Health inspection·March 2, 2023

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to provide showers consistently for two of two sampled residents (Residents 19, 65) reviewed for ADLs (activities related to personal care). As a result, residents' preferences and choices were not honored and respected. Findings: 1. Resident 19 was readmitted to the facility on [DATE], per the facility's admission Record. Resident 19's history and physical, dated 1/25/23, indicated he had the capacity to understand and make decisions. On 2/27/23, a record review was conducted. Resident 19's MDS (an assessment tool), dated 1/23/23, indicated his BIMS (test the residents' ability to recall) was 15, which indicated intact cognition. The MDS for ADL indicated Resident 19 needed physical help and required one-person physical assist. On 2/27/23 at 9:16 A.M., a concurrent observation and interview of Resident 19 was conducted in his room. Resident 19 was sitting in his wheelchair watering his plants. Resident 19 stated his shower days were Mondays, Wednesdays, and Saturdays. Resident 19 stated the physician ordered three times a week showers. Resident 19 stated he did not consistently receive the showers as per the physician's order. Resident 19 stated he complained to the DSD about it and, It was sickening, and it was all talk. On 2/28/23 at 10:23 A.M., an interview was conducted with CNA 21. CNA 21 stated she had been assigned to Resident 19 in the past. CNA 21 stated Resident 19 was very alert and oriented and required some help when receiving showers. CNA 21 stated had not given showers to Resident 19. On 2/28/23 at 10:28 A.M., an interview was conducted with CNA 22. CNA 22 stated he had not provided showers to Resident 19. CNA 22 stated he had been assigned to Resident 19 occasionally, but had not provided him with showers. CNA 22 stated Resident 19 had an order to get an extra showers each week for a total of three of Mondays, Wednesdays and Saturdays. On 2/28/23 at 10:49 A.M., an interview was conducted with CNA 23. CNA 23 stated she was one of the CNAs primarily assigned to provide showers to the residents. CNA 23 stated she had not provided showers to Resident 19. CNA 23 stated all residents should have been getting their showers regularly two times a week for personal hygiene. CNA 23 stated Resident 19 used to have showers on Mondays and Page 1 of 16 555263 555263 03/02/2023 Castle Manor Nursing & Rehabilitation Center 541 V Avenue National City, CA 91950

F 0561 Saturdays, but now was ordered showers on Mondays, Wednesdays and Saturdays. Level of Harm - Minimal harm or potential for actual harm On 2/28/23 at 2:10 P.M., an interview was conducted with CNA 24. CNA 24 stated she was one of the CNAs primarily assigned to provide showers to the residents. CNA 24 stated she had not given showers to Resident 19. Residents Affected - Few On 3/1/23, a record review was conducted. Resident 19's physician order dated 2/17/23, indicated Resident 19 had showers ordered three times a week. For December 2022, Resident 19's shower sheets indicated Resident 19 received eight out of nine scheduled showers. For January 2023, Resident 19 received three of nine scheduled showers. For February 2023, Resident 19 received four of eight scheduled showers. On 3/1/23 at 7:59 A.M., an interview was conducted with the DSD (responsible for CNAs training and development). The DSD stated the expectation was for the CNAs to ensure residents were provided showers for good hygiene and to prevent infection. On 3/2/23 at 8:11 A.M., a concurrent interview and record review was conducted with LN 21. LN 21 stated it was important for residents to have their showers for good hygiene, to prevent infection, and to do body checks to see open areas which needed treatment right away. On 3/2/23 at 9:04 A.M., an interview was conducted with the DON. The DON stated the expectation was for the CNAs to provide showers to the residents to promote good hygiene and prevent skin complications. A review of the facility's policy titled,Resident Self Determination and Participation, revised February 2021, indicated, .1. Each resident is allowed to choose activities .that are consistent with his or her interests .including: a. daily routine, such as .bathing schedules . 2. Resident 65 was admitted to the facility on [DATE], per the facility's admission Record. Resident 65's history and physical, dated 11/18/22, indicated she had the capacity to understand and make decisions. On 2/27/23, a record review was conducted. Resident 65's MDS (an assessment tool), dated 2/23/23, indicated her BIMS (test the residents' ability to recall) was 15, which indicated intact cognition. The MDS for ADL indicated Resident 65 needed physical help and required one-person physical assist. On 2/27/23 at 9:54 A.M., a concurrent observation and interview was conducted with Resident 65 in her room. Resident 65 was sitting up in bed, with bandage on her left leg. Resident 65 stated her shower days were Tuesdays and Fridays. Resident 65 stated she did not get her showers for almost two weeks. Resident 65 stated it was not good because she had open wounds which needed to get healed. On 2/27/23, a record review was conducted. Resident 65' shower days were scheduled Tuesdays and Fridays. For December 2022, Resident 65 received three of nine scheduled showers. 555263 Page 2 of 16 555263 03/02/2023 Castle Manor Nursing & Rehabilitation Center 541 V Avenue National City, CA 91950

