Health inspection·August 11, 2022

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 professional standards of practice were followed for one of 21 sampled residents (48) when the physician's orders were not clarified and transcribed correctly. Residents Affected - Few This failure resulted in the physician's order not being followed. Findings: Resident 48 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus (too much sugar circulating in your blood stream), per the facility's admission Record. On 8/10/22 at 2:48 P.M., Resident 48's record review was conducted. Resident 48 was discharged to the general acute hospital on 6/15/22 due to chest pain and she was readmitted back to the facility on 6/17/22. The Medication Reconciliation / Physician Order Form from the acute hospital, was signed as a physician telephone order dated 6/17/22, indicated the list of medications that Resident 48 would continue to take, medications to stop, and new medications. On 8/10/22 at 3:07 P.M., an interview was conducted with Licensed Nurse (LN) 31. The LN 31 stated, Resident 48 was receiving Humalog Insulin (medication for blood sugar) according to her Insulin sliding scale (Medication dose based on the blood sugar level). On 8/11/22 at 10:26 A.M., a concurrent interview with LN 32 and review of Resident 48 record was conducted. LN 32 stated, the Medication Reconciliation/Physician Order Form received from the acute hospital on 6/17/22, was not transcribed correctly into Resident 48's record. LN 32 stated the order for Humalog Insulin sliding scale was missing the additional instruction which indicated If patient receives evening snack (2100), administer one-half (1/2) the calculated sliding scale dose. LN 32 reviewed Resident 48's Medication Administration Record (MAR) and stated that Resident 48 received full dose of Humalog Insulin sliding scale dose at bedtime (2100) since June 18,2022 until August 10,2022. On 8/11/22 at 10 A.M., an interview was conducted with CNA 36. CNA 36 stated, Resident 48 received snacks at night. On 8/11/22 at 10:51 A.M., an interview was conducted with Resident 48. Resident 48 stated she received snacks at night. On 8/11/22 at 11:30 A.M., an interview was conducted with the DON. The DON stated, Medication Page 1 of 25 055964 055964 08/11/2022 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Reconciliation /Physician Order Form from the acute hospital must be transcribed by the LN correctly and clarified with the physician, if needed. A review of the facility's provided policy, dated November 2017, titled Physician Medication Orders, indicated . 4. orders must be transcribed immediately in the resident's chart by the person receiving the order . 055964 Page 2 of 25 055964 08/11/2022 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the manufacturer's setting for air loss mattress was followed for one of 21 sampled residents (Resident 339). Residents Affected - Few This failure had the potential to affect Resident 339's skin integrity and comfort. Findings: Resident 339 was admitted to the facility on [DATE] with diagnoses which included acute osteomyelitis of right and left ankle foot (infection of the bone), diabetes mellitus (too much sugar circulating in your body), non- pressure chronic ulcer of right and left foot (sore caused by poor circulation) and cellulitis of right and left lower limb (infection of the skin), per the facility's admission Record. On 8/9/22 at 11:04 A.M., an observation and interview were conducted with Resident 339. Resident 339 was in his bed. Resident 339 was awake and responded verbally. He stated he was tired after his therapy. Resident 339 stated dressing on his right and left lower leg were changed daily. Resident 339 observed to have an air loss mattress in his bed. The air loss mattress setting was set on # 5 or equivalent to 210 pounds. Resident 339 stated his weight was about 300 pounds. On 8/10/22 at 9:17 A.M., an observation and interview were conducted with Resident 339. Resident 339 was in bed and stated that he had pain in his indwelling catheter site (soft, plastic or rubber tube that is inserted into the bladder to drain the urine) and uncomfortable in bed. Resident 339 refused his dressing changed and repositioned in bed. Resident 339 air loss mattress setting was #5 or equivalent to 210 pounds. On 8/10/22 at 10:06 A.M., an interview was conducted with Licensed Nurse (LN) 31. LN 31 stated the setting for Resident 339 air loss mattress was incorrect. The mattress setting should have been based on resident's weight. LN 31 stated that Resident 339 air loss mattress should have been set at # 7 which was equivalent to his weight. Joint record review was conducted with LN 31. LN 31 stated Resident 339 weight as of 8/6/22 was 300.2 lbs. On 8/10/22 at 10:12 P.M., an interview was conducted with LN 41. LN 41 stated, Resident 339 air loss mattress was set to #5. LN 41 stated, the number displayed on the panel should have been based on the weight and comfort of the resident. On 8/10/22 at 10:31 A.M., a joint record review and interview was conducted with the DON. The DON stated correct setting for the air loss mattress was very important to prevent skin breakdown and distribute the patient's body weight. A review of the user manual for air loss mattress, provided by the facility, page 22 indicated . The Comfort Control LED displays the patient comfort pressure levels from 0-9 and provides a guide to the caregiver to set approximate comfort pressure level depending on the patient weight . 055964 Page 3 of 25 055964 08/11/2022 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that fall prevention interventions were implemented for one Resident (64). In addition, the facility failed to ensure adequate supervision to residents when an exit door was propped open. This failure caused Resident 64 to experience a fall and the potential for residents to go outside the facility without staff supervision. Findings: 1. Resident 64 was admitted to the facility on [DATE] with diagnoses that included right sided stroke and hemiparesis (muscle weakness that affects one side of the body) and hemiplegia (partial paralysis on one side of the body), per the facility's admission Record. An observation of Resident 64 was conducted on 8/8/22 at 3:00 P.M. Resident 64 was reclining in bed watching TV. A review of Resident 64's fall risk assessment, dated, 7/5/22 indicated a score of 20 (high risk). A review of Resident 64's record was conducted on 8/9/22 at 9:15 A.M. The record indicated Resident 64 had a fall on 7/24/22. The change of condition (COC): indicated .patient had an assisted fall @ 9:30. During the transfer from bed to wheelchair (w/c), the left side of the w/c started to roll, causing the patient weights shifted on her right sided weakness, CNA eased her down to the floor . An interview was conducted on 8/10/22 at 9:32 A.M., with certified nurse assistant (CNA) 11. CNA 11 stated, Resident fell while I was transferring her; she is a 2-person transfer; I assisted her to the ground. I called for help (for the transfer) and I should have waited for help and done a 2-person transfer. The ADL (activities of daily living) care plan says 1-2 person transfer. An interview was conducted with the director of nursing (DON) on 8/10/22 at 9:57 A.M. The DON stated, The CNA could not support the resident's weight; the resident sometimes needs 2 person assist, care plan says 1-2. A joint interview was conducted with the DON and Administrator (admn) on 8/11/22 at 11:13 A.M. The admn and DON stated, The CNA should have called for help to prevent falls. A review of the facility's policy, dated 4/2018, titled, Fall/Accident Management, indicated, .the facility strives to provide each resident with adequate supervision and assistance to minimize the risks associated with falls . 