Health inspection·August 29, 2019

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to update a care plan for one of 20 (7) residents reviewed for care plans. This failure resulted in Resident 7 receiving less nutrition than ordered following an episode of hypoglycemia (low blood sugar). Findings: Per the Record of Admission, Resident 7 was admitted to the facility on [DATE] with diagnoses including cancer, dysphagia (difficulty swallowing), gastrostomy (procedure in which a tube is placed in the stomach for nutritional support), and severe malnutrition (lack of proper nutrition). On 8/26/19 at 2:25 P.M., an interview was conducted with Resident 7's FM. The FM stated she was almost constantly at Resident 7's bedside. Resident 7's FM stated she was worried because she did not think Resident 7 was getting enough of his tube feeding. FM stated Resident 7 had to go to the emergency department the previous week (8/22/19) because he had low blood sugar. His FM stated she thought Resident 7 was still not receiving all the tube feeding he should have been. On 8/27/19, a record review was conducted. An After Visit Summary, dated 8/22/19, stated Resident 7 had been seen in the emergency department (E.D.) for hypoglycemia that day. Resident 7's discharge instructions from the E.D. read as follows: Please continue the patient's tube feeds as they are instructed. The patient became hypoglycemic today because he went too long without any nutrition. Do not do this again. On 8/27/19, a record review was conducted. Resident 7 had a care plan for nutrition; however, it had not been updated since 6/13/19. There were no new interventions put in place since Resident 7 had his hypoglycemic episode. A short-term care plan, dated 8/22/19, ending on 8/25/19 was written regarding Resident 7's hypoglycemic episode. The intervention listed was to monitor Resident 7 for any significant changes and notify MD, PRN. During the record review, the physician's orders, dated 8/12/19, for Resident 7 were reviewed. The resident's physician ordered for Resident 7 to receive tube feeding formula 80 ml an hour for 20 hours per day, for a total of 1,600 ml per day. On 8/27/19, a record review of Resident 7's Intake and Output Record was conducted. Page 1 of 16 555263 555263 08/29/2019 Castle Manor Nursing & Rehabilitation Center 541 V Avenue National City, CA 91950

F 0656 On 8/20/19, Resident 7's tube feeding formula intake total was 1,520 ml. Level of Harm - Minimal harm or potential for actual harm On 8/21/19, Resident 7's tube feeding formula intake total was 1,200 ml. On 8/22/19, Resident 7's tube feeding formula intake total was 1,200 ml. Residents Affected - Few On 8/23/19, Resident 7's tube feeding formula intake total was 1,260 ml. On 8/24/19, Resident 7's tube feeding formula intake total was 1,260 ml. On 8/25/19, Resident 7's tube feeding formula intake total was 1,270 ml. On 8/26/19, Resident 7's tube feeding formula intake total was 1,290 ml. On 8/27/19 at 11:02 A.M., a joint interview and record review was conducted with LN 21. LN 21 stated all care plans, IDT meetings, and status change notifications were in the chart. LN 21 was unable to find any updates to Resident 7's care plan or any new interventions put in place to ensure Resident 7 received all his tube feeding. On 8/28/19 at 2:09 P.M., a joint interview and record review with the DON was conducted. The DON stated there was no charting identifying Resident 7 as at risk to receive less tube feeding than ordered. The DON stated no new interventions were added to Resident 7's care plan after his hypoglycemic episode to ensure the resident received the correct tube feeding formula amount. The DON stated, It was wrong. The facility policy, titled Care and Service-Care Plan, revised October 2017, indicated, The care plan is comprehensive for each resident including measurable objectives and timeframes to meet the residents' medical, nursing, mental and psychosocial needs. 555263 Page 2 of 16 555263 08/29/2019 Castle Manor Nursing & Rehabilitation Center 541 V 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 change the dressing as ordered for one of one residents (7) reviewed for quality of care. Residents Affected - Few This failure had the potential to cause an infection at Resident 7's GT (a procedure in which a tube is placed in the stomach for nutritional support) site. Findings: Per the Record of Admission, Resident 7 was admitted to the facility on [DATE] with diagnoses including cancer and a GT. On 8/27/19 at 9:53 A.M., a joint interview and observation was conducted with Resident 7. Resident 7 stated that the dressing protecting his GT site was supposed to be changed every day. He stated the dressing had not been changed in two days. An observation of the dressing itself showed the date 8/25/19 was written on it. On 8/27/19, a record review for Resident 7 was conducted. A physician's order, dated 5/21/19, read Cleanse GT site with normal saline and cover with dry dressing daily. Resident 7 had a care plan for GT site care. It was titled At risk for irritation at feeding tube site and listed as an intervention, provide G-tube site care and treatment as ordered. On 8/28/19, a record review was conducted. Resident 7 had a TAR for 8/1/19-8/31/19. The TAR had an allotted space for the order Cleanse G-tube site with normal saline and cover with dry dressing daily. The treatment nurses initialed the dates the treatments were performed. Resident 7's TAR was initialed daily, including the dates 8/26 and 8/27. On 8/29/19 at 3:18 P.M., a joint interview and record review was conducted with LN 23. LN 23 stated she was the treatment nurse. While jointly reviewing Resident 7's TAR, LN 23 identified the initials on dates 8/26 and 8/27 as her own. LN 23 stated when she changed dressings, she labeled them with the date they were changed. LN 23 stated she did not know why Resident 7's dressing had 8/25/19 written on it if it had been changed on 8/26 and 8/27. LN 23 stated she could not remember changing Resident 7's dressing on those two days. LN 23 stated she most likely did not change the dressing on 8/26 and 8/27. LN 23 stated it was important to keep Resident 7's g-tube site clean for infection control, especially since he has cancer. A facility policy, dated February 2017 and titled Physician's Orders indicated, It is the policy of this facility to verify physician orders will be carried out/administered/or implemented as received .from the physician . 555263 Page 3 of 16 555263 08/29/2019 Castle Manor Nursing & Rehabilitation Center 541 V Avenue National City, CA 91950