F 0561 For January 2023, Resident 65 received three of nine scheduled showers. Level of Harm - Minimal harm or potential for actual harm For February 2023, Resident 65 received three of seven scheduled showers. Residents Affected - Few On 2/28/23 at 10:15 A.M., an interview was conducted with CNA 21. CNA 21 stated Resident 65 was very alert and oriented and required some help when receiving showers. CNA 21 stated had not given showers to Resident 65. On 2/28/23 at 10:28 A.M., an interview was conducted with CNA 22. CNA 22 stated he had not provided showers to Resident 65. CNA 22 stated he had been assigned to Resident 65 occasionally, but had not provided her with showers. On 2/28/23 at 10:49 A.M., an interview was conducted with CNA 23. CNA 23 stated she was one of the CNAs primarily assigned to provide showers to the residents. CNA 23 stated she had not provided showers to Resident 65. CNA 23 stated all residents should be getting their showers regularly two times a week for personal hygiene. On 2/28/23 at 2:10 P.M., an interview was conducted with CNA 24. CNA 24 stated she was one of the CNAs primarily assigned to provide showers to the residents. CNA 24 stated she had not given showers to Resident 65. On 3/1/23 at 7:59 A.M., an interview was conducted with the DSD (responsible for CNAs training and development). The DSD stated the expectation was for the CNAs to ensure residents were provided showers for good hygiene and to prevent infection. On 3/2/23 at 8:11 A.M., a concurrent interview and record review was conducted with LN 21. LN 21 stated it was important for residents to have their showers for good hygiene, to prevent infection, and to do body checks to see open areas which needed treatment right away. On 3/2/23 at 9:04 A.M., an interview was conducted with the DON. The DON stated the expectation was for the CNAs to provide showers to the residents to promote good hygiene and prevent skin complications. A review of the facility's policy titled, Resident Self Determination and Participation, revised February 2021, indicated, .1. Each resident is allowed to choose activities .that are consistent with his or her interests .including: a. daily routine, such as .bathing schedules . 555263 Page 3 of 16 555263 03/02/2023 Castle Manor Nursing & Rehabilitation Center 541 V Avenue National City, CA 91950

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to develop a care plan (detailed plan with information about a patient's treatment, goal, and interventions) related to dialysis (treatment to remove waste from the body) access care for one of two sampled residents reviewed for dialysis (Resident 19). As a result, there was the potential for undetected complications after dialysis. Findings: Resident 19 was readmitted to the facility on [DATE], with diagnoses which included dependence on dialysis, per the facility's admission Record. Resident 19's history and physical, dated 1/25/23, indicated the physician documented Resident 19 had the capacity to understand and make decisions. On 2/27/23, a record review was conducted. Resident 19's MDS (an assessment tool), dated 1/23/23, indicated his BIMS (test the residents' ability to recall) was 15, which indicated intact cognition. Resident 19's physicians order, dated 1/24/23 indicated Resident 19's dialysis access pressure dressings was to be removed four- six hours after dialysis. There was no care plan related to dialysis access care. On 2/27/23 at 9:16 A.M., a concurrent observation and interview with Resident 19 was conducted in his room. Resident 19 was sitting in his wheelchair watering his plants. Resident 19 stated he went for dialysis on Tuesdays, Thursdays, and Saturdays. Resident 19 stated the staff had nothing to do with his dialysis access. Resident 19 stated he took all the pressure dressings the following morning after his dialysis. Resident 19 stated the doctor ordered for the nurses to remove the pressure dressings. Resident 19 stated he preferred to do it himself because when the nurses removed the dressings, they junked it up and tears my skin. On 3/2/23 at 8:11 A.M., a concurrent interview and record review was conducted with LN 21. LN 21 stated LNs were responsible to check Resident 19's access after his dialysis. LN 21 stated Resident 19 removed his own dressings. LN 21 was unable to locate a care plan related to dialysis access care. LN 21 stated it was the LNs responsibility to ensure a care plan was developed related to his dialysis access to prevent complications. On 3/2/23 at 9:04 A.M., an interview was conducted with the DON. The DON stated the LNs should have developed a care plan related to Resident 19's dialysis access care. A review of the facility's policy titled, Care Plans - Comprehensive, revised October 2017, indicated, .An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing .needs is developed for each resident . 555263 Page 4 of 16 555263 03/02/2023 Castle Manor Nursing & Rehabilitation Center 541 V Avenue National City, CA 91950