2. On 8/8/22 at 12:50 P.M., an observation was conducted during the initial screening. The exit door leading to the smoking area was opened. The door was propped with a piece of wood. An unsampled resident (55) was seen wheeled outside the door by a visitor; no alarm was triggered and no staff present at the smoking area. A sign inside the door above the fire alarm indicated Close door at all times. 055964 Page 4 of 25 055964 08/11/2022 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 8/8/22 at 1:02 P.M., an interview was conducted with CNA 37. CNA 37 stated the door should be closed at all times. CNA 37 stated, the door was propped open during the smoking time. The door will alarm only for those residents who have WanderGuard bracelet (a device that trigger alarm for residents trying to leave unattended) On 8/8/22 at 1:10 P.M., an interview was conducted with the admission Coordinator, who was assigned to supervised residents during the scheduled smoking time. The admission Coordinator stated, the exit door should be closed at all times to make sure residents were monitored and supervised during smoking times. On 8/9/22 at 4:03 P.M., an observation of the exit door propped open. An interview was conducted with CNA 38. CNA 38 stated, the exit door was opened with a piece of wood until 5:00 P.M. Residents were observed going in and out of the exit door. There was no staff at the smoking area. On 8/11/22 at 7:30 A.M., an interview was conducted with the Maintenance Director. The Maintenance Director stated, all exit door should be closed at all times and should not be propped open to ensure the safety of the residents. On 8/11/22 at 11:36 A.M., an interview with the DON was conducted. The DON stated, exit doors should be closed at all times. A review of the facility's policy, dated 7/1/20, titled Safety Supervision of Residents, indicated . Resident safety and supervision and assistance to prevent accidents are facility - wide priorities . Resident supervision is a core component of the system approach to safety . The facility did not provide a specific policy regarding doors. 055964 Page 5 of 25 055964 08/11/2022 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview and record review, the facility failed to provide appropriate care and treatment to a Gastrostomy Tube (GT, a tube placed surgically directly into to the stomach to deliver liquid food) for one of one sampled resident (Resident 82) when the LN did not verify GT placement prior to administering medication. This failure increased the risk for Resident 82 to develop complications related to improper GT placement. Findings: During a medication pass observation on 8/8/22 at 9:28 A.M., at North Station, Hall 1, with LN 60. LN 60 prepared Resident 82's medications which included a valproic acid (medication for seizures and mental disorders). LN 60 used a stethoscope (medical instrument for detecting sounds) to hear Resident 82's bowel sound. LN 60 then administered Resident 82's medications through the GT and restarted the liquid food. During an interview on 8/8/22 at 4:25 P.M., with LN 60. LN 60 acknowledged she did not check Resident 82's gastric residual volume prior to administering valproic acid. LN 60 stated, We are supposed to check gastric residual volume [GT placement] before giving medication. During an interview on 8/8/22 at 4:32 P.M., with the DSD. The DSD stated, the nursing staff was expected to check gastric residual volume for residents with GT prior to administering medications. The DSD stated, We want to make sure resident not getting too much fluid. During an interview on 8/11/22 at 2:29 P.M., with the DON. The DON stated, Prior to administering medications, nurse should be checking placement for any G-tube medication by aspirating prior to medication administration to verify placement and verify medication correctly . patient could be at risk for vomiting or aspiration if they have too much fluid, so important to check fluid volume . During a review of ASPEN Safe Practices for Enteral Nutrition Therapy, a nationally recognized guideline for enteral nutrition indicated, A gastric residual volume of between 250 and 500 mL should lead to implementation of measures to reduce risk of aspiration 055964 Page 6 of 25 055964 08/11/2022 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 obtain and follow physician's order for residents receiving oxygen therapy for two of four sampled residents (Resident 25,340). Residents Affected - Few This deficient practice had the potential to result in complications from lack of or excessive oxygen therapy. Findings: 1. Resident 25 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (cause airflow blockage and breathing-related problems), per the facility's admission Record. On 8/9/22 at 1:45 P.M, an observation with Resident 25 was conducted inside the resident's room. Resident 25 was in her bed and wore a nasal cannula (device used to deliver oxygen through the nose). The oxygen was set and delivered at 4.5 L(litter)/min. On 8/10/22 at 9:39 A.M., an observation was conducted with Resident 25. Resident 25 observed in her bed without an oxygen. On 8/10/22 at 2:44 P.M., a concurrent observation with Resident 25 and an interview with certified nurse assistant (CNA) 36 was conducted. Resident 25 was observed in bed without an oxygen. CNA 36 stated, Resident 25 required oxygen when her blood saturation level was low. On 8/10/22 at 3:13 P.M., an interview was conducted with the Licensed nurse (LN )31. The LN 31 stated, Resident 25 did not require oxygen therapy. Oxygen therapy would have been administered when Resident 25 oxygen saturation level was low. On 8/10/22 at 3:15 P.M., a concurrent record review and interview with LN 31 was conducted. Resident 25's physician order, dated 8/2/22, indicated Oxygen at 2 liters per minute every shift. LN 31 stated, Resident 25 should have received oxygen at 2L/min at all times. A review of Resident 25's undated care plan indicated, Resident 25 oxygen setting was at 2 liters per minute via nasal cannula every shift. 