F 0692 Provide enough food/fluids to maintain a resident's health. 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 two of seven residents (7, 52) reviewed for nutrition received tube feeding and hydration as ordered. Residents Affected - Few This failure resulted in Resident 52 not receiving the correct amount of tube feeding and hydration, and Resident 7 requiring treatment in the Emergency Department for hypoglycemia (low blood sugar). Further, the facility did not ensure Resident 7 received tube feedings as ordered in the days following the hypoglycemic episode. Findings: 1. Per the Record of Admission, Resident 7 was admitted to the facility on [DATE] with diagnoses including cancer, dysphagia (difficulty swallowing), gastrostomy (procedure in which a tube is placed in the stomach for nutritional support), and severe malnutrition (lack of proper nutrition). On 8/26/19 at 2:25 P.M., an interview was conducted with Resident 7's FM. The FM stated she was almost constantly at Resident 7's bedside. Resident 7's FM stated she was worried because she did not think Resident 7 was getting enough of tube feeding. She stated Resident 7 had to go to the emergency department the previous week (8/22/19) because he had low blood sugar. His FM stated she thought Resident 7 was still not receiving all the tube feeding he should have been. On 8/27/19, a record review was conducted. An After Visit Summary, dated 8/22/19, stated Resident 7 had been seen in the emergency department (E.D.) for hypoglycemia that day. The discharge instructions from the E.D. read as follows: Please continue the patient's tube feeds as they are instructed. The patient became hypoglycemic today because he went too long without any nutrition. Do not do this again. During the record review, Resident 7's Medical Nutrition (Initial) Therapy Assessment, dated 5/25/19, was reviewed. The RD stated Resident 7 had severe malnutrition and a cancer diagnosis. Because of these nutritional concerns, the RD recommended Resident 7 receive 1,600 ml of tube feeding formula per day. During the record review, the physician's orders, dated 8/12/19, for Resident 7 were reviewed. The resident's physician ordered for Resident 7 to receive tube feeding formula 80 ml an hour for 20 hours per day, for a total of 1,600 ml per day. The orders stated to have the tube feeding turned off for four hours per day. On 8/27/19, a record review of Resident 7's Intake and Output Record was conducted. On 8/20/19, Resident 7's tube feeding formula intake total was 1,520 ml. On 8/21/19, Resident 7's tube feeding formula intake total was 1,200 ml. On 8/22/19, Resident 7's tube feeding formula intake total was 1,200 ml. On 8/23/19, Resident 7's tube feeding formula intake total was 1,260 ml. 555263 Page 4 of 16 555263 08/29/2019 Castle Manor Nursing & Rehabilitation Center 541 V Avenue National City, CA 91950

F 0692 On 8/24/19, Resident 7's tube feeding formula intake total was 1,260 ml. Level of Harm - Minimal harm or potential for actual harm On 8/25/19, Resident 7's tube feeding formula intake total was 1,270 ml. On 8/26/19, Resident 7's tube feeding formula intake total was 1,290 ml. Residents Affected - Few On 8/28/19 at 11:02 A.M., a joint interview and record review was conducted with LN 21. LN 21 stated she worked regularly with Resident 7. LN 21 stated Resident 7 left the facility five days a week for treatment. LN 21 stated while Resident 7 received that treatment, he was usually out of the facility for four to eight hours. During the time he was gone, LN 21 stated Resident 7's tube feeding was turned off. LN 21 stated the physician's orders for Resident 7's tube feeding were for him to receive 1,600 ml per day. LN 21 stated that based on the Intake and Output Record, Resident 7 was receiving a lower amount of tube feeding than was ordered. On 8/28/19 at 11:10 A.M., a joint interview and record review was conducted with LN 22. LN 22 stated she worked regularly with Resident 7. LN 22 stated that based on the Intake and Output Record, Resident 7 received less than the amount of tube feeding formula than was ordered. LN 22 stated if Resident 7 had his tube feeding turned off for longer than 4 hours in a day, the resident's doctor or the RD should be notified so that changes could be made to Resident 7's orders. LN 22 stated if Resident 7 did not get the nutrition he needed, it could make it harder to heal from his cancer. On 8/29/19 at 12:30 P.M., a joint interview and record review was conducted with the RD. The RD stated that since Resident 7 had cancer, it was very import that he received all of the tube feeding as ordered. The RD stated the tube feeding orders came from calculations made of Resident 7's nutritional needs. The RD stated she expected Resident 7 to receive 100% of his tube feeding formula as ordered. She stated if Resident 7 had his tube feeding turned off for longer than the ordered 4 hours, the feeding should have been adjusted so the resident could get all his nutrition. The RD stated she would expect the LNs to notify herself or Resident 7's doctor if he was not able to get the ordered amount of tube feeding formula. The RD stated, Not having enough nutrition could definitely effect his health, it can keep him from healing. Cancer patients need good nutrition. On 8/29/19 at 3:34 P.M., an interview was conducted with the DON. The DON stated Resident 7 should have been administered the correct amount of tube feeding formula. He stated, If he doesn't, we won't be able to meet his nutritional needs or keep him hydrated. The DON stated the facility needed to ensure correct nutrition and hydration for each resident. The facility policy, titled Enteral Feeding and dated November 2017, indicated, .ensure that a resident maintains acceptable parameters of nutritional status; is offered sufficient fluid intake to maintain proper hydration and health . 