Health inspection·May 7, 2021

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. 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: Residents Affected - Few 1. Obtain consent prior to administering psychotropic medications, and 2. Failed to utilize practitioner's (physician, nurse practitioner, or physician assistant) to obtain resident consent for vaccines for six residents sampled for consents (228, 9, 28, 48, 62, 233). As a result, the residents may not have been fully informed of the risks and benefits of the psychotropic medications and vaccines. Findings: 1. Per the facility's admission Record, Resident 228 was admitted to the facility on [DATE], with diagnoses to include Alzheimer's disease (A progressive disease that destroys memory and other mental functions), and dementia (a progressive physical and mental decline). Per the facility's Telephone/Verbal Order Signature Details, dated 5/6/21, Resident 228 had an order on 4/29/21 for hydroxyzine (a medication which can treat anxiety) 25mg every 6 hours as needed for agitation, and an order on 5/5/21 for divalproex sodium 125mg two times per day for dementia with behavioral disturbance. On 5/6/21 at 8:36 A.M., a telephone interview was conducted with RP 1 (responsible party). RP 1 stated, the facility did not call to notify him when they ordered any new medications for Resident 228, and they did not tell him about her new medications, including hydroxyzine until he asked for Resident 228's medication list. RP 1 did not mention divalproex sodium when he described Resident 228's new medications. RP 1 further stated, he had not spoken with the facility's physician since she was admitted to the facility, and he wanted the facility to notify him when they ordered new medications for Resident 228. On 5/6/21 at 2:10 P.M., a concurrent interview and record review was conducted with LN 61. LN 61 stated, when the facility ordered a new psychotropic medication (a medication which alter's a person's mental state) LN's called a resident's RP to obtain verbal consent over the phone. LN 61 further stated, the facility ordered divalproex sodium for Resident 228 on 5/5/21, but she was not able to find a consent form for divalproex sodium in Resident 228's medical record. LN 61 stated, she entered the order for hydroxyzine, but did not get consent from RP 1 because other LNs at the facility told her she did not need to get a consent for hydroxyzine. Page 1 of 14 056388 056388 05/07/2021 Paradise Valley Health Care 2575 E. Eighth St. National City, CA 91950

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 5/6/21 at 3:35 P.M., a concurrent interview and record review was conducted with the ADON. The ADON stated, if a medication was being used for anxiety or behaviors, the facility had to obtain consent prior to administering the medication. The ADON further stated, consents must be obtained by a practitioner, and not by LNs. The ADON stated, when the facility obtained consents, it should have been documented under progress notes and on the consent form. The ADON stated, a resident's RP should be notified of any newly ordered medications, and the facility should not administer psychotropic medications until they have obtained consent. The ADON reviewed Resident 228's medical record and was unable to find evidence of consents for hydroxyzine or divalproex sodium. Per the facility's MAR (Medication Administration Record), for Resident 228, dated 5/1/21-5/31/21, the facility administered divalproex sodium on 5/6/21 at 9 A.M., and 1 P.M. Per the facility's MAR (Medication Administration Record), for Resident 228, dated 5/1/21-5/31/21, the facility administered hydroxyzine on 5/1/21, 5/2, 5/3, 5/4, 5/5, and 5/6. Per the facility's policy, titled Behavior Management, dated 12/31/15, .3. Whenever an order is obtained for psychotropic medication(s), the licensed nurse verifies that informed consent has been obtained . 2. Per the facility's admission Record, Resident 9 was admitted to the facility on [DATE], with diagnoses to include Chronic Obstructive Pulmonary Disease (a breathing disorder), and Unspecified Asthma (A respiratory condition marked by spasms in the lungs). Per the facility's admission Record, Resident 18 was admitted to the facility on [DATE], with diagnoses to include COVID-19 (An acute respiratory illness in humans caused by a coronavirus), and Contact with and (suspected) exposure to other viral communicable diseases. Per the facility's admission Record, Resident 48 was admitted to the facility on [DATE], with diagnoses to include Pneumonia (Lung inflammation caused by bacterial or viral infection), and Acute Respiratory Failure with Hypoxia (A condition that occurs when fluid builds up in the air sacs in the lungs, causing abnormally low concentration