trends, educational needs, common casual factors, (i.e., toileting needs, staffing patterns, etc.), and will develop strategies for systemic correction and resolution . 055954 Page 10 of 13 055954 09/22/2022 National City Post Acute 220 East 24th Street National City, CA 91950

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications and medical supplies were labeled and stored according to the facility policy and manufacturer's guidelines, when: 1. The pharmacy label on the medication bubble pack did not match the physician's order on the Medication Administration Record (MAR), for one of 11 residents reviewed during the medication administration observation (Resident 236). This failure had the potential to result in Resident 236 to not receive the correct frequency and dosage of the medication prescribed by the physician; 2. One opened vial of tuberculin testing solution (test for tuberculosis - lung infection) was not labeled with a date when it was opened, and readily available to administer. This failure had the potential to not be able to determine the effect and potency of the tuberculin testing solution; and 3. Expired medical supplies were stored and readily available for use. This failure had the potential for residents of the facility to receive expired medical supplies. Findings: 1. On [DATE], at 12:35 p.m., during the medication administration observation conducted with Registered Nurse (RN) 1 for Resident 236, one bubble pack with a refill date of [DATE], was observed with a label indicating, .gabapentin (medication for nerve pain) 300 mg (milligrams - unit of measurement) .take 1 (one) capsule by mouth 2 (two) times a day . In a concurrent interview with RN 1, he stated a new physician's order, dated [DATE], indicated to administer the gabapentin 300 mg one capsule by mouth three times a day. He stated a label should have been placed on the bubble pack indicating the change in directions for the administration of gabapentin 300 mg three times a day for Resident 236. On [DATE], Resident 236's record was reviewed. Resident 236 was admitted to the facility on [DATE], with diagnoses which included osteomyelitis of the left ankle and foot (swelling in the bone) and diabetic neuropathy (pain from nerve damage). The Order Summary Report, included a physician's order dated [DATE], which indicated, .Gabapentin Capsule 300 MG Give 1 (one) capsule by mouth three times a day . On [DATE], at 6:34 p.m., the Director of Nursing (DON) was interviewed. The DON stated the bubble pack for Resident 236's gabapentin medication should have a sticker indicating there was a change in the frequency to be administered. 2. On [DATE], at 5:15 p.m., during an inspection of the medical storage room conducted with RN 4, 055954 Page 11 of 13 055954 09/22/2022 National City Post Acute 220 East 24th Street National City, CA 91950

F 0761 one opened vial of tuberculin testing solution was observed to have no date when it was opened. Level of Harm - Minimal harm or potential for actual harm During an interview with RN 4, she stated the tuberculin solution should have a date written when the vial was opened. The RN stated the undated opened vial of tuberculin testing solution should be discarded. Residents Affected - Few According to the undated manufacturer's guidelines for tuberculin testing solution, .Storage .A vial of TUBERSOL (brand of tuberculin testing solution) which has been entered and in use for 30 days should be discarded. 3. On [DATE], at 5:30 p. m., the following expired medial supplies were observed to be stored and readily available for use: - five boxes of gastrostomy (surgical opening through the stomach) feeding tubes, with expiration dates of [DATE]; - three boxes of gastrostomy feeding tubes, with expiration dates of [DATE]; and - two gravity drainage bags, with expiration dates of [DATE]. In a concurrent interview with RN 4, she stated the expired gastrostomy feeding tubes and gravity drainage bags should be discarded and not readily available for use. The facility's policy and procedure titled, Medication Administration - General Guidelines, dated [DATE], was reviewed. The policy indicated, .Prior to administration, the medication and dosage schedule on the resident's medication administration record (MAR) is compared with the medication label. If the label and MAR are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule . The facility's policy and procedure titled, Medication Ordering and Receiving from Pharmacy, dated [DATE], was reviewed. The policy indicated, .If the physician's directions for use change or the label is inaccurate, the nurse may place a change of order label on the container indicating there is a change in directions for use, taking care not to cover important label information .When such a label appears on the container, the medication nurse checks the resident's medication administration record (MAR) or the physician's order for current information .The dispensing pharmacy is informed prior to the next refill of the prescription so the new container will show an accurate label . The facility's policy and procedure titled, Medication Storage in the Facility dated [DATE], was reviewed. The policy indicated, .Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal .Medication storage conditions are monitored on a routine basis and corrective action taken if problems are identified . 055954 Page 12 of 13 055954 09/22/2022 National City Post Acute 220 East 24th Street National City, CA 91950

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 expired food items were not stored in the refrigerator, readily available for use. This failure had the potential to result in foodborne illness to an already vulnerable facility population. Findings: On September 19, 2022, at 11:10 a.m., an initial tour of the kitchen was conducted with the Certified Dietary Manager (CDM). The following food items were observed stored inside the refrigerator and freezer: - One plastic jar of Dijon mustard, approximately half full, was observed with an open date of November 23, 2021 and a used by date of June 2022. The opened jar of mustard had a Best By date of June 29, 2022 printed on the product label. In a concurrent interview, the CDM stated the mustard was expired and should not have been stored in the refrigerator, readily available for use. - An opened carton box of whole kernel corn was observed in the freezer with a date label of June 6, 2022. A bag of frozen corn kernels, weighing approximately three pounds, was observed inside the carton box readily available for use. In a concurrent interview, the CDM stated the date on the box represented the date when it was opened. She stated the corn was good for three months after the opening date. The CDM stated the box of corn should have been discarded on September 6, 2022, and it should not have been stored in the freezer, readily available for use. The facility policy and procedure titled, Storing Refrigerated Foods, revised January 2013, was reviewed. The policy and procedure indicated, .Purpose .Safely and sanitarily store refrigerated foods .store foods under refrigeration only for short periods of time. Refer to Storage Periods: Refrigerated Foods for maximum storage period standards . The facility policy and procedure titled, Storing Frozen Foods, revised January, 2013, was reviewed. The policy and procedure indicated, .store frozen foods only for periods of time that will not affect the quality of the product. Refer to Storage Periods: Frozen Foods foe (sic) maximum storage period standards . On September 19, 2022, at 11:40 a.m., an interview with the CDM was conducted. The CDM stated the list for storage periods for refrigerated foods and for frozen foods was not that specific as to include the open mustard jar or the frozen corn kernels. 055954 Page 13 of 13