2. Resident 52 was readmitted to the facility on [DATE] with diagnoses to include dysphagia (difficulty swallowing) and GT (procedure in which a tube is placed in the stomach for nutritional support), per the facility's Record of Admission. On 8/26/19 a record review was conducted. Resident 52's physician's orders indicated the resident could have nothing by mouth and dependent on tube feeding (TF) for all nutrition and hydration needs. On 8/27/19 at 10:10 A.M., an observation of Resident 52's TF was conducted. Resident 52 had a full 1500 ml TF bottle of (brand name) 1.5 hanging on an infusion pump. There was also a bag of water 555263 Page 5 of 16 555263 08/29/2019 Castle Manor Nursing & Rehabilitation Center 541 V Avenue National City, CA 91950

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few flush hanging on the infusion pump. Both the TF bottle and the bag of water flush were dated 8/27/19 at 2 A.M. The infusion pump indicated the contents of the TF bottle was infusing at 55 ml/hr and the water flush was infusing at 50 ml/hr. On 8/27/19 at 4:46 P.M., an observation of Resident 52's TF was conducted. Resident 52 had a 1400 ml (out of 1500 ml) full TF bottle of (brand name) 1.5 hanging on an infusion pump. There was also a bag of water flush hanging on the infusion pump. Both the TF bottle and the bag of water flush were dated 8/27/19 at 10:30 A.M. A review of Resident 52's physicians orders, dated 7/18/19, indicated the resident was to receive (brand name) 1.5 via TF at 55 ml/hr for 21 hours and water flushes at 50 ml/hr while receiving TF. On 8/28/19 at 10:56 A.M., a joint interview and record review was conducted with LN 11. LN 11 stated nurses were required to handwrite the date and time on the TF bottle and bag of water flush to indicate the exact date and time the TF was started. LN 11 stated on 8/27/19 around 8 to 9 A.M., she noticed Resident 52's TF infusion pump was off and the TF bottle was full. LN 11 stated the TF bottle and bag of water flush were both dated 8/27/19 at 2 A.M. LN 11 stated the TF should have been on and infusing since the previous shift (11 P.M. to 7 A.M.). LN 11 stated Resident 52 had not received any nutrients or hydration for approximately seven hours while the TF was off on 8/27/19. LN 11 stated at 10:30 A.M. on 8/27/19 she decided to hang a new TF bottle and bag of water flush in order to start fresh. LN 11 stated she should have notified the physician to inform them Resident 52's TF had not infused for approximately seven hours, but did not. LN 11 further stated nurses' have to turn off Resident 52's TF when doing care, and we often forget to restart it. LN 11 stated not turning the TF pump back on after giving care, affected the amount of food and water Resident 52 received. LN 11 stated Resident 52 ran the risk of becoming nutritionally compromised and dehydrated when the TF order was not carried out as ordered. On 8/28/19 at 4:04 P.M., a joint interview and record review was conducted with LN 12. LN 12 stated he took care of Resident 52 on 8/27/19 during the NOC shift (11 P.M. to 7 A.M.). LN 12 stated he did not realize Resident 52's TF had been off since 2 A.M. LN 12 stated he was supposed to check his residents TF infusion pumps at the end of his shift to record the residents' intake amounts. LN 12 stated he did not check Resident 52's TF before completing his shift. LN 12 stated if he had checked, he would have noticed Resident 52's TF was off. LN 12 stated accurate TF was important for Resident 52 as the TF was the only way he received nutrition and hydration. LN 21 stated approximately 7 hours was too long to go without TF, and possibly created a nutrition and fluid deficit for Resident 52. LN 12 stated the physician should have been notified for an order to adjust the TF rate appropriately to help get caught up. LN 12 further stated residents dependent on TF could become malnourished and dehydrated when TF was missed or not administered as ordered. On 8/29/19 at 12:16 P.M., an interview was conducted with the facility's RD. The RD stated Resident 52 was recently put on her weight variance list. The RD stated this was so I can keep an eye on him as he's had some weight loss. The RD stated, It's very important that a resident receives the entire amount of tube feeding and hydration. The RD stated the potential consequences for residents who did not receive the full amount of TF was dehydration and weight loss. The RD stated a vulnerable resident like Resident 52 may not be able to compensate for weight loss and dehydration. The RD stated when Resident 52's full TF amount could not be given, the RD or physician should have been notified in order to adjust the resident's TF rate. The RD stated, I expect residents to receive one hundred percent of their nutrition and hydration. The RD further stated when the TF and hydration order was not followed, the resident did not receive adequate nutrition and hydration. 555263 Page 6 of 16 555263 08/29/2019 Castle Manor Nursing & Rehabilitation Center 541 V Avenue National City, CA 91950