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 provide routine nail care to one of two residents (Resident 42), reviewed for Activities of Daily Living (ADL, activities related to personal care) for dependent residents. Residents Affected - Few As a result, Resident 42 was at risk for skin injury and infection. Findings: Resident 42 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (stroke), with right hemiplegia (paralysis on one side of the body), and diabetes (abnormal sugar levels), per the facility's admission Record. On 2/28/23 at 8:32 A.M., an observation was conducted of Resident 42 as he laid in bed. Resident 42 appeared asleep with his eyes closed. The right arm was resting on top of the covers with the right hand in a fist, with the wrist turned inward. On 2/28/23 Resident 42's clinical record was reviewed. According to the last quarterly MDS (a clinical assessment tool), dated 1/19/23, Resident 42 was unable to speak. The functional status indicated Resident 42 was impaired on both sides of his body. Per the care plan, titled ADL, dated 7/14/22, Resident 42 was completely dependent and required assistant with oral care, showers, bed mobility, dressing, toileting, and personal hygiene. On 2/28/23 at 1:27 P.M. an observation and interview was conducted with LN 21 of Resident 42. Resident 42 was lying in bed with his right hand in a fist. LN 21 extended the resident's right fingers, which revealed long fingernails on the middle finger, ring finger, and thumb. Two indentations were observed in Resident 42's right palm where the fingernails of the right middle and ring fingers met the palm of the hand. The fingernails were estimated to extend ½ to ¾ inch over the fingertips. The right palm indentation remained after one minute of the fingers being extended. LN 21 stated the resident's fingernails should not have been allowed to get to that length. LN 21 stated it was the CNAs responsibility to notice when the fingernails needed trimming. LN 21 stated the LNs should have also noticed the long fingernails during their weekly head-to-toe assessments. LN 21 stated Resident 42 could have sustained a cut to his right palm from the long fingernails. On 2/28/23 at 2:11 P.M., a record review was conducted of the facility's February 2023 shower sheets. Resident 42 received showers on 2/12/23, 2/16/23, and 2/23/23. The shower sheets contained no documented evidence the fingernails were checked or trimmed. On 2/28/23, the facility's Nursing Weekly Observations, dated 2/6/23, 2/14/23, and 2/21/23 were reviewed. There was no documented evidence the fingernails had been assessed. Section P. Additional Comments indicated on the 2/6/23 document, Head-to-toe skin check done today, patient has no new skin issues at this time. The 2/15/23 and 2/21/23 Weekly Observation, documented, .Skin assessment done, no new open areas or significant rashes, otherwise skin clear and intact . On 3/1/23 at 7:54 A.M., an interview was conducted with CNA 2. CNA 2 stated if a resident's 555263 Page 5 of 16 555263 03/02/2023 Castle Manor Nursing & Rehabilitation Center 541 V Avenue National City, CA 91950