2. Resident 340 was admitted to the facility on [DATE] with diagnoses which included cancer of the prostate, per the facility's admission Record. On 8/9/22 at 1:54 P.M., an observation of Resident 340 was conducted in his room. Resident 340 had an oxygen set at 3L (litter)/ (per) minute through nasal cannula (device used to deliver oxygen through the nose). On 8/10/22 at 12:12 P.M., a concurrent observation with Resident 340 and an interview with CNA 36 was conducted. Resident 340 was in bed with the oxygen set at 3.5 L per minute through nasal cannula. CNA 36 stated resident 340 used oxygen at all times. On 8/10/22 at 12:27 P.M., concurrent record review and interview with the LN 31 was conducted. LN 055964 Page 7 of 25 055964 08/11/2022 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 31 stated there was no physician order found for oxygen therapy. LN 31 further stated, Oxygen therapy should have a physician's order. On 8/11/22 at 11:40 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated, licensed staff should have obtained and followed physicians order related to oxygen therapy to make sure that residents received the proper oxygen treatment. A review of the facility policy titled, Oxygen Administration, dated, 7/1/2020, indicated, .1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration . 055964 Page 8 of 25 055964 08/11/2022 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a fluid restriction order for a resident (390) having dialysis was followed. This failure had the potential to cause fluid overload for the resident. Residents Affected - Few Findings: Resident 390 was admitted to the facility on [DATE] with diagnoses that included end-stage renal disease (kidneys stop working) and dependence on renal dialysis (removes waste products and excess fluid from the blood) per the facility's admission Record. On 8/09/22 at 9:28 A.M., and observation was conducted for Resident 390. Resident 390 was in bed, alert, and eating breakfast (eggs,juice,milk). In addition, there were two plastic (16.9 ounces) water bottles on the overbed table. On 8/10/22 at 8:30 A.M., a review of Resident 390's medical record was conducted. A physician's order, dated 8/8/22, indicated, fluid restriction 1200 mL (milliliters)/day. On 8/10/22 at 8:56 A.M. a concurrent record review and interview was conducted with the charge nurse (CN). The CN stated, The water bottles should not be there, he is on fluid restriction of 1200 cc per day. Any additional water can cause fluid overload. On 8/11/22 at 11:16 A.M., a joint interview was conducted with the Administrator (admn) and the Director of Nursing (DON). The DON stated, The nursing staff should assess compliance with fluid restriction; it is important so residents can reach their goals. A review of the facility's policy dated,11/2017, titled, Dialysis Management, Purpose: to provide residents who require dialysis care, services consistent with professional standards of practice . 055964 Page 9 of 25 055964 08/11/2022 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

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. Based on interview, and record review, the facility failed to implement its pharmaceutical policies and procedures when nursing staff did not ensure accurate controlled substance (CS, medications that can be easily abused and are under strict government control) accountability for two of two CS records reviewed (for Residents 40 and 88). This failure had the potential for diversion (used illegally) of controlled substance medications (a drug that can be abused or cause addiction). Findings: During an observation on 8/9/22 at 11:18 A.M., with LN 31 at the medication cart on South Station, Hall 3 was inspected. The medication cart was observed to have hydrocodone-acetaminophen (controlled pain medication) 5-325 milligrams (mg- unit of measurement) for Resident 40 and oxycodone-acetaminophen (controlled pain medication 5-325mg for Resident 88. During an interview on 8/9/22 at 3:40 P.M., with the DON. The DON was asked for the July 2022 narcotic records for hydrocodone-acetaminophen 5/325mg for Resident 40 and oxycodone-acetaminophen 5-325mg for Resident 88. The DON stated, that he was unable to locate the July 2022 narcotic (controlled drugs) records because they were unorganized. When asked what system the facility had in place to periodically reconcile controlled drug records, the DON stated, he was not aware that controlled drug records for schedule II drugs were supposed to be separated and did not separate the controlled drug records. The DON stated, No, we do not have a system to accurately keep track of CII [schedule II drugs] delivery forms. We have some delivery forms but no nurse signatures During a telephone interview on 8/11/22 at 11:20 A.M., with the Independent Consultant RPh (Registered Pharmacist). The IC - RPH stated that he was not familiar with control drug system keeping. During an interview on 8/11/22 at 2:29 P.M., with the DON. The DON stated, that the facility was expected to have appropriated track controlled medication to deter drug diversion. The DON stated, Without a proper system in place, facility at risk for drug diversion. During a review of the facility's policy and procedure titled, Controlled Substance Prescriptions, indicated, Receipt of Orders from Nurse Practitioners, Physician Assistants, Clinical Nurse Specialists, and Pharmacists . applicable formularies, protocols, or prescribing guidelines are kept on file in the facility and area followed closely. 055964 Page 10 of 25 055964 08/11/2022 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

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 one of four sampled residents (Resident 25) was free from an unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medication when licensed nurses did not attempt non-pharmacological interventions prior to the use of Quetiapine (medication for mental illness), administered multiple medications (Quetiapine and Duloxetine-medication for depression) for the same indication, and administered Quetiapine without appropriate behavioral monitoring. These failures increased the potential for medication interactions, adverse reactions, and unidentified risks associated with the use of psychotropic medications that included but not limited to sedation, respiratory depression, constipation, anxiety, agitation, and memory loss. Findings: During a review of Resident 25's admission Record, dated 8/11/22, the admission Record indicated, Resident 25 was admitted to the facility on [DATE], and had diagnoses including dementia, Parkinson's disease, depression, and insomnia. During a review of Resident 25's Order Summary Report, dated 8/11/22, the Order Summary Report indicated a provider order for : 3/8/22 quetiapine 50 mg at bedtime for anti-psychotic/anti-manic 8/1/22 quetiapine 37/5 mg at bedtime for depression 3/8/22 duloxetine 40 mg in the morning for depression 8/1/22 duloxetine 40 mg in the morning for pain During a review of Resident 25's Medication Administration Record (MAR), dated 7/1/22-7/31/22 and 8/1/22-8/31/22, the MAR indicated, Anti-Psychotic monitor of episodes of depression AEB [as evidenced by]: inability to fall asleep drug: quetiapine every shift . antidepressant monitor of depression AEB: verbalization of sadness. Drug: duloxetine every shift. During a concurrent interview and record review on 8/10/22 at 11:26 A.M. with LN 32, Resident 25's medical records and MAR dated 7/1/22-7/31/22 and 8/1/22-8/31/22 were reviewed. LN 32 stated, she was unable to find resident specific behavioral interventions for depression prior to the initiation of quetiapine for Resident 25. LN 32 stated, that