Health inspection·December 21, 2023

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. Based on observation, interview, and facility document and policy review, the facility failed to ensure the environment was free from accident hazards by failing to secure a stairwell that started at the ground floor and extended to the first, second, and third floor residential areas. Specifically, the first, second, and third floors had doors that exited to an exterior stairwell. None of the doors had any type of safety precaution to prevent a resident from exiting into the stairwell unattended. This deficient practice had the potential to affect 8 of 8 residents identified by the facility as at risk for elopement and 5 of 5 residents identified by the facility as ambulatory. Findings included: A review of an undated facility policy titled, WANDERGUARD, Code Alert etc. Resident Monitoring System revealed, It is the policy of this facility to provide a safe and secure environment to ensure the safety of any resident attempting to elope from the facility. During an interview on 12/18/2023 at 3:08 PM, the Director of Nursing (DON) stated a door security code was not needed to take the stairwell to the third-floor residential area. Observations on 12/18/2023 at 3:10 PM of the third floor revealed double fire doors that opened to an area near the elevator and a door leading to an outside landing and stairwell. The double fire doors and the door to the outside landing and stairwell were not secured with a code or locking system to prevent residents from exiting the unit through the door leading to the stairwell. During an interview on 12/18/2023 at 3:29 PM, Activities Assistant (AA) #5 stated there was no code required to go out of the facility to the stairwell, noting there was only a code outside on the ground level to prevent anyone from entering the building. During an interview on 12/19/2023 at 9:55 AM, the Social Services Director (SSD) stated the facility had a departure alert system for residents identified as at risk for elopement; however, the SSD stated the ground floor exit doors and front door were the only ones equipped with the departure alert system. During an interview on 12/19/2023 at 12:06 PM, the Dietary Director (DD) stated there was no code required to go out the doors to the stairwell. The DD stated anyone could leave the facility, but there was a code outside on the ground level to prevent anyone outside from entering. The DD further stated the facility used a departure alert system for some residents, but only the ground floor doors were equipped to alarm. Page 1 of 6 056388 056388 12/21/2023 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 Observation on 12/19/2023 at 12:08 PM of the second floor revealed the exit door to the outside landing and stairwell were not secured with a code or locking system to prevent residents from exiting the unit through the door leading to the stairwell. Observation on 12/20/2023 at 10:51 AM of the first floor revealed the exit door to the outside landing and stairwell was propped open. Observations on 12/20/2023 between 10:55 AM and 11:10 AM of the third floor revealed staff and residents passed near the exit door leading to the stairwell. During an interview on 12/20/2023 at 12:15 PM, Certified Nurse Aide (CNA) #2 stated she had never seen a resident try to exit through the door to the stairwell. During an interview on 12/20/2023 at 12:21 PM, Licensed Vocational Nurse (LVN) #4 stated the exit door to the stairwell was not secured or locked. LVN #4 stated she had never known a resident to go out the door to the stairwell. During an interview on 12/21/2023 at 7:14 AM, the DON stated there was no code required to go out the doors to the stairwell, but noted there was a code on the outside to prevent people from coming into the facility. The DON stated he had never known a resident to attempt to go down the stairs, and he did not think a resident would try to go outside to the stairwell and fall. The DON stated they conducted assessments on new residents to identify any resident at risk of wandering, and stated the ground level doors were equipped with a departure alert system. A review of a list provided by the facility labeled, Risk of Elopement- at Risk, dated 12/19/2023, reveled the facility identified eight residents who were at risk for elopement. During an interview on 12/21/2023 at 7:21 AM, the Administrator stated he was not aware of any resident attempting to exit through the doors leading to the stairwell. The Administrator stated the doors were heavy and they had never had a problem with any resident going out them. 056388 Page 2 of 6 056388 12/21/2023 Paradise Valley Health Care 2575 E. Eighth St. 