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few fingernails were long and they were diabetic (abnormal sugar levels in the blood), the LNs needed to be informed, so they could cut the nails. CNA 2 stated CNAs were allowed to trim fingernails of non-diabetic residents. CNA 2 stated she documented a resident's nails on the shower sheet and if they were trimmed or not. On 3/1/23 at 9:51 A.M., an interview was conducted with the DON. The DON stated the CNAs and LNs routinely checked fingernails and toenails every Saturday. The DON stated she expected all residents' fingernails and toenails to be maintained, to prevent injury or infection. The DON stated nail care was important for hygiene. According to the facility's policy, titled Activities of Daily Living (ADLs), Supporting, dated March 2018, .2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently .a. hygiene ( .grooming .) . According to the facility's policy, titled Fingernails/toenails, Care of, dated February 2018, .1. Nail care included regular cleaning and trimming .Documentation: The following information should be recorded in the resident's medical record: 1. The date and time the nail care was given. 2. The name and title of the individual who administered nail care . 555263 Page 6 of 16 555263 03/02/2023 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 consistently provide wound care as ordered by the physician for four of six residents, (Residents 2, 13, 26, 226), reviewed for skin integrity. Residents Affected - Some As a results, residents were at risk for wound deterioration and delayed healing. Findings: 1. Resident 2 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (stroke) and need for assistance with personal care, per the facility's admission Record. On 2/27/23 at 9:56 A.M., an observation was conducted outside Resident 2's room. Outside of the room, signage indicated contact precautions were required, and a cart containing PPE (personal protective equipment, medical supplies to maintain infection control) was present. The resident was sitting in a wheelchair watching television. On 2/28/23, Resident 2's clinical record was reviewed: The MDS (a clinical assessment tool), dated 1/23/23, listed a cognitive score of nine, indicating moderately impaired cognition. According to the physicians orders, dated 1/23/23, .bilateral lower extremities .clean with normal saline (NS), pat dry, apply xeroform (medicated dressing) and cover with dry dressing and wrap with kerlix every day .Dry skin on bilateral foot: apply skin protectant ointment every day .open wound on the sacro-coccygeal (bottom of spine) cleanse with NS, pat dry, apply santyl (medication) ointment and cover with foam dressing . According to the skin integrity care plan, dated 1/18/23, Resident 2 had an actual impairment to the skin with interventions of medications and treatments as ordered by the physician. According to the February 2023 TAR (a document for recording wound treatments), Resident 2 had no wound treatments or xeroform applied to the lower extremities on 2/5/23 and 2/7/23. No documentation of wound treatment or protective ointment for the feet was identified for 2/5/23. No wound treatment or santyl ointment for the open sacro-coccygeal wound was found for 2/5/23, 2/7/23, and 2/16/23. 2. Resident 13 was admitted to the facility on [DATE], with diagnoses which included pressure-induced deep tissue damage of left heel and dementia (memory loss), per the facility's admission Record. On 2/28/23 at 10:24 A.M., Resident 13 was observed lying in bed with a dressing on his left foot. The heel of the foot was resting directly on the mattress and not elevated on a pillow. On 2/28/23 Resident 13's clinical record was reviewed: The MDS, dated [DATE], listed a cognitive score of eight, indicating moderately impaired cognition. According to the physicians orders, dated 2/4/23, .Left lower leg with multiple open wounds, site 555263 Page 7 of 16 555263 03/02/2023 Castle Manor Nursing & Rehabilitation Center 541 V Avenue National City, CA 91950