maybe there was a certain reason why Resident 25 was sad, and behavioral intervention could help Resident 25, without her needing medication. LN 32 stated, Because of side effects, adding medication that is not really needed and can affect her [Resident 25] kidney and change her behavior. During an interview on 8/10/22 at 2:35 P.M., Resident 25's Physician Order Summary dated 8/11/22, and MAR dated 71/22-7/31/22 and 8/1/22-8/31/22 were reviewed. LN 32 acknowledged Duloxetine and Quetiapine were both indicated for depression, Resident 25 was being administered both medications 055964 Page 11 of 25 055964 08/11/2022 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few concurrently, and both medications were initiated at the same time. LN 32 stated, No, not appropriate for Resident [25] to be on two medications that treat same condition yes, we have both duloxetine and quetiapine for depression, it will enhance toxic effects . no, cannot tell if one drug is lowest effective dose but both started at once. When asked about the behavioral monitoring to evaluate the effectiveness of Resident 25's Quetiapine dose, LN 32 stated, They put Quetiapine for behaviors of inability to fall asleep. LN 32 acknowledged Quetiapine was not indicated for insomnia, and inability to fall asleep was not the behavior manifested by Resident 25 for depression. LN 32 acknowledged that Resident 25 had a diagnosis of dementia and Quetiapine had a black box warning (BBW- warning required by the government for certain medications that carry dangerous side effects). LN 32 stated, Yes, Quetiapine has BBW, increased mortality in elderly patient with dementia . yes this patient [Resident 25] has dementia]. During an interview on 8/11/22 at 10:15 A.M., with the ADON of Resident 25's Hospital Discharge Summary dated 3/8/22, and Facility Psychiatrist Evaluation dated 6/13/22 were reviewed. Resident 25's Hospital Discharge Summary indicated Resident 25 did not have a diagnosis for antipsychotic or anti-manic, and Resident 25 was discharged to the facility on 3/8/22. The ADON acknowledged Resident 25 did not have a diagnosis for antipsychotic or anti-manic and stated, No, antipsychotic or anti-manic is not an appropriate indication for Seroquel [brand name for Quetiapine] . no history of behavior, can be considered chemical restraint, can have negative outcomes and can affect normal daily life and participating in life. The ADON was unable to provide documentation of a diagnosis of psychosis or manic for Resident 25's Facility Psychiatrist Evaluation. During a telephone interview on 8/11/22 at 10:59 A.M., with MD 60, MD 60 stated Resident 25 was on Quetiapine because Resident 25 had agitation and delirium in the past and would discontinue the medication. During a telephone interview on 8/11/22 at 11:20 A.M., with the IC-RPh (Independent Consultant RPh), the IC-RPh stated, Quetiapine was not appropriate for Resident 25 if Resident 25 did not have a history of behavior problems. The IC-RPh acknowledged it was not appropriate to give two medications for the same indication, and stated, .usually start with one [medication] and go slow. During an interview on 8/11/22 at 2:29 P.M., with the DON, the DON stated, psychotropic meds should be used appropriately to treat patients who require medication as indicated because patients can experience side effects if used incorrectly non-pharmacological interventions as primary interventions before use of psychotropic medications . using two medications at once to treat same condition to treat patient could cause increased side effects . unable to determine if having one medication is effective versus having two medications at once. During a review of the facility's policy and procedure titled, Psychoactive Medications dated 10/17, indicated, The IDT [interdisciplinary team-group of healthcare professionals working together to ensure best care for resident] will check the physician orders for the medication to ensure the order contains the name of the medication, dose, route, times and behavior(s) for which the medication is being administered. The order may also include monitoring requirements for the behavior(s) and the diagnosis 055964 Page 12 of 25 055964 08/11/2022 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the facility medication error rate did not exceed five percent or greater when observation of 25 opportunities during the medication pass resulted in two errors. The calculated medication error rate was 8 percent. Residents Affected - Few These failures placed Residents 65 and 289 at risk for irritation, sensitivity, and infection at site of application and injection. Findings: 1. During a medication pass observation on 8/8/22 at 8:22 A.M., at North Station, Hall 1, with LN 60. LN 60 prepared Resident 65's medications which included a Lidocaine patch (medication used to alleviate pain). LN 60 applied the lidocaine patch to the lower left of Resident 65's back. Another patch was observed on the lower right of Resident 65's back. During a concurrent observation, interview, and record review on 8/8/22 at 3:29 P.M., with LN 60, Resident 65's Order Summary Report, dated 8/9/22, and Medication Administration Record (MAR), dated 8/1/228/31/22, were reviewed. Resident 65 was observed to have two lidocaine patches on his lower back. LN 60 acknowledged the lidocaine patch on the lower right of Resident 65's back should have been removed. LN 60 stated, Lidocaine patch once a day according to schedule, on at 9am and remove at 9pm . the old patch was still there on right lower back and applied new one on left lower back . old patch should have been removed last night at 9pm. Resident [65] still getting medication that they should not get. Patch documented that it was removed 8/7/22 20:44 but not removed, new patch placed 8/8/22 8:18 AM. During a review of Resident 65's Order Summary Report, dated 8/9/22, the Order Summary Report, indicated a physician's order for Lidocaine patch 4% Apply to lower back topically one time a day and remove per schedule, order date 10/22/21. During a review of Resident 65's MAR, dated 8/1/22-8/31/22, the MAR, indicated lidocaine patch was applied to Resident 65's lower back on 8/7/22 at 10 A.M., removed on 8/7/22 at 8 P.M., and a new patch was applied to Resident 65's back on 8/8/22 at approximately 8 A.M. During an interview on 8/8/22 at 4:36 P.M., with the DSD, the DSD acknowledged the old lidocaine patch should have been removed according to manufacturer specification. The DSD stated, specific order for what time to put on and what time to take off . resident getting overly medicated if two patches at once, they can overdose and have adverse reactions from that. During a telephone interview on 8/11/22 at 11:20 A.M. with IC-RPh (Independent Consultant RPh), IC-RPh stated, it was not appropriate to have two lidocaine patches on Resident 65. IC-RPh stated, [lidocaine patches] should be 12 [hours] on, 12 [hours] off, should not be left on for 24 hours It could build up resistance and cause irritation on skin. During an interview on 8/11/22 at 2:29 P.M., with the DON, the DON stated, nursing staff were expected to follow physician orders and patch should be off as ordered, or patient would not be receiving correct medication amount. During a review of the outer package for Resident 65's lidocaine patch, the manufacturer's 055964 Page 13 of 25 055964 08/11/2022 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