F 0692 Level of Harm - Minimal harm or potential for actual harm On 8/29/19 at 12:39 P.M., an interview was conducted with the DON. The DON stated Resident 52's TF and hydration order should have been followed and carried out. The facility's policy titled Enteral Feeding-Restore Eating Skills, revised December 2018, did not provide guidance pertaining to administering nutrition or hydration via TF. Residents Affected - Few 555263 Page 7 of 16 555263 08/29/2019 Castle Manor Nursing & Rehabilitation Center 541 V 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 observation, interview, and record review, the facility failed to ensure one of 5 residents (45) reviewed for medications had the root cause of their yelling fully investigated prior to initiating and continuing the resident on an antipsychotic medication (a drug that affects brain activities associated with mental processes and behavior). This failure put Resident 45 at risk for unnecessary medications and had the potential to disrupt the resident's means of communication. Findings: Resident 45 was admitted to the facility on [DATE] with diagnoses to include hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body), aphasia (loss of ability to express speech) following a stroke, and dysarthria (slurred or slow speech that is difficult to understand), per the facility's Record of Admission. On 8/28/19, a record review was conducted. Resident 45's physician's orders, dated 11/2/18, indicated the resident was taking risperidone 0.5 mg (an antipsychotic medication) twice a day for major depression with psychotic (disconnection from reality and may include symptoms such a hallucinations and delusions) features. Resident 45's written care plan for antipsychotic medication (risperidone), dated 11/2/18 and revised 5/22/19, indicated the resident's psychotic features were exhibited by: constant - loud disruptive yelling. On 8/29/19 at 7:46 A.M., a joint interview and record review was conducted with the SSD. The SSD stated she was a member of the facility's IDT and she participated in the facility's psychotropic medication committee. The SSD stated Resident 45 was put on risperidone due to frequent episodes of yelling and occasional resistiveness to care. The SSD stated, She (Resident 45) would just yell out. The SSD stated the facility did not know what was the cause of the yelling. On 8/29/19 at 8:10 A.M., an interview was conducted with CNA 13. CNA 13 stated she regularly took care of Resident 45. CNA 13 stated Resident 45 yelled out when she needed something. CNA 13 stated she was able to understand what Resident 45 wanted by the tone of her yell. CNA 13 stated Resident 45 was not very verbal and the resident could sometimes become frustrated when staff did not understand her. CNA 13 stated Resident 45 would yell out when she was uncomfortable or wet. CNA 13 stated Resident 45 could not consistently use her call light, and instead would yell out. CNA 13 stated Resident 45 would keep yelling out until staff assisted her. CNA 13 stated she has not had any problem with Resident 45's behavior, nor observed her yelling for no apparent reason. On 8/29/19 at 8:25 A.M., an observation was conducted near the front nurse's station. Resident 45 was yelling, Uhhh. Uhh. Uhhhh. The yelling could be heard in the vicinity of the nurse's station and down the adjacent hall. CNA 13 was observed heading toward Resident 45's room. CNA 13 went into Resident 45's room and then walked down the hall in the direction of the kitchen. Resident 45 had stopped yelling. On 8/29/19 at 8:26 A.M., CNA 13 was observed heading back toward Resident 45's room with a small 555263 Page 8 of 16 555263 08/29/2019 Castle Manor Nursing & Rehabilitation Center 541 V Avenue National City, CA 91950

F 0758 carton in her hand. CNA 13 stated Resident 45 had asked her for more milk. Level of Harm - Minimal harm or potential for actual harm 8/29/19 at 8:33 A.M., an interview was conducted with CNA 14. CNA 14 stated she was familiar with Resident 45. CNA 14 stated Resident 45 yelled frequently when she first was admitted , but I think it was because she was in a new place and wasn't sleeping a lot. CNA 14 stated Resident 45 yelled to communicate with us- she can't really use words to communicate. CNA 14 stated Resident 45 would yell until staff understood and helped her. CNA 14 stated she could not recall any incident where Resident 45's behavior could not be managed by talking to her or trying to understand her. CNA 14 stated she had not witnessed Resident 45 yell nonstop. CNA 14 further stated she was known as the shower lady, and had no issues giving Resident 45 a shower. CNA 14 stated when staff took the time to explain to Resident 45 what was going to happen, the resident was receptive. Residents Affected - Few On 8/29/19 at 8:52 A.M., an interview was conducted with AA 1. AA 1 stated she knew Resident 45 well and worked with her during activities. AA 1 stated Resident 45 communicated what she wanted or needed by way of yelling. AA 1 stated Resident 45 would yell out when she was done participating in activities and wanted to go back to bed. AA 1 stated Resident 45 would yell when she did not want or like something. AA 1 stated Resident 45 has always been well behaved. AA 1 stated she had not noticed any changes in Resident 45's behavior since she was admitted . On 8/29/19 at 9:30 A.M., a joint interview and record review was conducted with LN 15. LN 15 stated Resident 45 could not speak with formed words and communicated by loudly yelling out. LN 15 stated Resident 45 responded positively to music, conversation, and got along well with staff who understood her. LN 15 stated she had not witnessed Resident 45 have an episode of yelling that could not be controlled with music or conversation in a long time. LN 15 reviewed the target behavior for the use of risperidone loud disruptive yelling, and stated Resident 45 should not be given an antipsychotic medication for the way she communicated. LN 15 reviewed the indication for the use of risperidone major depressive disorder with psychotic features, and stated, How would you know if the resident was psychotic since she can't speak? LN 15 stated she