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility policy review, the facility failed to ensure food was covered to prevent potential contamination during meal delivery to resident rooms. Specifically, the facility failed to ensure food was covered during meal delivery to resident rooms located on 1 (second floor) of 3 residential floors. This deficient practice had the potential to affect 29 residents who consumed their meals on the second floor of the facility. Findings included: A review of a facility policy titled, Food Preparation and Service, revised in November 2022, revealed, When meals are assembled in the kitchen and then delivered to residents' rooms or dining areas to be distributed, covering foods is appropriate, either individually or in a mobile food cart. Observations on 12/19/2023 at 12:06 PM revealed the food delivery cart was delivered to the second floor. The cart was parked between the shower room and room [ROOM NUMBER]. The puddings on the trays were not covered. Staff were observed removing the meal trays from the cart and carrying the trays with the uncovered puddings down the hallway to residents' rooms. Observations on 12/20/2023 at 12:08 PM revealed a food delivery cart was parked between room [ROOM NUMBER] and a shower room. Staff removed a tray from the cart and delivered the meal tray to room [ROOM NUMBER], which was approximately 20 feet down the hallway. The pureed dessert was uncovered on the meal tray. Staff then removed a meal tray from the cart and took the meal tray to the dining room, which was approximately 20 feet down the hall. The chocolate chip bar was uncovered on the tray. During an interview on 12/20/2023 at 12:12 PM, Certified Nurse Aide (CNA) #1 stated food should be covered to prevent any germs from getting in it and to maintain the temperature. CNA #1 stated that when an item was uncovered and carried down the hall, it could get germs in it. During an interview on 12/20/2023 at 12:15 PM, CNA #2 stated food was covered to maintain the temperature and to protect it from germs, chemicals, and other contaminants. CNA #2 stated everything on the tray should be covered, because when it was carried down the hall, anything could happen to it. During an interview on 12/20/2023 at 12:17 PM, Licensed Vocational Nurse (LVN) #3, who was sitting with Resident #188, stated food should be covered to maintain the temperature and to protect the food from germs, dirt, and contamination. When the surveyor asked LVN #3 what could happen to the food if it was carried down the hallway uncovered, Resident #188 replied that it could get germs on it. During an interview on 12/20/2023 at 12:21 PM, LVN #4 stated food should be covered to keep it warm and safe from contamination. LVN #4 stated all food items should be covered, because if it was carried down the hallway uncovered, there was a potential for contamination. During an interview on 12/20/2023 at 1:25 PM, the Dietary Director (DD) stated most of the food should be covered but the dessert was sometimes an exception due to presentation. The DD stated he believed the dessert was covered during transportation on the covered cart, noting nursing staff should be taking the cart to each room, instead of carrying the meal trays down the hallway. 056388 Page 3 of 6 056388 12/21/2023 Paradise Valley Health Care 2575 E. Eighth St. National City, CA 91950

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 12/20/2023 at 1:27 PM, the Registered Dietitian (RD) stated for presentation reasons they did not individually cover the dessert items, but noted the entire food delivery cart was covered. The RD stated the nursing staff should be taking the cart to the residents' doorways before removing the trays, instead of carrying the meal trays down the hallway. During an interview on 12/21/2023 at 7:21 AM, the Administrator stated he expected staff to follow the regulations for delivering food to residents' rooms. The Administrator stated he expected the food to be delivered in a safe and sanitary manner. 056388 Page 4 of 6 056388 12/21/2023 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 interview and facility document and policy review, the facility failed to ensure their water management plan was fully implemented to prevent the potential for waterborne illnesses, including Legionella (a bacteria most commonly transmitted through contaminated water sources that could cause Legionnaires' disease). This failure had the potential to affect all 81 residents residing in the facility. Residents Affected - Many Findings included: A review of the facility's policy titled, Legionella Water Management Program, revised in September 2022, revealed, Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella. The Policy Interpretation and Implementation section specified, 1. As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team. 2. The water management team consists of at least the following personnel: a. The infection preventionist; b. The administrator c. The medical director (or designee); d. The director of maintenance; and e. The director of environmental services. 