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1, site 2, site 3, and site 4: cleanse with NS, pat dry and apply xeroform (medicated dressing) then cover with dry dressing and wrap with kerlix every day .Left heel blister-cleanse with NS, pat dry and cover with 4X4 gauge soaked with betadine solution everyday .Bilateral LE (lower extremities) with dry skin: Apply skin protector ointment every day . According to the skin integrity care plan, dated 2/4/23, Resident 13 had actual impairment to skin integrity, with interventions such as a wound consult and treatment. The February 2023 TAR was reviewed. Resident 13 had no wound treatment or xeroform applied to site 1, site 2, site 3, and site 4 on 2/16/23 and 2/26/23. The left heel blister had no wound treatment or betadine gauze and the bilateral LE had no wound treatment or ointment applied on 2/26/23. 3. Resident 26 was admitted to the facility on [DATE], with diagnoses which included adult failure to thrive and need for personal assistance with personal care, per the facility's admission Record. On 2/27/23 at 8:03 A.M., Resident 26 was observed asleep lying in the bed and covered with a heavy blanket. On 2/28/23, Resident 26's clinical record was reviewed. The MDS, dated [DATE], listed no cognitive assessment, due to being non-verbal. According to the physician's order, dated 2/13/23, .arterial wound (a lack of arterial blood flow to the tissue), on the left metatarsal (toe), cleanse with NS and pat dry, paint site with betadine daily and leave open every day .arterial wound on left great toe-paint site with betadine daily and leave open every day .arterial wound on left heal; cleanse with NS, pat dry, apply iodosorb gel (medication) ointment on the wound bed then paint peri-wound (around wound) with betadine and cover with dressing then wrap with kerlix every day . According to the wound care plan, dated 2/12/23, Resident 26 had interventions such as administer medications as ordered by the physician, monitor/document wound listed. The February 2023 TAR was reviewed. Resident 26 had no wound care or betadine applied to the metatarsal or the left great toe on 2/10/23. The left heel had no wound care or medicated dressing applied on 2/10/23. On 3/1/23 at 8:58 A.M., an interview was conducted with the LN 22. LN 22 stated he worked Monday through Friday, so on weekends the medication nurses were expected to complete the wound treatments. LN 22 stated wound treatments should have been performed regularly according to the physician's order to promote wound healing. LN 22 stated if wound care was not performed as ordered, the wounds could worsen or become infected. On 3/1/23 at 9:45 A.M., an interview was conducted with LN 21. LN 21 stated if wound treatments were missed or not completed, the wounds could worsen and there was a possibility of an infection. LN 21 stated the physician's order should always be followed. On 3/1/23 at 9:51 A.M., an interview was conducted with the DON. The DON stated wound treatments should have always been done according to the physician's order. The DON stated if a wound treatment was missed, there was a potential for harm with the wound worsening or infection could occur. The DON 555263 Page 8 of 16 555263 03/02/2023 Castle Manor Nursing & Rehabilitation Center 541 V Avenue National City, CA 91950

F 0684 stated she expected all wound treatments to be completed during the week and on the weekends. Level of Harm - Minimal harm or potential for actual harm According to the facility's job description,dated 2003 and titled Treatment Nurse, Nursing Services-MED-PASS, The primary purpose of your job description is to provide skin care to residents under the medical direction and supervision of the residents' attending physician, the Director of Nursing Services or the Medical director of the facility, with an emphasis on treatment and therapy of skin disorders . Residents Affected - Some According to the facility's policy, titled Wound Care, dated October 2010, .Documentation: The following information should be recorded in the resident's medical record: .2. The date and time the wound care was given; .7. If the resident refused the treatment and the reason(s) why . 4. Resident 226 was admitted to the facility 2/11/23, with diagnoses which included wound debridement (the removal of dead or infected skin tissue to help a wound heal) and needed surgical aftercare, per the facility's admission Record. On 2/28/23, a record review was conducted. Resident 226's history and physical, dated 2/14/23, indicated Resident 226 was able to make decisions. On 2/28/23 at 9:03 A.M., an observation was conducted outside Resident 226's room. The resident's door had a posted sign indicating contact precautions were required. The sign indicated PPE was required to enter the resident's room. Resident 226 was sitting in a wheelchair wheeling herself from the bathroom to the bed. A wound vacuum (vac, a device that helps heal the wound from the inside using a small pump which removed fluid and germs from the wound) was attached in the right side of Resident 226's wheelchair. On 2/28/23, Resident 226's clinical record was reviewed. Per Resident 226's physician's orders dated 2/11/23, indicated the wound vac and dressings were to be changed every Monday, Wednesday, and Friday. Per Resident 226's skin integrity care plan, dated 2/12/23, the wound vac was to be connected upon admission and treated as ordered by the physician. Per Resident 226's February 2023 TAR (a document for recording treatments), Resident 226 had no wound vac dressing changed on 2/13/23 and 2/15/23. On 3/1/23 at 12:02 P.M., a concurrent interview and record review of Resident 226's TAR was conducted with LN 22. LN 22 stated he did not know why there were no signature on the TAR for 2/13/23 and 2/15/23. On 3/1/23 at 3:04 P.M., a concurrent interview and review of Resident 226's clinical record was conducted with the ADON. The ADON stated there should have not been blank dates in Resident 226's TAR. The ADON stated Resident 226's wound vac dressing should have been changed on 2/13/23 and 2/15/23. The ADON stated the first wound vac and dressings changed was to be done on Monday (2/13/23). On 3/1/23 at 3:30 P.M., a concurrent interview and review of Resident 226's clinical record was 555263 Page 9 of 16 555263 03/02/2023 Castle Manor Nursing & Rehabilitation Center 541 V Avenue National City, CA 91950