should have questioned the use of risperidone for this resident. On 8/29/19 at 10:41 A.M., an interview was conducted with the DON. The DON stated the facility's procedure for putting a resident on an antipsychotic medication was to conduct 72 hour observations, document the observations, request and check labs, identify the root cause of the behavior, and try non-pharmacological interventions to address the behavior identified. The DON stated Our process was not followed in this case (for Resident 45). The DON stated the cause of Resident 45's yelling had not been looked into, nor identified. The DON stated Resident 45 yelled as a means of communication and should not have received an antipsychotic medication for that. The DON stated the facility should have tried non-pharmacological interventions to address Resident 45's yelling before placing the resident on risperidone. The DON stated non-pharmacological interventions should have also been attempted when reevaluating the need to continue the risperidone for Resident 45. The DON stated Resident 45 did not need to be on risperidone. The DON stated this situation should not have happened. Per the facility's policy titled Psychoactive Medications, Revised October 2017, It is the policy of this facility to use chemical restraints for the purpose of discipline or convenience and that chemical restraints are only initiated to treat a resident's medical symptoms and improve quality of life . 2. For residents with behavioral problems . the IDT will develop appropriate strategies to intervene with the behavior(s) and document the interventions and rationale in the clinical record and/or care plan as indicated 555263 Page 9 of 16 555263 08/29/2019 Castle Manor Nursing & Rehabilitation Center 541 V Avenue National City, CA 91950

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and record review, the facility failed to ensure the dietary staff were competent on the ambient temperature food cool down process and following hand hygiene standards in the kitchen. These failures placed residents at risk of foodborne illness. The facility census was 89. Findings: 1. According to the Federal Food and Drug Administration (FDA) Food Code 2017, Section 3-501.14 Cooling, Time/Temperature control for Safety Food shall be cooled within 4 hours to 5oC (degrees Celsius) (41oF) (degrees Fahrenheit) or less if prepared from ingredients at ambient temperature, such as .canned tuna. On 8/26/19 at 9:30 A.M., a joint inspection of the facility's reach-in refrigerator was conducted with the DDS. The reach-in refrigerator's temperature was 48 degrees F (Fahrenheit). The DDS stated the refrigerator's temperature was not within an acceptable range. The DDS stated the refrigerator temperature should be at 41 degrees F or less. Inside the refrigerator there were plates of cut fruit and approximately twenty sandwiches: Chicken salad, egg salad, and tuna salad. A randomly selected chicken salad sandwich was tested for temperature and was 56 degrees F. On 8/26/19 at 9:34 A.M., a joint observation and interview was conducted with DA 1. DA 1 randomly selected a tuna salad sandwich from the reach-in refrigerator. The tuna salad sandwich's temperature was 51 degrees F. DA 1 stated she prepared the tuna salad sandwiches around 6:30 A.M. and placed them in the refrigerator around 7 A.M. DA 1 stated the canned tuna had not been pre-cooled in the refrigerator and was room temperature when prepared. DA 1 stated the facility's cool down process for ambient temperature food was up to the refrigerator to get it to the proper temp (temperature). DA 1 stated the facility did not keep cool down logs. On 8/26/19 at 9:45 A.M., an interview was conducted with the DDS. The DDS stated the facility did not have a cool down process for ambient temperature food. The DDS stated the cool down process was dependent on a working refrigerator. The DDS stated she thought the cool down process would be similar to hot food wherein the food should reach an internal temperature of 41 degrees F or less in 6 hours. The DDS stated there were no cool down logs kept, and she would rely on the residents to tell her if the sandwiches were too warm. On 8/26/19 at 4:30 P.M., a joint interview and record review was conducted with the DDS. The DDS reviewed the in-service training records for the dietary department and stated there had been no in-service training conducted on the topic of ambient temperature food cool down. The DDS stated as the dietary manager, she herself had not received in-service training regarding ambient temperature food cool down process. The DDS stated the dietary department as a whole was unfamiliar with the cool down for ambient temperature food and had not been educated on the process. On 8/28/19 at 8:38 A.M., an interview was conducted with the facility's RD. The RD stated the cool down process for ambient temperature foods such as canned tuna or chicken should have been followed. 555263 Page 10 of 16 555263 08/29/2019 Castle Manor Nursing & Rehabilitation Center 541 V Avenue National City, CA 91950