F 0759 instructions for lidocaine patch indicated, Use one patch for up to 12 hours. Level of Harm - Minimal harm or potential for actual harm 2. During a medication pass observation on 8/8/22 at 12:02 P.M., at South Station, Hall 4, with LN 41, LN 41 prepared Resident 289's medications which included insulin aspart (medication to decrease blood sugar). LN 41 was observed administering insulin aspart 7 units (unit of measurement) subcutaneously (injection under the skin) to Resident 289's left upper arm. Residents Affected - Few During a concurrent interview and record review on 8/8/22 at 3:07 P.M., with LN 41, Resident 289's Order Summary Report'', dated 8/9/22, and MAR dated, 8/1/22-8/31/22, were reviewed. LN 41 acknowledged she administered Resident 289's insulin to the same site. Resident 289 was administered insulin aspart earlier in the morning 8/8/22 at 7:49 A.M. LN 41 stated, injections should be rotated on sites, can cause discoloration, no not good for resident [289]. During a review of Resident 289's Order Summary Report, dated 8/9/22, the Order Summary Report, indicated a physician's order for Insulin aspart 100 unit/milliliters (ml- unit of measure) inject 7 units subcutaneously before meals. During a review of Resident 289's MAR, dated 8/1/22-8/31/22, the MAR indicated Resident 289 was administered insulin 7 units on 8/8/22 at 7:44 A.M., to the left arm, and on 8/8/22 at 11:30 A.M. to the left arm. During an interview on 8/8/22 at 4:37 P.M., with the DSD, the DSD stated, Very important [rotating insulin injection sites] because want to make sure insulin is being absorbed effectively, if same site absorption, may be affected and can also cause bruising. During a telephone interview on 8/11/22 at 11:20 A.M. with IC-RPh, the IC-RPh acknowledged it was not appropriate for insulin injections to be administered to the same site. The IC-RPh stated, .should be rotated on different sites when administering insulin, to avoid build-up of fatty tissue when it's given at same location, and it can cause pain. During an interview on 8/11/22 at 2:29 P.M. with the DON, the DON stated, nursing staff was expected to rotate insulin administration site for absorption purposes and to decrease risk for skin issues and infections. During a review of a professional reference review Lexicomp, the manufacturer's instructions for insulin aspart indicated, Rotate injection sites within the same region to avoid lipodystrophy [lose fat from some parts of the body, while gaining it in others] or localized cutaneous amyloidosis [abnormal protein builds up in the skin]. 055964 Page 14 of 25 055964 08/11/2022 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a facility significant medication error when Valproic Acid (medication for seizures and mental disorders) was ordered and administered to Resident 82 for a seizure diagnosis. Resident 82 did not have a history or diagnosis of seizures. Residents Affected - Few During a review of Resident 82's admission Record (AR, document with resident information), dated 8/9/22, the AR indicated Resident 82 was admitted to the facility on [DATE], with diagnosis including diabetes, dysphagia (difficulty swallowing), and dementia (memory loss) . During a review of Resident 82's Order Summary Report, dated 8/9/22, the Order Summary Report, indicated a physician's order for Valproic Acid 250 milligrams (mg- unit of measure) per 5 milliliters (ml- unit of measure) twice daily for seizures. During a medication pass observation on 8/8/22 at 9:28 A.M., at North Station, Hall 1 with LN 60. LN 60 prepared Resident 82's medications which included valproic acid. LN 60 was observed administering 10 ml of valproic acid 250 mg per 5 ml, to Resident 82 via gastrostomy tube (g tube- tube inserted through the stomach). During a concurrent interview and record review on 8/8/22 at 4:06 P.M., with LN 60 of Resident 82's Medication Administration Record (MAR) were reviewed. LN 60 was unable to provide documentation for the diagnosis of seizure and valproic labs for Resident 82. LN 60 stated, No, cannot tell if medication is in normal value if level not measured, if value is high and we still give it, patient will be overmedicated . I double checked and I do not see that Resident [82] has history of seizure. If they don't have diagnosis and you are giving medication, it's an error and it's not good for the patient; no valproic labs were ordered. During a review of Resident 82's MAR, dated 9/21, 10/21, 11/21, 12/21, 1/22, 2/22, 3/22, 4/22, 5/22, 6/22, 7/22, 8/22, the MAR indicated Resident 82 was administered 10 ml of valproic acid 250 mg per 5 ml twice a day from 9/23/21 to 8/9/22, with doses held in the months of 11/21, 3/22, 5/22, 6/22, 7/22. During an interview on 8/8/22 at 4:39 P.M. with the DSD, the DSD stated, that nursing staff was expected to clarify an order for resident with the physician if the resident did not have a diagnosis. During a concurrent interview and record review on 8/9/22 at 2:49 P.M., with LN 32 of Resident 82's MAR dated 8/9/22 was reviewed. LN 32 was unable to provide documentation for Resident 82's diagnosis of seizure. LN 32 stated, I'm not sure why they put diagnosis for seizure for valproic acid for [Resident 82] . Resident [82] had medication in hospital but it did not have an indication, the order should have been clarified with the doctor . no, the resident does not have a psych [psychiatric-mental illness] diagnosis from hospital . if resident getting medication they don't need, they can get side effects. During a telephone interview on 8/11/22 at 11:20 A.M., with IC-RPh, the IC-RPh stated, that he was not aware that Resident 82 did not have a diagnosis for seizures, and had request that valproic acid labs be drawn multiple times on 3/1/22 and 8/1/22. The IC-RPh stated, High doses can cause multiple side effect and there's a threshold that manufacturer recommends, without that it can cause toxicity and if they have seizures and not monitored, can cause seizure . it would be an unnecessary 055964 Page 15 of 25 055964 08/11/2022 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medication, it can expose [Resident 82] to long term side effects of the medication, resident should not be on medication that they should not be on. During an interview on 8/11/22 at 2:29 P.M., with the DON, the DON stated, that nursing staff was expected to clarify orders with physician for appropriate indication and be able to accurately evaluate the therapeutic use of medication. The DON stated, It is Important to have labs to be able to measure medication to be therapeutic or adverse reactions or risk for seizures if resident has accurate seizure diagnosis . there could be drug interactions to other medications or risk for seizures if resident has accurate seizure diagnosis. During a review of a professional reference review Lexicomp, the manufacturer's adverse reactions considerations for Valproic Acid include, drowsiness, lethargy, changes in level of consciousness, slowing of cognition, vomiting . During a review of the National Council Licensure Examination for Registered Nurses article Medication Administration, the Medication Administration article indicated, Preparing and administering medications and using the rights of medication administration. The Ten Rights of Medications Administration are the right, or correct: 1. Medication . 