of oxygen in the blood). Per the facility's admission Record, Resident 62 was admitted to the facility on [DATE], with diagnoses to include Chronic Kidney Disease (The gradual loss of kidney function), and Anemia (A condition marked by a deficiency of red blood cells). Per the facility's admission Record, Resident 233 was admitted to the facility on [DATE], with diagnoses to include Pleural Effusion (A buildup of fluid in the pleural space, an area between the layers of tissue that line the lungs and the chest wall), and Acute Kidney Failure (A condition that occurs when the kidneys suddenly become unable to filter waste products from the blood). On 5/6/21 at 9A.M., an interview and record review was conducted with the Infection Preventionist (IP). The IP stated that the consents for the 5 residents (9, 28, 48, 62, and 233) were obtained by nurses. The IP also stated that they didn't have a policy specifically for obtaining consents for vaccination. On 5/6/21 at 2:49 P.M., an interview was conducted with the Charge Nurse (LN42) on 2nd floor. LN42 stated that she had the residents sign the consent for vaccinations, then she would call the doctor for the order and forward it to pharmacy, and then she would administer the vaccine. 056388 Page 2 of 14 056388 05/07/2021 Paradise Valley Health Care 2575 E. Eighth St. National City, CA 91950

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 5/7/21 at 1:50 P.M., an interview was conducted with the Assistant Director of Nursing (ADON) and the Administrator (Admin). The ADON stated that the nurses were the ones who obtained the consents for vaccinations. The Admin stated that the physicians should be the ones who obtain the consents for vaccinations, and apologized because he stated that the nurses were doing it. According to the facility's policy, dated April 2017, titled, Informed Consent Policy, .2. The physician will provide education and discuss with the resident or responsible party, informing them of risks, benefits, and alternatives or options of a proposed treatment, care or intervention. According to the facility's policy, dated October 2019, titled, Pneumococcal Vaccine, .3.When indicated, the physician will obtain an informed consent. According to the facility's policy, dated October 2019, titled, Influenza Vaccine, .When necessary, the physician will obtain informed consent. 056388 Page 3 of 14 056388 05/07/2021 Paradise Valley Health Care 2575 E. Eighth St. 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 keep the environment free of accident hazards for two of 30 sampled residents (9, 279) when: 1. Resident 9 kept her smoking materials at her bedside. 2. Resident 239 was left alone with a chemical disinfectant on her bedside table. Findings: 1. According to the admission Record, Resident 9 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a type of breathing disease). Her Brief Interview for Mental Status (BIMS) score was 15, meaning Resident 9 was mentally intact. On 5/4/21 at 4:04 P.M., an observation was conducted of Resident 9. Resident 9 was sitting in a wheelchair bedside her bed. On her bedside table lay a cigarette lighter and a clear plastic bag containing cigarettes. On 5/5/21 at 12:17 P.M., a joint observation and interview was conducted with Resident 9. Resident 9 was lying in her bed and stated her cigarette lighter and cigarettes were in her purse. On 5/6/21 at 3:45 P.M., a joint observation and interview was conducted with Resident 9. A box of cigarettes was observed to be laying on Resident 9's bed. Resident 9 pulled a cigarette lighter from her pocket, then stated she was allowed to keep those items with her in her room. Resident 9 further stated facility staff had never discussed with her whether she was permitted to keep smoking supplies in her room. On 5/6/21 a record review was conducted. Per the facility's Smoking Safety Assessment for the resident, dated 5/1/21, question four of the assessment read: Does resident attempt to keep smoking paraphernalia on self or in room? The documented answer was no Resident 9's smoking care plan, revised 4/22/21, included an intervention that indicated, Cigarettes and lighter will be stored at the nurse's station. On 5/7/21 at 8:47 A.M., an interview was conducted with a social worker (SW). The SW stated social workers or nurses were required to review each point of the Smoking Safety Assessment with residents who smoked. The SW stated it was facility policy that smoking supplies were kept at the nurse's station, to be checked out and returned by residents who smoked. The SW stated Resident 9 was not permitted to keep a lighter or cigarettes at her bedside. On 5/7/21 at 11:09 A.M., an interview was conducted with the ADON. The ADON stated it was not acceptable for Resident 9 to keep smoking supplies at her bedside. The ADON stated the protocol required all smokers to store their materials at the nurse's station. The ADON stated the nursing staff should have noticed Resident 9's lighter and cigarettes in her room and removed them from her possession. According to the Facility Smoking Policy, signed and dated by Resident 9 on 5/1/21: .6. Residents 056388 Page 4 of 14 056388 05/07/2021 Paradise Valley Health Care 2575 E. Eighth St. National City, CA 91950