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some conducted with LN 23. LN 23 stated she wrote the late entry for 2/13/23, indicating Resident 226's wound vac dressing had been changed on 2/11/23. LN 23 stated Resident 226's treatment on 2/13/23 (Monday) was missed and the physician should have been informed. On 3/1/23 at 3:48 P.M., an interview was conducted with LN 24. LN 24 stated she changed Resident 226's wound vac dressings on 2/15/23 but she forgot to sign the TAR. On 3/2/23 at 9:04 A.M., an interview was conducted with the DON. The DON stated the LNs were supposed to give treatment per the physician's orders and if they did the treatment, the LNs should have documented in the TAR. The DON stated wound dressing changed and treatment was important to promote wound healing. According to the facility's job description,dated 2003 and titled Treatment Nurse, Nursing Services-MED-PASS, The primary purpose of your job description is to provide skin care to residents under the medical direction and supervision of the residents' attending physician, the Director of Nursing Services or the Medical director of the facility, with an emphasis on treatment and therapy of skin disorders . According to the facility's policy, titled Wound Care, dated October 2010, .Documentation: The following information should be recorded in the resident's medical record: .2. The date and time the wound care was given; .7. If the resident refused the treatment and the reason(s) why . 555263 Page 10 of 16 555263 03/02/2023 Castle Manor Nursing & Rehabilitation Center 541 V Avenue National City, CA 91950

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 set a Low Air Loss (LAL) mattress per the physician's order and according to the resident's weight for one of six residents (Resident 45), reviewed for pressure ulcers (injuries to the skin and underlying tissue). Residents Affected - Few As a result, there was a potential for Resident 45 to develop pressure ulcers. Findings: Resident 45 was admitted to the facility on [DATE], with diagnoses to include reduced mobility, per the facility admission Record. On 2/27/23 at 9:16 A.M., an observation of Resident 45 was conducted. Resident 45 was in bed, eating breakfast. Resident 45 appeared to be thin. Resident 45's LAL mattress was set to 260 pounds. A label applied to the LAL mattress control panel indicated the settings should have been 100 pounds. On 2/28/23 at 10:29 A.M., an observation and interview was conducted with Resident 45. Resident 45 was in bed, and stated she did not know if she had a pressure ulcer. The LAL mattress was set to 260 pounds. On 2/28/23 at 10:30 A.M., an interview was conducted with CNA 23. Per CNA 23, Resident 45 had a LAL mattress to prevent skin problems. CNA 23 stated she only checked to see if the LAL mattress was on, she was not responsible for checking the settings. On 2/28/23 at 1 P.M., an interview was conducted with LN 11. LN 11 stated she was frequently assigned to Resident 45 and was familiar with her care. Per LN 11, the LAL mattress settings were checked every shift by the nurse assigned, and were based on the physician's orders and the resident's weight. On 2/28/23 at 1:04 P.M., an observation of Resident 45's LAL mattress settings was conducted with LN 11. LN 11 changed the weight from 260 pounds to 100 pounds. Per LN 11, The settings are wrong. It (the mattress) should be set to 100 pounds. The sticker says 100 pounds. Having the wrong settings could affect her skin. On 2/28/23 at 3:27 P.M., an interview was conducted with the DON. The DON stated, My expectation is for staff to follow physician's orders. On 2/28/23, a record review was conducted. Per a physician's order, dated 12/19/22, Resident 45 was ordered a LAL mattress with settings based on comfort or weight of the resident and to check the settings every shift. The facility was unable to provide a policy regarding following physician's orders. Per a facility's policy titled Pressure Ulcer/ skin breakdown, revised April 2018, .the nurse shall .Assessment and Recognition .2. d. Current treatments, including support surfaces . 555263 Page 11 of 16 555263 03/02/2023 Castle Manor Nursing & Rehabilitation Center 541 V Avenue National City, CA 91950

