Health inspection·June 29, 2023

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to protect the privacy of personal information for five of five sampled residents (Resident's 40, 6, 42, 10, and 19) when Licensed Vocational Nurse 1 (LVN 1) left the electronic health record (EHR) exposed to public view during medication administration. This failure had the potential to violate Resident 40, 6, 42, 10, and 19's right to privacy and confidentiality of medical information. Residents Affected - Few Findings: During a medication administration observation on June 28, 2023, at 1:18 PM, the computer screen displayed the EHR for Resident 40. LVN 1 walked away from the medication cart, leaving the EHR exposed to public view. During an interview with LVN 1, on June 28, 2023, at 1:25 PM, LVN 1 stated, it's ok to leave the computer screen exposed with the resident's health information as long as it's facing the door to the resident's room. During a second observation on June 28, 2023, at 1:30 PM, LVN 1 walked away from the medication cart and walked into Resident 6's room leaving the EHR exposed to public view. During a third observation on June 28, 2023, at 1:45 PM, LVN 1 walked away from the medication cart leaving the EHR exposed to public view and walked inside Resident 42's room. During a fourth observation on June 28, 2023, at 1:50 PM, LVN 1 walked away from the medication cart and into Resident 10's room leaving the EHR exposed to public view. A resident walked inside the room, moved the medication cart with the EHR exposed. During a fifth observation on June 28, 2023, at 2:05 PM, LVN 1 walked inside Resident 19's room to give his medication, left the EHR unlocked and exposed to public view. During an interview with Director of Staff Development (DSD), on June 29, 2023, at 8:30 AM, DSD stated the computer screen containing the EHR should be locked before walking away, to protect privacy of each resident. During an observation and interview with Licensed Vocational Nurse 2 (LVN 2), on June 28, 2023, at 6:04 PM, LVN 2 stated the medication cart and the computer screen with the resident's health information should be both locked before walking away. During a concurrent interview and record review with the Director of Nursing (DON) on June 29, Page 1 of 18 555521 555521 06/29/2023 Rancho Mesa Care Center 9333 LA Mesa Dr Alta Loma, CA 91701

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2023, at 2:24 PM. The DON reviewed the Medication Pass Guidelines dated March 8, 2023 which indicated .3. Medication Administration .b. Confidentiality of MAR (Medication Administration Record) is protected (e.g., resident names covered, book closed when unattended). DON stated that the laptop screen should be locked before walking away from it. During a record review of the facility policy and procedure titled, Confidentiality of Information and Personal Privacy revised October 2017, indicated, Policy Statement: Our facility will protect and safeguard resident confidentiality and personal privacy .Policy Interpretation and Implementation: 1. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records . 555521 Page 2 of 18 555521 06/29/2023 Rancho Mesa Care Center 9333 LA Mesa Dr Alta Loma, CA 91701

F 0641 Ensure each resident receives an accurate assessment. 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 the Minimum Data Set (MDS- a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status) assessments were completed accurately to reflect the residents' current health status, care, and services for one of eight residents' (Resident 4) reviewed for antibiotic therapy. Residents Affected - Few Findings: A review of Resident 4's face sheet (a document containing resident's basic information and diagnoses) indicated Resident 4 was admitted on [DATE], with diagnoses that included Type 2 diabetes mellitus, (a chronic condition that affects the way the body processes blood sugar), and benign prostatic hyperplasia with lower urinary tract symptoms. (age-associated prostate gland enlargement that can cause urination difficulty with any combination of urinary symptoms). During a review of Resident 4's Minimum Data Set, (MDS), dated [DATE], the MDS indicated Resident 4 was receiving antibiotic therapy for five (5) days. A review of Resident 4's physician's order and interview with Registered Nurse 1 (RN 1) on June 29, 2023, at 3:30 PM was conducted. Resident 4's physician's order, from May 24, 2023, to June 29, 2023, indicated Resident 4 had no order for antibiotic therapy on admission and after MDS assessment. RN 1 verified Resident 4 did not receive any antibiotics since May 24, 2023, admission to the facility. During a concurrent interview and record review of physician's order and MDS assessment, with the Director of Nursing (DON) and Registered Nurse 1 (RN 1), on June 29, 2023, at 3:32 PM, the DON, stated the assessment for Resident 4's MDS was done and signed by the facility's MDS coordinator on May 30, 2023. The RN 1 verified that the MDS assessment under Section N (Medications) indicated Resident 4 was receiving antibiotic therapy for five days was miscoded. RN 1 stated the accuracy of MDS assessment is important to ensure Resident 4 receives the appropriate care and services related to antibiotic use. During an interview and record review with the Director of Nursing (DON), on June 29, 2023, at 3:32 PM, the policy and procedure, titled, Residents Assessments, revised on November 2019, indicated, 1. The Resident Assessment Coordinator is responsible for ensuring that the Interdisciplinary Team conducts timely and appropriately resident assessments and reviews 11. All persons who have completed any portion of the MDS Residents Assessment Form must sign the document attesting to the accuracy of such information. The DON stated the MDS section for medications for Resident 4 did not accurately reflect Resident 4's actual medications. The DON stated the facility did not follow their policy. 555521 Page 3 of 18 555521 06/29/2023 Rancho Mesa Care Center 9333 LA Mesa Dr Alta Loma, CA 91701