F 0689 Level of Harm - Minimal harm or potential for actual harm are not permitted to keep cigarettes, matches, or lighters in their possession. All smoking materials must be kept by facility personnel . 2. According to the admission Record, Resident 239 was admitted to the facility on [DATE] with diagnoses including intracranial injury (brain dysfunction caused by an outside force) and memory deficit. Residents Affected - Few On 5/5/21 at 9:30 A.M., an observation of Resident 239 was conducted. Resident 239 was observed to be laying in bed with her eyes closed with her bedside table pulled approximately 10 inches from the resident . Resident 239 was alone in the room. Her . The table was wet with a substance that smelled like cleanser. Resident 239's open water cup and open milk carton were sitting in the wet substance. Resident 239 was alone in the room. On 5/5/21 at 9:35 A.M., a housekeeper (HK) was observed entering Resident 239's room. The HK was interviewed at this time. The HK stated she was the one who had sprayed Resident 239's table and she had used a virucidal (having the ability to destroy viruses) chemical. The HK stated she left it on the table without wiping it off because it required one minute to kill germs. The HK stated she had moved Resident 239's drinks prior to spraying and set them down in the disinfectant after spraying. When demonstrating this, the HK lifted Resident 239's water and milk. The table was dry under both drinks, indicating they had not been moved while the disinfectant was sprayed. On 5/7/21 at 10:25 A.M., an interview was conducted with the Housekeeping Supervisor (HS). The HS stated the disinfectant used on Resident 239's bedside table was used throughout the facility for cleaning tables, floors, bedrails, and other surfaces. The HS stated the contact time (the amount of time required for a surface to remain wet with a cleaner for germ killing to take place) was three minutes for the chemical used. The HS stated the bedside table should be moved away from the resident, everything taken off the table, and then the table should be sprayed. After spraying, it should remain wet for 3 minutes, without placing it back near the resident with bedside items. After 3 minutes, the HS stated the table should be wiped off. The HS stated residents should not be left alone with a table wet with the disinfectant. The HS stated residents should not touch the disinfectant. On 5/7/21 at 11:09 A.M., an interview was conducted with the ADON. The ADON stated it was not safe to leave a resident unattended with disinfectant on their bedside table. The facility was not able to provide a policy regarding specific cleaning procedures. The disinfectant's Directions for Use indicated: .Food products .must be removed or carefully protected prior to using this product . The Safety Data Sheet for the disinfectant used indicated: .Health Hazards-serious eye damage/eye irritation .prolonged inhalation may be harmful . 056388 Page 5 of 14 056388 05/07/2021 Paradise Valley Health Care 2575 E. Eighth St. 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to correctly label a gastrostomy tube feeding (tube inserted in the abdomen to provide liquid nutrients) bottle and water flush bag for one of one sampled resident investigated for tube feeding (48). This failure had the potential for residents to receive expired feeding formula and contaminated water. Findings: Resident 48 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes (abnormal blood sugar) and dysphagia (difficulty swallowing) per the facility's admission Record. An observation was conducted of Resident 48's room on [DATE] at 10:23 A.M. Inside the room was a tube feeding machine pump with a half-empty formula feeding bottle and a clear bag with a half-filled colorless liquid inside. The feeding formula bottle did not have a date or time it was hung. The clear bag did not have a label or resident identifier. On [DATE] at 3:19 P.M., an interview was conducted with Resident 48. Resident 48 stated he did not know when his tube feeding bottle and water flush bag was hung. Resident 48 further stated that there should be a date on the tube feeding bottle and the water flush bag. On [DATE] at 4:04 P.M., an interview was conducted with LN 40. LN 40 stated the tube feeding