3. The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread and to reduce the risk of Legionnaires' disease. The policy further specified, 5. The water management program includes the following elements: a. An interdisciplinary water management team (see above); b. A detailed description and diagram of the water system in the facility, including the following: (1) Receiving; (2) Cold water distribution; (3) Heating; (4) Hot water distribution; and (5) Waste. c. The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria included the following: (1) Storage tanks; (2) Water heaters; (3) Filters; (4) Aerators; (5) Showerheads and hoses; (6) Misters, atomizers, air washers and humidifiers; (7) Hot tubs; (8) Fountains; and (9) Medical devices such as CPAP [continuous positive airway pressure] machines, hydrotherapy equipment, etc. d. The identification of situations that can lead to Legionella growth, such as: (1) construction; (2) water main breaks; (3) changes in municipal water quality; (4) the presence of the biofilm, scale or sediment; (5) water temperature fluctuations; (6) water pressure changes; (7) water stagnation; and (8) inadequate disinfection. e. Specific measures used to control the introduction and/or spread of Legionella (e.g. temperature, disinfectants); f. The control limits or parameters that are acceptable and that are monitored; g. A diagram of where control measures are applied; h. A system to monitor control limits and the effectiveness of control measures; i. A plan for when control limits are not met and/or control measures are not effective; j. Documentation of the program. During an interview on 12/20/2023 at 8:21 AM, the Maintenance Director stated the facility did not have a waterborne illness plan. He stated the facility did not have any stagnant water, so they did not perform any testing and did not need a waterborne illness plan. The Maintenance Director stated the facility did have drinking water dispensers that were cleaned by an outside company every three months. He further stated any shower heads were cleaned by housekeeping staff, so there was no need to test them for waterborne pathogens. 056388 Page 5 of 6 056388 12/21/2023 Paradise Valley Health Care 2575 E. Eighth St. National City, CA 91950

F 0880 Level of Harm - Minimal harm or potential for actual harm During an interview on 12/21/2023 at 7:23 AM, the Administrator stated the local water authority came to the facility on [DATE] and provided them a printout of the prior six months of water testing. The Administrator said the water authority's testing only included Escherichia coli. He said he knew the water authority tested the water that came into the facility from the outside, and he thought they tested other items, such as the shower heads and ice machine. Residents Affected - Many A review of a letter addressed to the facility from the local water authority, dated 12/20/2023, revealed they tested the bacteriological water quality and chlorine residual every week near the facility to ensure compliance with all state and federal drinking water standards. The letter included the results of the testing for the timeframe from July 2023 to December 2023 that consisted of only chlorine residual, the presence or absence of total coliform, and the presence or absence of Escherichia coli. During an interview on 12/21/2023 at 8:18 AM, the Infection Preventionist (IP) stated she did not have anything to do with the water management plan, noting the Maintenance Director was responsible for the water management plan. During an interview on 12/21/2023 at 8:53 AM, the Maintenance Director stated he had a diagram and checked water temperatures. He stated the local water authority also did testing, but he believed they only tested the water where it came into the building. The Maintenance Director further stated he disinfected the shower heads and the ice machine weekly but did not document it. During an interview on 12/21/2023 at 9:06 AM, the Maintenance Director provided a copy of an undated water source diagram. The following areas were highlighted on the diagram as areas at risk for potential waterborne pathogens: the fire suppression system (sprinkler system), water dispensers, ice machines, cold water distribution, sinks, showers, water heaters, heat exchangers, hot water storage with heat exchangers, washing machines, and the sanitary sewer system. After the surveyor and Maintenance Director reviewed the water source diagram, the Maintenance Director said he had no evidence of any testing of the highlighted areas, because no one had ever told him he needed to conduct any type of testing. The Maintenance Director stated he had now read the policy, so he knew what needed to be included and what he needed to be doing. During an interview on 12/21/2023 at 9:25 AM, the Director of Nursing (DON) stated he expected the residents to be protected from any waterborne illnesses, and they should be drinking safe water. The DON said the Maintenance Director was responsible for performing any water testing. During an interview on 12/21/2023 at 9:28 AM, the Administrator stated his expectation was to follow whatever the regulations and guidelines the state and the Centers for Medicare and Medicaid Services (CMS) dictated. He stated he wanted the water to be safe for all the residents, noting that was most important as they did not want anyone to get sick. During an interview on 12/21/2023 at 11:24 AM, the Assistant Lab Supervisor (ALS) from the local water authority stated they conducted weekly water testing at the facility. The ALS confirmed the local water authority did not perform any water testing inside the facility, noting they only tested the drinking water that came into and out of the facility. 056388 Page 6 of 6