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The RD stated using a cool down log helped track the exact times to ensure accuracy of the process. The RD stated dietary staff should have been competent on the cool down process. The RD stated not following the cool down process could contribute to the development of foodborne illnesses. Per the facility's policy titled Cooling and Reheating Potentially Hazardous Foods (PHF) also called Time/Temperature Control for Safety (TCS), dated 2018, Ambient Temperature Foods: Potentially hazardous foods shall be cooled within 4 hours to 41 degrees F or less if prepared from ingredients at ambient temperature, such as reconstituted foods and canned tuna. Use cool down log . 2. According to the 2017 Federal FDA Food Code, Section 2-301.14, When to Wash, Food Employees shall clean their hands .immediately before .working with .clean equipment and UTENSILS .and .(E) after handling soiled equipment or utensils . On 8/26/19 at 9:19 A.M., a joint observation and interview was conducted with DW 1 and the DDS. DW 1 was at the three compartment sink in the dish machine room. DW 1 placed dirty dishes and silverware in the last compartment sink. DW 1 turned around and cleared the clean dishes from the dish machine and placed them on the drying rack. DW 1 went back to the sink and loaded the dirty dishes on to the washing rack to be run through the dishwasher. DW 1 then went to the clean side of the dish machine to clear additional clean dishes from the dish washing machine. DW 1 stated he had moved back and forth from a dirty area of the dish washing room to a clean area. DW 1 stated the correct procedure was for staff to wash their hands when moving between dirty and clean areas to avoid cross contamination. DW 1 stated . I should have washed my hands. The DDS acknowledged DW 1 had not washed his hands between clean and dirty tasks. The DDS stated DW 1 should have washed his hands between the tasks of handling the dirty and clean dishes. On 8/27/19 at 3:30 P.M., a joint interview and record review was conducted with the DDS. The DDS stated she had conducted an in-service titled Dishwashing and Sanitation, dated 5/15/19, that included a demonstration, . 7. Sanitize hands or remove gloves before handling sanitized dishes . The DDS stated DW 1 had attended the in-service. The DDS stated she would need to in-service the dietary staff again. On 8/28/19 at 8:38 A.M., an interview was conducted with the facility's RD. The RD stated DW 1 should have washed his hands between handling dirty dishes and clean dishes. The RD stated it was her expectation for kitchen staff to wash their hands when moving between dirty and clean tasks. Per the facility's policy titled Hand Washing, dated 2017, .1. When to wash hands . f. After handling soiled equipment or utensils. g. as often as necessary to remove soil or contamination and to prevent cross contamination when changing tasks 555263 Page 11 of 16 555263 08/29/2019 Castle Manor Nursing & Rehabilitation Center 541 V Avenue National City, CA 91950

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 record review, the facility failed to ensure practices that mitigated the risk of resident food contamination were followed, when: 1. Prepared tuna sandwiches were not accurately cooled down to ensure food safety. 2. A dishwasher (DW) touched dirty dishes and then handled clean dishes without washing his hands. 3. A ready for use resident ice cart had small black dots resembling mold in it. 4. A nutritional shake stored with ready to use shakes was expired. 5. The dates on loaves of bread were inaccurate. These failures to mitigate potential food contamination may result in food borne illness. The facility census at the time of survey was 89. Findings: 1. According to the Food and Drug Administration (FDA) Food Code 2017, Section 3-501.14 Cooling, Time/Temperature control for Safety Food shall be cooled within 4 hours to 5oC (degrees Celsius) (41oF) (degrees Fahrenheit) or less if prepared from ingredients at ambient temperature, such as .canned tuna. On 8/26/19 at 9:30 A.M., a joint inspection of the facility's reach-in refrigerator was conducted with the DDS. The reach-in refrigerator's temperature was 48 degrees F (Fahrenheit). The DDS stated the refrigerator's temperature was not within an acceptable range. The DDS stated the refrigerator temperature should be at 41 degrees F or less. Inside the refrigerator there were plates of cut fruit and approximately twenty sandwiches: Chicken salad, egg salad, and tuna salad. A randomly selected chicken salad sandwich was tested for temperature and was 56 degrees F. On 8/26/19 at 9:34 A.M., a joint observation and interview was conducted with DA 1. DA 1 randomly selected a tuna salad sandwich from the reach-in refrigerator. The tuna salad sandwich's temperature was 51 degrees F. DA 1 stated she prepared the tuna salad sandwiches around 6:30 A.M. and placed them in the refrigerator around 7 A.M. DA 1 stated the canned tuna had not been pre-cooled in the refrigerator and was room temperature when prepared. DA 1 stated the facility's cool down process for ambient temperature food was up to the refrigerator to get it to the proper temp (temperature). DA 1 stated the facility did not keep cool down logs. On 8/26/19 at 9:45 A.M., an interview was conducted with the DDS. The DDS stated the facility did not have a cool down process for ambient temperature food. The DDS stated the cool down process was dependent on a working refrigerator. The DDS stated she thought the cool down process would be similar to hot food wherein the food should reach an internal temperature of 41 degrees F or less in 6 hours. The DDS stated there were no cool down logs kept, and she would rely on the residents to tell her if the sandwiches were too warm. 555263 Page 12 of 16 555263 08/29/2019 Castle Manor Nursing & Rehabilitation Center 541 V Avenue National City, CA 91950