bottle and the water flush bag should have a label, date, and time. LN 40 stated she did not see a date and time on both the tube feeding bottle and the water flush bag did not have any label. On [DATE] at 4:06 P.M., an interview was conducted with LN 41. LN 41 stated the correct process was to put label on both the tube feeding bottle and the water flush bag. LN 41 further stated that the label should include the date and time when it was hung. On [DATE] at 9:32 A.M., an interview was conducted with LN 42. LN 42 stated all tube feeding bottles and water flush bag should have a label, especially the date and time in order for the staff to know if the tube feeding formula and the water flush was okay to use or not. On [DATE] at 10:53 A.M., an interview was conducted with the ADON. The ADON stated tube feeding bottles and water flush bags should have labels including the date and the time it was hung. Per the facility's policy titled, Enteral Tube Feeding via Continuous Pump, revised 11/2018, . Initiate Feeding . 5. On the formula label document initials, date and time the formula was hung/administered, and initial that the label was checked against the order . 056388 Page 6 of 14 056388 05/07/2021 Paradise Valley Health Care 2575 E. Eighth St. National City, CA 91950

F 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to remove expired medications from the facility. Residents Affected - Few This failure had the potential for the facility to administer expired medications to residents. Findings: On 5/6/21 at 10:20 A.M., an observation was conducted of the Emergency kits (E-kits, containers of multiple medications used if a resident was ordered a medication and it was not in the facility). The E-kit contained six vials of expired medications. A separate E-kit on that floor had completely expired in 2020, meaning every medication it contained was expired. On 5/6/21 at 10:27 A.M., an observation was conducted on another floor's medications. On this floor, the E-kit contained nine vials of expired medications. On 5/6/21 at 10:34 A.M., an interview was conducted with LN 55. LN 55 stated all expired medications needed to be removed from the unit. On 5/6/21 at 10:46 A.M., an interview was conducted with LN 56. LN 56 stated all expired medications needed to be removed from the floor. LN 56 stated expired medications could accidentally be given to a resident and you don't know what the side effects could be if you give an expired med(ication). LN 56 stated medication nurses or charge nurses were responsible for checking for expired medications. LN 56 stated the E-kits were not checked for expired medications. On 5/7/21 at 10:56 A.M., an interview was conducted with the ADON. The ADON stated usually E-kits that are close to their expiration date are swapped out for new ones prior to their expiration. The ADON stated the expired E-kit and medications should have been removed from the floors. On 5/7/21 at 1:40 P.M., an interview was conducted with the pharmacist for the facility. The pharmacist stated it was the facility's responsibility to check the medications and E-kits for expiration and notify the pharmacy. The pharmacist stated E-kits and expired medications would be replaced when the pharmacy was notified. On 5/7/21 at 2:01 P.M., an interview was conducted with the ADON. The ADON stated that prior to this, E-kits were only checked for expired medications when a medication was used. The ADON stated a new procedure needed to be started to ensure no medications were expired. According to the facility policy, titled Storage of Medications, revised November 2020: .discontinued, outdated, or deteriorated drugs .are returned to the dispensing pharmacy or destroyed . 056388 Page 7 of 14 056388 05/07/2021 Paradise Valley Health Care 2575 E. Eighth St. National City, CA 91950

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to honor the meal preferences for 1 of 2 residents investigated for meal preferences (229). As a result, Resident 229's plate contained food she would not eat. Findings: Per the facility's admission Record, Resident 229 admitted to the facility on [DATE]. Per the facility's dining card, dated 5/6/21, Resident 229's dislikes included Vegetables . Per the facility's menu for Resident 229, dated 5/3/21 - 5/9, Italian [NAME] Beans had a line drawn through it. On 5/4/21 at 3:45 P.M., a concurrent observation and interview was conducted with Resident 229. Resident 229 stated the facility gave her greenbeans for lunch even though she had told them she did not want vegetables. A full serving of green beans was observed on resident 229's lunch meal tray. On 5/6/21 at 8:05 A.M., a concurrent interview and record review was conducted with the RD. The RD stated, green beans were crossed out on Resident 229's menu, which indicated she did not want them. Per the facility's policy titled System for Recording Food Preferences, updated 10/17/19, .1. Note the food and beverage preferences on the individual's meal ticket . 056388 Page 8 of 14 056388 05/07/2021 Paradise Valley Health Care 2575 E. Eighth St. National City, CA 91950