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess for a decline in range of motion (ROM, distance and direction a joint can be extended) for one of one resident (Resident 42), reviewed for positioning and limited ROM. As a result, Resident 42 had the potential for contractures (shortening of muscles and tendons, often leading to permanent deformity and stiffening of joints) and a decline in movement. Findings: Resident 42 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (stroke), with right hemiplegia (paralysis on one side of the body), per the facility's admission Record. On 2/28/23 at 8:32 A.M., an observation was conducted of Resident 42 as he laid in bed. Resident 42 appeared asleep with his eyes closed. The right arm was resting on top of the blanket with the right hand in a fist and the wrist was turned inward. On 2/28/23, Resident 42's clinical record was reviewed. The physician's order had no current or past order for physical therapy (PT) or restorative nursing assistance (RNA-a certified nursing assistant with specialized training to provide individualized range of motion exercises). Per the MDS, (a clinical assessment tool), dated 1/19/23, Resident 42 was unable to speak. The functional status indicated two-staff were required for assistance with bed mobility and transfers, with impairment to both arms. Resident 42's care plans were reviewed. There was no documented evidence a ROM or RNA plan had been developed for maintenance or improved movement. There was no documented evidence a PT assessment had been conducted. According to the facility's Nursing Weekly Observations, dated 2/6/23, 2/14/23, and 2/21/23, Section H: Musculoskeletal Assessment, Resident 42 was documented as, .dependent with all care and mobility; non ambulatory and did not have any splints, braces, or prostheses . On 2/28/23 at 1:10 P.M., an interview was conducted with the DSD. The DSD stated she oversaw the RNA program and scheduling of the RNAs. The DSD stated the CNAs were to report any concerns regarding residents to the charge nurses. The charge nurses would assess and obtain a PT evaluation as needed. On 2/28/23 at 1:13 P.M., an interview and record review was conducted with the Director of Rehabilitation (DOR). The DOR stated if the CNAs or LNs suspected a contracture or noticed a decline in range of motion, they should notify the rehabilitation department or call the physician to obtain an order for assessment and services. The DOR reviewed Resident 42's rehabilitation history and stated the resident had never been assessed by physical therapy since his admission in 2019. 555263 Page 12 of 16 555263 03/02/2023 Castle Manor Nursing & Rehabilitation Center 541 V Avenue National City, CA 91950

F 0688 Level of Harm - Minimal harm or potential for actual harm On 2/28/23 at 1:27 P.M., an interview was conducted with LN 21. LN 21 stated CNAs were to report any decline observed while providing care. LN 21 stated the LNs should be assessing the residents ROM and needs, during their weekly nursing evaluations, which consisted of head-to-toe assessments. LN 21 stated if a resident had a decline in ROM or beginning contractures, they should have been in the RNA program for improvement or maintenance. Residents Affected - Few On 2/28/23 at 1:32 P.M., an observation was conducted of LN 21 in Resident 42's room. LN 21 assessed Resident 42's right hand. LN 21 opened the resident's fingers, and the resident moaned. LN 21 was unable to fully extend the fingers without causing increased moaning from Resident 42. LN 21 stated a PT or RNA services should have been implemented. On 3/1/23 at 9:51 A.M., an interview was conducted with the DON. The DON stated the CNAs should have identified Resident 42's decline and possible contractures. The DON stated the resident should have been receiving RNA services due to his immobility. According to the facility's policy, titled Resident Mobility and Range of Motion, dated July 2017, 1. Resident will not experience an avoidable reduction in Range of Motion (ROM). 2. Resident with limited range of motion will received treatment and services to increase and/or prevent a further decrease in ROM .Interpretation: . 2. As part of the comprehensive assessment, the nurse will also identify conditions that place the resident at risk for complications related to ROM and mobility, including: .c. muscle wasting and atrophy; .e. contractures . 555263 Page 13 of 16 555263 03/02/2023 Castle Manor Nursing & Rehabilitation Center 541 V Avenue National City, CA 91950