055964 Page 16 of 25 055964 08/11/2022 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue 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. Based on observation, interview, and record review, the facility failed to ensure medications had proper storage and labeling when: a. For Resident 390, two inhalers and for Resident 11, one inhaler that that required to be dated when opened, did not have patient identifiers or expiration date/date open stickers, and were found in a medication cart, and an inhaler was found to have been discontinued b. For Resident 58, an expired eye drop was found in a medication cart c. For Resident 79, a discontinued psychotropic (drugs that affects brain activities associated with mental processes and behavior) medication was found in a medication cart. These failures had the potential to be incorrectly administered and decrease medication potency that could compromise the therapeutic effectiveness of stored medications, medications for Residents 390, 11, 58, and 79. Findings: a. During a concurrent observation and interview on 8/9/22 at 10:07 A.M. at North Station, Hall 2 medication cart with LN 61, one medication inhaler Trelegy Ellipta (medication for lung disease) for Resident 11, and two medication inhalers (Wixela and Spiriva- medications for lung disease) for Resident 390 that required to be dated when opened was observed to not have patient identifiers, expiration dates/date open stickers, were found in the medication cart. LN 61 acknowledged the inhalers have been removed from the manufacturer packaging and used to administer medication to Residents 11 and 390, and was unable to determine when the inhalers were removed from the manufacturer packaging. LN 61 stated, I can't tell when they were opened . no patient identifier . if got misplaced, can't tell if it was for that resident, can't tell when it was opened, can't tell when it expired. LN 61 stated, it is important to have patient identifier so you can know if right medicine for the patient . if med [medication] expired, resident can have a reaction. During an interview on 8/10/22 at 10:35 A.M. with LN 1, LN 1 stated, Resident 11's Trelegy inhaler had been discontinued on 5/27/22. LN 1 stated, Discontinued medications should be discarded right away because if left in cart, it might be used and cause medication error . can cause adverse effect to patient. During a review of Resident 11's Order Summary Report, dated 8/10/22, the Order Summary Report, indicated a physician's order for Trelegy Ellipta Aerosol Powder 100-62.5-25 micrograms/inhalation, 1 puff inhale orally in the morning for Chronic Obstructive Pulmonary Disease (COPD-lung disease), discontinued 5/27/2022. During a review of Resident 390's Order Summary Report, dated 8/9/22, the Order Summary Report, indicated a physician's order for Wixela Aerosol Powder 250-50 micrograms/actuation, 1 inhalation orally twice daily for COPD, order date 7/16/22 and Spiriva Respimat Aerosol Solution 2.5 micrograms/actuation, 2 puffs inhale once daily for COPD, order date 7/16/22. 055964 Page 17 of 25 055964 08/11/2022 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 390's Medication Administration Record (MAR), dated 7/1/22-7/31/22 and 8/1/22-8/31/22, the MAR, indicated Resident 390 was administered Wixela twice daily from 7/17/22 to 8/9/22 and Spiriva once daily from 7/17/22 to 8/9/22. b. During a concurrent observation and interview on 8/9/22 at 11:02 A.M. at South Station, Hall 3 with LN 31, an eye drop medication (latanoprost- medication for blood pressure in the eyes) for Resident 58 that was expired, was found in the medication cart. LN 31 acknowledged Resident 58's the bottle of latanoprost eye drops was opened on 6/29/22 and was expired. During an interview on 8/9/22 at 11:08 A.M., with MDA (Maintenance Director Assistant) and Resident 58, MDA translated Resident 58's response from Spanish to English. Resident 58 stated he received the latanoprost eye drops for his eyes the previous night. LN 31 stated, expired medications should have not been given to a resident. LN 31 was unable to provide documentation for a physician's order for latanoprost. LN 31 stated, no nursing cannot give medication without order, we have to follow the order, no order, no medication . it could harm resident if not order, especially eyes, it's very important. c. During a concurrent observation and interview on 8/9/22 at 11:18 A.M., at South Station, Hall 3 medication cart with LN 31, a psychotropic medication (Seroquel- medication for mental disorders) for Resident 79 that was discontinued, was found in the medication cart. During a concurrent interview and record review on 8/9/22 at 11:24 A.M., with LN 32, LN 32 stated, Resident 79's Seroquel medication was discontinued on 6/8/22. LN 32 stated, No, medication should not be in cart to prevent wrong medication administration . there is no order in there so it should not be kept in there. During a review of Resident 79's Order Summary Report, dated 8/10/22, the Order Summary Report, indicated a physician's order for Quetiapine 25 mg every 4 hours as needed for Psychosis, discontinued 6/8/22. During a telephone interview on 8/11/22 at 11:20 A.M., with the IC-RPh, The IC-RPh stated, inhalers do have beyond use date once they open packaging . if they are not dated, medication would not be effective later on, potency is not 100%, they would get full dose and would decrease medication effectiveness . if not label correctly, someone can get the wrong medication. Discontinued medications should be removed from medication cart so it would prevent nursing from accidentally administered, it would fall under unnecessary medication for the resident and they could get side effects from medications. During an interview on 8/11/22 at 2:29 P.M., with the DON, the DON, stated, Expectation for nursing staff is to appropriate label medication and place expiration date . if no label, there could be confusion in patient getting correct medication and if medication expired, it loses its efficacy so patient not getting therapeutic dose. Expectation not to give expired medication to patient . patient not to get correct dosage, negatively impact patient. During med-pass [medications administered to residents by nursing staff], expectation that med-nurse checks medication against the order and administer medication as ordered by physician. If medication is administered and there is no physician order, it can negative affect patient and cause a change in condition to patient. As soon as medications are discontinued, expectation for nurses destroy medication with patient identifier, there could be med error where nurse could accidentally give medication to patient if it is not removed from cart. 055964 Page 18 of 25 055964 08/11/2022 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of the facility's policy and procedure titled, Medication Storage in the Facility, dated 8/19, 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 . During a review of the facility's policy and procedure titled, Labeling of Medication Containers, dated 4/07, indicated, Labels for individual drug containers shall include all necessary information, such as: The resident's name the expiration date when applicable . 