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to remove expired items from the dry storage room and ensure staff covered all facial hair in the kitchen. Residents Affected - Few As a result, there was the risk of: 1. The facility providing expired food to residents 2. Unsecured hair falling onto food. Findings: 1. On 5/4/21 at 8:05 A.M., the DS (Dietary Supervisor) was observed with facial hair on the front of his neck uncovered by his facial mask. On 5/4/21 at 8:25 A.M., the DS stated, he should have been wearing a beard net. Per the facility's policy titled Employee Sanitary Practices, dated 2019, . 1. Wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food . 2. On 5/4/21 at 8:12 A.M., an observation was conducted of the dry storage room. A container of dried shredded coconut had a label dated 5/1/21. There was another number written under the 5, which was unclear if it was a 3 or an 8. Four individual servings of honey thickened lemon flavored water were observed with the use by dates of 4/29/21. On 5/4/21 at 8:15 A.M., the DS stated the expired thickened water should have been thrown out. The DS further stated, the container of dried, shredded, coconut should have been thrown out because the label was not clear. The DS stated, the staff should have gotten a new label if they wrote it down wrong instead of writing a new date over it. Per the facility's policy titled Food Storage, dated 2017, .d. Date marking to indicate the date or day by which a use by potentially hazardous food should be consumed, sold, or discarded will be visible on all high risk food . 056388 Page 9 of 14 056388 05/07/2021 Paradise Valley Health Care 2575 E. Eighth St. 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 follow proper infection control practice when: Residents Affected - Some 1. Two Certified Nurse Assistants (CNA 70, 71) entered, and exited the PUI isolation rooms (Person Under Investigation for COVID-19 [a contagious respiratory infection]) without performing hand hygiene, not wearing gloves and gowns while handling and passing meal trays in between residents. 2. The facility placed in the same room, residents that were considered PUI and residents that have been cleared and had completed quarantine days (a period of isolation). These failures had the potential to spread infection amongst the residents, staff, and visitors. In addition, placing PUI residents and cleared residents in the same room had the potential to infect the residents that had already been cleared from COVID-19. Findings: 1a. On 5/4/21 at 12:09 A.M., CNA 62 was observed walking into room [ROOM NUMBER] carrying a meal tray, without donning a gown or gloves, then walked out of the room with an empty meal tray. CNA 62 did not perform hand hygiene prior to going in or out of the room. On 5/4/21 at 12:25 P.M., CNA 62 was observed entering room [ROOM NUMBER] without a gown or gloves, then left the room, picked up a meal tray, and delivered the meal tray to room [ROOM NUMBER]. CNA 62 did not perform hand hygiene between rooms [ROOM NUMBERS]. On 5/4/21 at 310 P.M., the entry to room was observed, and the label read, 118a 4/10 to 4/23, and 118b 4/21 to 5/4, On 5/4/21 at 3:15 P.M., the SC stated, the dates outside of a resident's room indicated when the resident's quarantine isolation ended. The SC further stated, if one resident in a room was on isolation, but the other resident had finished their 14 day isolation, staff should still wear PPE when visiting either resident. The SC stated, the second date listed was the last day of a resident's isolation. On 5/6/21 at 7:58 A.M., CNA 62 stated, when she dropped off the lunch tray for room [ROOM NUMBER] on 5/4, she forgot to put on the gown and gloves. On 5/6/21 at 9:35 A.M., an interview was conducted with the IP. The IP stated, when a CNA entered an isolation room to drop off a meal tray, they should have worn the appropriate PPE, including a gown and gloves. 2a. On 5/4/21 at 10:00 A.M., an observation was conducted on the third floor hallway. Each resident room was labeled with residents' names with dates written in red ink. On 5/4/21 at 10:44 A.M., an interview was conducted with CNA 52. CNA 52 stated the red dates next to the names indicated quarantine for Covid-19. She stated the first date listed was the resident's admission date, and the the second date indicated when that resident had finished their quarantine days. CNA 52 further stated that if a resident did not have a date beside their name, it meant that 056388 Page 10 of 14 056388 05/07/2021 Paradise Valley Health Care 2575 E. Eighth St. National City, CA 91950