F 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of one residents reviewed for dental services received a referral to the dentist (Resident 45). Residents Affected - Few This failure had the potential to lead to decreased food intake and weight loss. Findings: Resident 45 was admitted to the facility on [DATE], with diagnoses to include failure to thrive (a syndrome of weight loss, decreased appetite and poor nutrition), per the facility admission Record. On 2/27/23 at 9:13 A.M., a concurrent observation and interview was conducted with Resident 45. Resident 45 was seated in bed, with a breakfast tray in front of her. Resident 45 stated she was not very hungry, but she would eat what she could. A denture cup with dentures inside was next to the breakfast tray. On 2/28/23 at 12:47 P.M., a concurrent observation and interview was conducted with Resident 45. Resident 45 was seated in bed, with a lunch tray in front of her, and the denture cup with dentures inside was next to the tray. Resident 45 stated she might be able to chew the roast beef if she had the dentures in. Resident 45 stated nobody had offered to assist her with the dentures. On 2/28/23 at 12:49 P.M., an interview was conducted with CNA 23. CNA 23 stated Resident 45 needed to be set up for meals. Per CNA 23, she assisted Resident 45 by opening food containers for her, and cutting up her meat. CNA 23 stated Resident 45 had her own teeth on top, and sometimes used her bottom dentures. CNA 23 stated she had not offered to assist Resident 45 with the dentures. Per CNA 23, The denture might help her eat better. CNA 23 stated if Resident 45 refused to wear her dentures, she should have informed the charge nurse but she had not done that. On 2/28/23 at 2:42 P.M., an interview was conducted with LN 11. LN 11 stated she was frequently assigned to Resident 45. LN 11 stated she was not aware Resident 45 needed a denture to chew food. Per LN 11, if Resident 45 did not have her dentures in, it could cause her to eat less. LN 11 stated if Resident 45 needed her dentures fitted, she would inform the SSD to schedule a dentist appointment. LN 11 stated she had not been told Resident 45 used, or refused to wear her denture. On 2/28/23, a record review was conducted. Resident 45's BIMS, dated 12/6/22, was 13, indicating intact cognition. Resident 45's care plan indicated she was at potential risk for diet texture intolerance and/or denture issues, with approaches to include coordinating dental care and dental consults as needed. On 2/28/23 at 2:30 P.M., an interview was conducted with the SSD. The SSD stated she was not informed of a problem with Resident 45's lower dentures. The SSD stated the nurses informed her of any dental problems and her department would order a dental consult. Per the SSD, It looks like it got missed. On 2/28/23 at 3:27 P.M., an interview was conducted with the DON. The DON stated the CNAs should 555263 Page 14 of 16 555263 03/02/2023 Castle Manor Nursing & Rehabilitation Center 541 V Avenue National City, CA 91950

F 0790 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few have reported any concerns about dentures or eating to the nurse, then the nurse should have spoken to the SSD to arrange a dental consult. The DON stated, That did not happen today the way I would have wanted. Per a facility policy, dated October 2017 and titled Dental Services, The facility assists all residents in obtaining needed dental services .to meet the needs of each resident . 555263 Page 15 of 16 555263 03/02/2023 Castle Manor Nursing & Rehabilitation Center 541 V Avenue National City, CA 91950

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe infection control practices when a urinary catheter (a tube inserted into the bladder to aide in urine flow) bag and dignity bag (a bag used to cover and conceal contents inside) was lying on the floor for one of three residents reviewed for urinary catheter care (Resident 276). Residents Affected - Few This failure had the potential for cross contamination (spread of germs and bacteria) and infection. Findings: Resident 276 was admitted on [DATE] with diagnoses which included obstructive uropathy (blockage of urinary flow) with lower urinary tract infections (UTI), per the admission Record. During an observation on 2/27/23 at 9:35 A.M., in Resident 276's room, Resident 276 was in bed with a urinary catheter visible next to the bed. Resident 276's catheter bag and privacy bag were on the floor. During an interview with CNA 31 on 2/28/23 at 10:12 A.M., CNA 31 stated Resident 276's urinary catheter bag should have always been elevated or off the floor for infection control purposes. During an interview with LN 31 on 2/28/23 at 10:53 A.M., LN 31 stated Resident 276's privacy bag and catheter bag should have not touched the floor for infection control purposes. On 3/1/23, a record review was conducted. Resident 276's urinary catheter care plan, dated 2/14/23, indicated no part of the catheter should be touching the floor. During an interview with the interim IP on 3/2/23 at 8:32 A.M., the interim IP stated urinary catheter bag should have been off the floor, at all times. Interim IP stated that it was important for urinary catheter bag not to touched the floor to prevent cross contamination. During an interview with DON on 3/2/23 at 9:30 A.M., the DON stated staff doing direct care with residents were all trained to handle urinary catheter. The DON stated the urinary catheter bag and dignity bag should have not touched the floor for infection control issues. Per the facility's policy titled Catheter Care, Urinary, revised September 2014, indicated, .Infection Control: 2.b. Be sure the catheter tubing and drainage bag are kept off the floor . 555263 Page 16 of 16