055964 Page 19 of 25 055964 08/11/2022 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue 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 and interview, the facility failed to ensure sanitary conditions were maintained when one can of condensed milk was dented, and two cans of white hominy (a type of corn from white corn kernels) had rusted lid and were not removed from the storage. These failures had the potential to cause widespread food borne illnesses among residents who consume food from the kitchen. Findings: On 8/8/22 at 11:05 A.M., an observation and interview were conducted with the Certified Dietary Manager (CDM) of the dry storage room. On the shelf, one can of condensed milk was dented. On the lower shelf, 2 cans of white hominy had rusted lids. The CDM stated she and the staff checked the storage room every day for outdated food items, dented cans, and rusty lids. The CDM further stated, those canned food items should have been removed from the shelf. Per the facility's policy, dated 2020, titled Storage of Food and Supplies, indicated .15. Foods in unlabeled rusty, leaking, broken containers or cans with side seam dents, rim dents or swell shall not be retained or used. 055964 Page 20 of 25 055964 08/11/2022 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

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 observe infection control measures when: Residents Affected - Some 1. Nursing staff failed to properly disinfect resident's glucometer for four randomly selected residents (Residents 241, 46, 67, 34) according to manufacturer's specifications. 2. Nursing staff failed to remove personal protective equipment gown after resident care prior to leaving resident room. 3. Tube feed formula was not discarded upon completion. 4. Tube feed tubing was not labeled. 5. An indwelling catheter bag was in contact with the floor. These deficient practices have the potential for the development and the spread of infection to all residents. Findings: 1. During a medication pass observation on 8/8/22 at 8:07 A.M., at North Station, Hall 1, LN 60, LN 60 was observed using a glucometer to check Resident 67's concentration of blood glucose. LN 60 was observed wiping the glucometer with bleach disposable wipes for approximately 12 seconds, then placing the glucometer on the medication cart. During a medication pass observation on 8/8/22 at 9:07 A.M., at North Station, Hall 1, with LN 60, LN 60 was observed using a glucometer to check Resident 34's concentration of blood glucose. LN 60 was observed wiping the glucometer with bleach disposable wipes for approximately 12 seconds, then placing the glucometer on the medication cart. During a medication pass observation on 8/8/22 at 11:44 A.M., at South Station, Hall 4, with LN 41, LN 41 was observed using a glucometer to check Resident 46's concentration of blood glucose. LN 41 was observed wiping the glucometer with alcohol wipes for approximately 7 seconds, then placing the glucometer on the medication cart. During a medication pass observation on 8/8/22 at 12:14 P.M., at South Station, Hall 4, with LN 41, LN 41 was observed using a glucometer to check Resident 241's concentration of blood glucose. LN 41 was observed wiping the glucometer with alcohol wipes for approximately 7 seconds, then placing the glucometer on the medication cart. During an interview on 8/8/22 at 3:18 P.M., with LN 41, LN 41 stated, Before you start, you have to clean with alcohol wipes and after you use it you have to clean . When asked about contact time (time for bleach wipes to effectively killing pathogens), LN 41 stated, contact time is to make sure all bacteria or pathogen is cleaned off glucometer. LN 41 acknowledged she did not use the appropriate wipes to disinfect the glucometer and did not allow for contact time after using the glucometer to check Resident 46 and 241's blood glucose. 055964 Page 21 of 25 055964 08/11/2022 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

F 0880 Level of Harm - Minimal harm or potential for actual harm During an interview on 8/8/22 at 4:17 P.M., with LN 60, LN 60 stated, she had cleaned the glucometer before and after using it. LN 60 stated, she was unaware what the contact time and reviewed the manufacturer specification for the bleach wipes. LN 60 stated the contact time for the bleach wipes was two minutes and acknowledged she did not allow contact time for two minutes after using the glucometer to check Residents 67 and 34's blood glucose. Residents Affected - Some During an interview on 8/8/22 at 4:32 P.M., with the DSD, the DSD stated, the expectation was for nursing staff to sanitize the glucometer after each use and to follow manufacturer's instructions for wet to dry time. The DSD stated, If not disinfected, not killing pathogens effectively . using glucometer for other patient so can transmit pathogen. During an interview on 8/11/22 at 2:29 P.M., with the DON, the DON stated, anytime glucometer is used, expectation for nursing staff to disinfect glucometer according to manufacturer and allow wet to dry time before using it on another patient . important for infection control, making infections don't spread across the facility. During a review of the manufacturer's instructions for dwell time for the bleach wipes provided by the facility, the manufacturer's instructions indicated, Unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for two (2) minutes. Let air dry. During a review of the facility's policy and procedure titled, Assure Platinum Glucose Monitor Cleaning/Disinfecting, indicated, The glucose meter should be cleaned and disinfected after use on each patient. Commercially available EPA-registered disinfectant or detergent of germicide wipe may be used to clean and disinfect the Assure Platinum Glucose Meter. Open disinfectant package. Follow product label instructions to disinfect the meter. 