F 0880 they were long-term residents whose admission and quarantine dates were long past. Level of Harm - Minimal harm or potential for actual harm On 5/6/21 at 9 A.M., an interview was conducted with the IP. The IP stated persons under investigation for Covid-19 were admitted into rooms where residents were already found to be uninfected. The IP stated this was the practice of the facility and it was done because there were no available rooms to move residents to after their observation period. The IP stated residents who shared rooms with residents needed to be monitored for Covid-19 for another 14 days. The IP stated this was not acceptable infection control and said, It's not right. Residents Affected - Some On 5/6/21 at 3:24 P.M., an observation was conducted of the dates on resident rooms. Room A had a resident admitted on [DATE] and their observation period ended on 4/22/21. Another resident was admitted to the room on 4/23/21 with their observation period to end on 5/6/21. Room B had a resident admitted on [DATE] and their observation period ended on 4/10/21. Another resident was admitted to the room on 5/6/21 with their observation period to end on 5/19/21. Room C had a resident with no date beside their name, which meant they were a long-term resident with no recent observation period. Another resident was admitted on [DATE] and their observation period to ended on 3/17/21. Room D had a resident admitted on [DATE] and their observation period ended on 4/7/21. Another resident was admitted on [DATE] and their observation period ended on 4/25/21. A third resident was admitted to the room on 5/5/21 with their observation period to end on 5/18/21. Room E had a resident admitted on [DATE] and their observation period ended on 4/30/21. Another resident was admitted to the room on 5/4/21 with their observation period to end on 5/17/21. Room F had four residents in total. Three of the residents had no dates beside their names, which meant they were long-term residents with no recent observation periods. The fourth resident was admitted to the room on 4/28/21 with their observation period to end on 5/11/21. Room G had three residents in total. One resident, had no dates beside their name, which meant they were a long term resident with no recent observation period. Another resident was admitted to the room on 4/29/21 with their observation period to end on 5/12/21. Another resident was admitted to the room on 5/6/21 with their observation period to end on 5/19/21. Room H had a resident admitted on [DATE] and their observation period ended on 4/20/21. Another resident was admitted to the room on 4/27/21 with their observation period to end on 5/10/21. On 5/7/21 at 9:55 A.M., an interview was conducted with LN 53. LN 53 stated when residents were admitted to the facility, they were observed for signs and symptoms of Covid-19 for 14 days. LN 53 stated that residents under observation for Covid-19 were placed on droplet precautions and staff who entered the room were required to wear an N95 respirator, a gown, gloves, and a face shield or goggles. She stated this was to protect staff from exposure to Covid-19. LN 53 stated residents under quarantine were not permitted to leave their rooms. LN 53 stated the whole room was considered a quarantined area, even if only one resident was being observed for Covid-19. LN 53 stated residents who had finished their quarantine were potentially exposed if their roommate was found to be infected. On 5/7/21 at 11:20 A.M., an interview was conducted with the ADON. The ADON stated the decision to 056388 Page 11 of 14 056388 05/07/2021 Paradise Valley Health Care 2575 E. Eighth St. National City, CA 91950

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some mix residents who were under observation for Covid-19 with residents who were past their quarantine was a joint decision reached by the DON, the Administrator, and the IP. She stated it was what the facility had always done and had not been considered a problem. According to the facility's current Covid-19 Pandemic Mitigation Plan, .D. All residents who are not suspected to be infected with Covid-19 are in rooms or units that do not include confirmed or suspected cases .E. Upon admission, new and readmitted residents with unknown Covid-19 status are placed in a separate observation unit in the building .Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their exposure (or admission to the facility) . 