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 8/28/19 at 8:38 A.M., an interview was conducted with the facility's RD. The RD stated the cool down process for ambient temperature foods such as canned tuna or chicken should have been followed. The RD stated using a cool down log helped track the exact times to ensure accuracy of the process. The RD stated not following the cool down process could contribute to the development of foodborne illnesses. Per the facility's policy titled Cooling and Reheating Potentially Hazardous Foods (PHF) also called Time/Temperature Control for Safety (TCS), dated 2018, Ambient Temperature Foods: Potentially hazardous foods shall be cooled within 4 hours to 41 degrees F or less if prepared from ingredients at ambient temperature, such as reconstituted foods and canned tuna. Use cool down log . 2. According to the 2017 Federal FDA Food Code, Section 2-301.14, When to Wash, Food Employees shall clean their hands .immediately before .working with .clean equipment and UTENSILS .and .(E) after handling soiled equipment or utensils . On 8/26/19 at 9:19 A.M., a joint observation and interview was conducted with DW 1 and the DDS. DW 1 was at the three compartment sink in the dish machine room. DW 1 placed dirty dishes and silverware in the last compartment sink. DW 1 turned around and cleared the clean dishes from the dish machine and placed them on the drying rack. DW 1 went back to the sink and loaded the dirty dishes on to the washing rack to be run through the dishwasher. DW 1 then went to the clean side of the dish machine to clear additional clean dishes from the dish washing machine. DW 1 stated he had moved back and forth from a dirty area of the dish washing room to a clean area. DW 1 stated the correct procedure was for staff to wash their hands when moving between dirty and clean areas to avoid cross contamination. DW 1 stated . I should have washed my hands. The DDS acknowledged DW 1 had not washed his hand between clean and dirty tasks. The DDS stated DW 1 should have washed his hands between the tasks of handling the dirty and clean dishes. On 8/28/19 at 8:38 A.M., an interview was conducted with the facility's RD. The RD stated DW 1 should have washed his hands between handling dirty dishes and clean dishes. The RD stated it was her expectation for kitchen staff to wash their hands when moving between dirty and clean tasks. Per the facility's policy titled Hand Washing, dated 2017, .1. When to wash hands . f. After handling soiled equipment or utensils. g. as often as necessary to remove soil or contamination and to prevent cross contamination when changing tasks 3. On 8/26/19 at 8:40 A.M., a joint inspection of the dry storage room was conducted with the DDS. Three rolling ice carts were observed. The DDS stated after the ice carts were thoroughly cleaned and sanitized they were placed in the dry storage room and were ready for immediate use. On 8/26/19 at 8:55 A.M., a joint observation and interview was conducted with DW 1 and the DDS. DW 1 stated the three rolling ice carts had been cleaned inside and out and were ready to be filled with ice and delivered to the resident units. DW 1 stated there were no liners used, and when filled, the ice would come into direct contact with inside of the ice compartment. Two of the rolling ice carts were observed visibly soiled with brown stains on the outside of the ice storage compartments. Inside of each ice storage compartment, were small black dots resembling mold. DW 1 stated the black dots should not be present inside the ice compartments and that both rolling ice cart should have been better cleaned. DW 1 stated he had not completely cleaned them. The DDS stated there should not have been black dots resembling mold on the inside of the ice compartments. The DDS stated ice was considered food and the residents consumed the ice. The DDS stated the rolling ice carts should have 555263 Page 13 of 16 555263 08/29/2019 Castle Manor Nursing & Rehabilitation Center 541 V Avenue National City, CA 91950

F 0812 been thoroughly cleaned. Level of Harm - Minimal harm or potential for actual harm The facility's undated policy titled Procedures: Ice Machine/ Ice Cart -Cleaning & Sanitizing, did not provide guidance for cleaning and sanitizing the rolling ice carts used on resident units. Residents Affected - Many 4. On 8/26/19 a kitchen inspection was conducted with the DDS. In the walk-in refrigerator, there was a tray of supplemental shakes. A strawberry flavored supplemental shake had a labeled date of 8/25/19. The DDS stated once the supplemental shakes were pulled from the freezer, they were good for 14 days. The DDS stated the supplemental shake dated 8/25/19 was expired. The DDS stated it should have been pulled from circulation and discarded. The DDS stated the supplemental shakes should have been checked for expiration dates. Per the facility's policy titled Food Storage, dated 2017, . f.All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded 5. On 8/26/19 at 8:40 A.M., an inspection of the dry storage room was conducted with the DDS. Multiple racks of loaves of sliced bread were observed with yellow sticker dates [DATE] (October 22, 2019). On 8/26/19 at 8:42 A.M., a joint observation and interview was conducted with CK 1. CK 1 stated she received the bread delivery and the yellow sticker dates on each loaf was the receive date. CK 1 stated the bread was good for seven days after the receive sticker date and then it had to be discarded. CK 1 stated the sticker dates marked [DATE] were incorrect and was confusing. CK 1 stated it was very important that the receive dates be correct. CK 1 stated she did not check her work after dating the bread. On 8/26/19 at 8:50 A.M., a joint observation and interview was conducted with the DDS. The DDS stated the [DATE] sticker date was wrong and should have been checked and corrected. On 8/28/19 at 8:38 A.M., an interview was conducted with the facility's RD. The RD stated the food labeling procedure should be consistent and the dating should be accurate. The RD stated it was her expectation for kitchen staff to double check their work for accuracy. Per the facility's policy titled Food Storage, dated 2017, . f.All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded 555263 Page 14 of 16 555263 08/29/2019 Castle Manor Nursing & Rehabilitation Center 541 V Avenue National City, CA 91950