2. During a medication pass observation on 8/8/22 at 12:02 P.M., at South Station, Hall 4, LN 41 was observed wearing personal protective equipment gown out of Resident 289's room after patient care, to medication cart in the hallway. During a medication pass observation on 8/8/22 at 12:14 P.M., at South Station, Hall 4, LN 41 was observed wearing personal protective equipment gown out of Resident 241's room after patient care, to medication cart in the hallway. During an interview on 8/8/22 at 3:23 P.M., with LN 41, LN 41 acknowledged she did not remove her gown after performing patient care for Residents 289 and 241, prior to leaving the residents' room. LN 41 stated, Wear gown for contact precaution so we don't share bacteria or virus to other patients . Yes, supposed to take off gown before leave room . if don't remove gown, going back and forth to medication cart can cause contamination. During an interview on 8/9/22 at 9:39 A.M., with the DSD, the DSD stated, expectation for nursing was, Every time you exit room, you have to do doffing-removing of gown, and when you enter, have to do donning (put on gown) all over again . important because once you go in, its considered contaminated and you don't want to contaminate other residents. During an interview on 8/11/22 at 2:29 P.M., the DON, the DON stated, any time glucometer is used, expectation for nursing staff to disinfect glucometer according to manufacturer and follow wet to dry time before using it on another patient . important for infection control, making sure staff is staff, and making sure infections don't spread across the facility. 055964 Page 22 of 25 055964 08/11/2022 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of the facility's policy and procedure titled, Personal Protective Equipment (PPE), indicated, Doffing (taking off) PPE: Remove gown or upper torso covering with sleeves. Disrobe in a manner that prevents touching of the outside of the garment. Dispose in trash receptable if disposable, or place in laundry receptacle if reusable. HCP[healthcare professional] may now exit resident room. 3. Resident 241 was admitted to the facility on [DATE] with diagnoses that included intracerebral hemorrhage (bleeding in the brain), per the facility's Record of Admission. On 8/8/22 at 9:19 A.M., an observation, interview and record review with LN 41 of 241's room was conducted. The following was noted hanging at Resident 241's bedside: 8/6/22 hung at 1800PM Water flush bag 200cc's 8/7/22 hung at 1800PM Water flush bag 300cc's 8/7/22 hung at 1800PM Tube feed 300cc's 8/8/22 hung at 0050AM Tube feed 200cc's LN 41 validated the above findings. LN 41 stated, she was not sure why the bags of tube feeds and water flushes were still hanging in Resident 241's room. A review of Resident 241's MAR (medication administration record) with LN 41 indicated, tube feedings of Fiber Source HN (a supplemental nutritional formula) at 130cc/hr from 6:00 P.M. to 6:00 A.M. via G-Tube (a tube inserted into the stomach for nutrition). LN 41 stated, the bags of tube feed and water flushes should not be hanging as the feedings and water flushes have been completed. LN 41 stated, she was not sure how long the bags of tube feed and water flushes were good for. LN 41 further stated, the tube feed and water flushes should have been thrown away after completion of the tube feeding infusion; to ensure they are not mistakenly given to the resident as they can make the resident sick. On 8/10/22 at 10:56 A.M., an interview with the IPIC (Infection Preventionist Infection Control) nurse was conducted. The IPIC nurse stated, she was not sure how long the bags of tube feeds or water flushes were good for. The IPIC further stated, the tube feeds and water flushes should have been discarded after completion of the tube feed to prevent the resident from potentially getting sick from old tube feed formula. On 8/10/22 at 1:56 P.M., an interview with the DON was conducted. The DON stated, it is the expectation for the staff to dispose tube feeds and flush bags as per the facility policy, and they are not. A review of the facility's policy titled, Ready to Hang Tube Feed Formula - Suggested Setup Procedure, not dated, indicated, .the maximum safe hangtime is 24 hours . 4. Resident 241 was admitted to the facility on [DATE] with diagnoses that included intracerebral hemorrhage (bleeding in the brain), per the facility's Record of Admission. On 8/8/22 at 9:19 A.M., an observation, interview and record review with LN 41 of 241's room was conducted. The following was noted hanging at the bedside: 055964 Page 23 of 25 055964 08/11/2022 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

F 0880 8/6/22 hung at 1800PM Water flush bag 200cc's; Tubing with no label, date and time Level of Harm - Minimal harm or potential for actual harm 8/7/22 hung at 1800 Water flush bag 300cc,s; Tubing with no label, date and time 8/7/22 hung at 1800PM Tube feed 300cc's; Tubing with no label, date and time Residents Affected - Some 8/8/22 hung at 0050AM Tube feed 200cc's; Tubing with no label, date and time LN 41 validated the above findings. LN 41 stated, the tube feed and water flush tubing where not labeled with a date and time. LN 41 stated, she was not sure how long the tubing for the tube feed or water flush was good for. LN 41 stated, the tubing for the tube feed and water flush should have been labeled in order to know when it needed to be change. On 8/10/22 at 11:00 A.M., an interview with the IPIC nurse was conducted. The IPIC nurse stated, she was not sure how long the tubing for the tube feed or water flush was good for. The IPIC further stated, the tubing for the tube feed and water flush should have been labeled in order to maintain safe infection control practices. On 8/10/22 at 1:56 P.M., an interview with the DON was conducted. The DON stated, it was the expectation for the staff to follow the facility infection control policy in order to prevent the spread of infection to residents and staff. A review of the facility's policy titled, Best Practice Guidelines for Tube Feeding Appendix D: Preventing Contamination of Formula and Delivery System, dated 1997-2006, indicated, .4. Change tubing at least every 24 hours . 5. Resident 78 was admitted on [DATE] with diagnoses which included paraplegia (complete paralysis of the lower half of the body, including both legs) and neuromuscular dysfunction of bladder (lacks bladder control due to brain, spinal cord or nerve problems), per the facility's admission Record. During an observation on 8/10/22 at 9:00 A.M., in Resident 78's room, Resident 78 was in a reclined position in his bed, with an indwelling urinary catheter (a tube in the bladder to drain urine). Resident 78's catheter bag was on the floor. During an interview with CNA 1 on 8/10/22 at 9:45 A.M., CNA 1 stated, indwelling urinary catheter bags should be off the floor at all times to prevent infection. During an interview with LN 1 on 8/10/22 at 2:54 P.M., LN 1 stated, part of the catheter care was to make sure drainage bags were placed below the bladder of the resident and should not be touching the floor to prevent infection. During an interview with IPIC on 8/11/22 at 8:03 A.M., IPIC stated, it was very important for indwelling catheter drainage bags not be on the floor to prevent infections. During an interview with the Director of Nursing (DON) on 8/11/22 at 10:30 A.M., the DON stated, LNs should make sure indwelling drainage bags were off the floor at all times. DON further stated, indwelling catheter drainage bags touching the floor was an infection control issue and should have been avoided. 055964 Page 24 of 25 055964 08/11/2022 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

F 0880 Per the facility's policy titled Urinary Tract Infections ( Catheter- Associated), Guidelines for Preventing, revised September 2017, .6.Maintain .Do not place the drainage bag on the floor Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 055964 Page 25 of 25