1b. On 5/4/21 at 11:45 AM, an observation was conducted on the third floor of the facility (PUI overflow wing). During the meal tray pass, CNA 70 and CNA 71 were observed passing meal trays to all the residents in the overflow wing. CNA 70 and CNA 71 did not perform hand hygiene prior to handling the meal trays and in between passing the meal trays from one resident to another. Both CNAs were also observed entering isolation rooms without wearing gloves and gowns. On 5/6/21 at 10:48 AM, an interview was conducted with CNA 70. CNA 70 was asked about the process for passing meal trays. CNA 70 stated she delivered the meal trays to the residents after the licensed nurses checked the meal trays. CNA 70 did not verbalize that she would perform hand hygiene prior to handling the meal trays. On 5/6/21 at 11:03 AM, an interview was conducted with CNA 71. CNA 71 was asked about the process for passing meal trays. CNA 71 stated she would wash her hands, don on (put on) gown and gloves, and will stand on the doorway; while another staff, who was outside the residents' room, handed her the meal trays for the residents inside the room. CNA 71 did not verbalize that she would perform hand hygiene in between passing the meal trays to each of the residents in the room. On 5/6/21 at 9 AM, an interview was conducted with the Infection Preventionist (IP). The IP stated CNA 70 and CNA 71 should have washed or sanitized their hands before and after handling the meal trays. The IP stated the CNAs were instructed to wear full personal protective equipment (PPE), which includes gown, gloves, face shield, and N-95 respirator (a respiratory protective device), when entering PUI rooms. On 5/7/21 at 1:50 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated the nurses and the CNAs should perform hand hygiene before handling the meal trays, in between and after passing the meal trays. The ADON also stated that staff should wear full PPE when entering a PUI room. According to the facility policy dated, October 2010, titled, Infection Control Guidelines for All Nursing Procedures, . 3. Employees must wash hands .c. Before and after direct contact with residents.d. After removing gloves. 4.If hands are not visibly soiled, use an alcohol-based hand rub .a. Before and after direct contact with residents.i. After contact with objects in the immediate vicinity of the residents.j. After removing gloves. According to the facility's COVID-19 pandemic mitigation plan, approved by CDPH on 10/14/2020, titled, Coronavirus Disease 2019 (COVID-19) Mitigation Plan for Skilled Nursing Facilities, .E. Staff have been trained on selecting, donning and doffing appropriate PPE and demonstrate competency of such skills during resident care. 056388 Page 12 of 14 056388 05/07/2021 Paradise Valley Health Care 2575 E. Eighth St. National City, CA 91950

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2b. On 5/6/21 at 9 AM, an interview was conducted with the IP (Infection Preventionist). The IP stated that residents who have completed their quarantine (a period of isolation) should not be placed in the same room as residents who were currently placed on quarantine. If the resident who completed the quarantine was placed in the same room with a resident who was just starting his or her quarantine, that would mean that the resident who completed the quarantine, will have to be placed on quarantine again. The IP stated that the practice was Not acceptable. According to the facility policy dated, March 2020, titled, Coronavirus Disease (COVID-19) Prevention and Control, .13. Residents with suspected or confirmed COVID-19 infection are placed in a separate room or cohorted with other residents with the same infection status. Residents who cannot be treated adequately or safely separated from other residents will be transferred. 056388 Page 13 of 14 056388 05/07/2021 Paradise Valley Health Care 2575 E. Eighth St. National City, CA 91950

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation, interview and record review, the facility failed to ensure resident rooms measured at least 80 square feet (sq. ft.) per resident in four resident bedrooms. This failure had the potential to impact resident care and quality of life. Findings: On 05/04/21 to 05/07/2021, during the re-certification survey, an observation of resident rooms was conducted. The following resident rooms measured less than 80 sq. ft. for each resident: Room Residents Room Size 109 2 95 sq. ft. per resident 110 2 97.5 sq. ft. per resident 209 4 43 sq. ft. per resident 221 4 45 sq. ft. per resident Upon observation and interview during the survey, no quality of care or quality of life concerns which negatively impacted the residents residing in those rooms were identified. The facility received a waiver (variation) of this requirement from CMS dated 7/15/2019. The Department recommends a continuation of the waiver as set forth in the CMS letter. 056388 Page 14 of 14