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately record the intake (amount of food or fluid taken into the body) for two of three residents with GT feedings (7, 3). As a result, the documentation related to nutrition and/or hydration was inaccurate. Findings: 1. Per the Record of Admission, Resident 7 was admitted to the facility on [DATE] with diagnoses including cancer, dysphagia (difficulty swallowing), gastrostomy (procedure in which a tube is placed in the stomach for nutritional support), and severe malnutrition (lack of proper nutrition). On 8/27/19, a record review for Resident 7 was conducted. Resident 7's I&O showed the intake totals for his tube feeding. Each day on the I&O, Resident 7's tube feeding amount was recorded by shift. On 8/21/19, the 11 P.M.-7 A.M. shift documented Resident 7 received 640 ml of tube feeding formula. That day, the 3P.M.-11 P.M. shift documented Resident 7 received 560 ml of tube feeding formula. The amount for the 7A.M.-3 P.M. shift was left blank. The tube feeding total for 8/21/19 was 1,200 ml. On 8/22/19, the 11P.M.-7 A.M. shift documented Resident 7 received 640 ml of tube feeding formula. That day, the 3 P.M.-11 P.M. shift documented Resident 7 received 560 ml of tube feeding formula. The amount for the 7A.M.-3 P.M. shift was left blank. The tube feeding total for 8/22/19 was 1,200 ml. On 8/27/19, immediately following the record review, the I&O for Resident 7 was taken to the facility's medical records office for a copy to be made. On 8/28/19 at 7:10 A.M., the copies from Resident 7's I&O were reviewed. The tube feeding intake records did not match what was written the previous day. For the 8/21/19 7 A.M.-3 P.M. shift, the tube feeding formula intake was no longer blank, it read 300 ml. The daily total no longer read 1200 ml, it read 1,500 ml. For the 8/22/19 7 A.M.-3 P.M. shift, the tube feeding formula intake was no longer blank, it read 300 ml. The daily total no longer read 1200 ml, it read 1,500 ml. On 8/28/19 at 7:50 A.M. a joint interview and record review was conducted with the DON. The DON stated it looked like the documentation had been changed. The DON stated it disturbed him and this was not his standard of practice. On 8/28/19 at 8:40 A.M., an interview was conducted with the ADON. The ADON stated she had made the changes to the I&O record for 8/21 and 8/22. The ADON stated the medical record office called her and she went and made changes to Resident 7's I&O before the copies were made. The ADON stated she remembered Resident 7 drank a shake before leaving for his treatment on both days, so she added 300 ml to the tube feeding column. The ADON agreed that a shake taken by mouth did not qualify as tube feeding. The ADON stated it was wrong to change the documentation. On 8/28/19, a record review for Resident 7 was conducted. Physician orders for Resident 7, dated 7/15/19, read as follows, Ensure (chocolate) liquid 240 ml per resident request to promote acceptance meal times. 555263 Page 15 of 16 555263 08/29/2019 Castle Manor Nursing & Rehabilitation Center 541 V Avenue National City, CA 91950

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 8/28/19 at 8:47 A.M., an interview was conducted with Resident 7's FM. She stated he did not drink his Ensure shake that morning. She stated she remembered this because he had never drunk his shake before leaving for treatment. The facility policy, titled Accuracy of Assessments and revised March 2018, indicated, The facility ensures each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment . 2. Per the Record of Admission, Resident 3 was admitted to the facility on [DATE] with diagnoses of gastrostomy (procedure in which a tube is placed in the stomach for nutritional support) and gastrointestinal hemorrhage (bleeding in the intestines). On 8/27/19, a record review for Resident 3 was conducted. Resident 3's I&O was reviewed. On 8/12/19, the 11 P.M.-7 A.M. shift documented Resident 3's tube feeding intake as 456 ml. The 7 A.M.-3 P.M. shift documented Resident 3's tube feeding as 300 ml. The 3 P.M.-11 P.M. shift documented Resident 3's tube feeding intake as 399 ml. The 24 hour total intake recorded for Resident 3 on 8/12/19 was 1,140 ml, however, the actual shift totals added up to 1,155 ml. On 8/13/19, the 11 P.M.-7 A.M. shift documented Resident 3's tube feeding intake as 456 ml. The 7 A.M.-3 P.M. shift documented Resident 3's tube feeding as 228 ml. The 3 P.M.-11 P.M. shift documented Resident 3's tube feeding as 399 ml. The 24 hour total intake recorded for Resident 3 on 8/13/19 was documented as 1,140 ml, however, the actual shift totals added up to 1,083 ml. This incorrect addition was repeated every day from 8/13/19 until 8/18/19. None of the 24 totals were accurate. On 8/28/19 at 4:20 P.M., a joint interview and record review was conducted with LN 24. LN 24 stated she has worked at the facility for 25 years. LN 24 stated it was the nurses on her shift's (3 P.M.-11 P.M.) job to add the 24 hour total I&Os for residents. LN 24 stated it was not permitted to write in just what the physician's order indicated Resident 3's tube feeding total should be, but what his intake actually was. LN 24 got a calculator and added the numbers. She stated the answers did not match the listed totals. She stated Resident 3's intake was not being documented correctly. LN 24 stated it was important for the intake documentation to be accurate so the RD could treat Resident 3 correctly. LN 24 stated Resident 3 could be at risk for dehydration or to not receive enough nutrition. On 8/29/19 at 12:30 P.M., a joint interview and record review was conducted with the RD. The RD stated the I&O needs to be accurate to the exact milliliter. She stated it was her expectation that the nurses who added the I&O totals should ensure the number is accurate. On 8/29/19 at 3:36 P.M., an interview was conducted with the DON. The DON stated the nurses taking care of residents with tube feeding pumps needed re-education on how to accurately document intake and output. He stated, We need to ensure correct nutrition and hydration for each resident. The facility policy, titled Accuracy of Assessments and revised March 2018, indicated, The facility ensures each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment . 555263 Page 16 of 16