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR- a screening done upon admission into a facility to determine if a resident with serious mental illness and/or intellectual/development disability require nursing facility services and/or specialized services) was completed accurately for one resident reviewed for PASSR (Resident 12). This failure had the potential to delay identification and treatment of Resident 12's mental disorder. Residents Affected - Few Findings: During a concurrent observation and interview with Resident 12, on June 26, 2023, at 8:19 AM, in Resident 12's room, Resident 12 was sitting on the edge of her bed eating breakfast. Resident 12 stated she was a survivor of satanic cult. During a review of Resident 12's Face sheet (contains demographic and medical information), it indicated Resident 12 was admitted to the facility on [DATE], with the diagnoses of schizophrenia (mental disorder in which a person interpret reality abnormally), hypertensive heart disease without heart failure (heart problems that occur because of high blood pressure, and bipolar disorder (mental illness that causes unusual shifts in mood). During a review of Resident 12's, (Hospital Name) Take Home Medication List, dated April 7, 2022, it indicated Resident 12 had an order to receive Caplyta (bipolar I and bipolar II depression medication) oral capsule and Seroquel (antipsychotic medication) tablet upon admission to the facility. During a review of Resident 12's PASRR Level I Screening, dated April 11, 2022, it indicated Resident 12 does not have any mental disorder diagnosis. During a concurrent interview and record review with the Administrator, on June 29, 2023, at 11:25 AM, the Administrator reviewed Resident 12's (Hospital Name) Take Home Medication List, dated April 7, 2022, and PASRR Level I Screening, dated April 11, 2022, and acknowledged the PASRR was not accurately completed. The Administrator stated, the admitting staff who completed the PASRR, did not have clinical knowledge. During an interview and record review, on June 29, 2023, at 11:27 AM, with the Administrator (Admin), the facility's policy and procedure (P&P) titled, Resident Pre-admission Screening (PASRR), undated, was reviewed. The P&P indicated, . 1. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASRR) process .b. if the level I screen indicates that the individual may meet criteria for a MD, ID, or RD, he or she is referred to the state PASRR representative for the Level II (evaluation and determination) screening process. The Admin stated the P&P was not followed. 555521 Page 4 of 18 555521 06/29/2023 Rancho Mesa Care Center 9333 LA Mesa Dr Alta Loma, CA 91701

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** Residents Affected - Some During a review of Resident 64's Face Sheet (a summary of medical and demographic data) dated June 27, 2023, the Face Sheet indicated, the Resident 64's admitting diagnoses on May 4, 2023 included; Type 2 diabetes mellitus with ketoacidosis without coma (is when the blood sugar is too high for too long), Type 2 diabetes with diabetic neuropathy (nerve damage cause by poor blood sugar control), pressure ulcer of sacral region, stage 4 (sacral is located in the lower back near the pelvis, stage 4 is a full thickness tissue loss with exposed bone, tendon or muscle). During a review of Resident 64's Physician Orders, dated May 5, 2023, indicated, 1. Diet Order : CCHO, REG [control carbohydrate diet], [REGULAR] thin liquids, May 4, 2023, indicated 2. Insulin Lispro (rapid acting insulin) [used to regulate blood sugar level] (U-100) 100 unit/ ml (unit per milliliter) - inject AC (before meals) and HS (at bedtime) per sliding scale: (a variable amount of insulin based on blood sugar levels) 0-69=0 units, Notify MD, give orange juice, 70-150= 0 units, 151-200=2 units, 201-250 = 4 units, 251-300 = 6 units, 301-300=8 units, 351-400 = 10 units, 401-999 = 12 units, notify MD. 3. Lantu 100 unit/ml (long-acting insulin) [use to regulate blood sugar level] inject 20 units [unit of measure] subcutaneous [under the skin] q HS, [Every night at bedtime] R/T [related to] DM [Diabetes Mellitus] *HOLD IF BS [blood sugar] <70 [less than 70]. During a review of Resident 64's Patient Care Plan: Diabetes Mellitus dated, May 4, 2023, the care plan indicated Problem/Needs At risk for hyperglycemia or hypoglycemia r/t [related to] Diabetes Mellitus Goals: Free from s/s [signs and symptoms] of hypoglycemia or hyperglycemia daily x 90 days. Approaches/Plan Medication/insulin as ordered, Monitor BS [blood sugar] per MD [Medical Doctor] order. During a review of Resident 64's Medication Administration Record, (MAR), dated June 2023, MAR indicated, documentation of blood sugar checks and insulin administration were missing for 11 schedule instances on 10 days as follows: June 4, 2023, at 11:30 AM June 8, 2023, at 9:00 PM June 10, 2023, at 11:30 AM June 11, 2023, at 4:30 PM June 11, 2023, at 9:00 PM June 16, 2023, at 11:30 AM June 17, 2023, at 11:30 AM June 18, 2023, at 4:30 PM June 21, 2023, at 4:30 PM 555521 Page 5 of 18 555521 06/29/2023 Rancho Mesa Care Center 9333 LA Mesa Dr Alta Loma, CA 91701

F 0684 June 24, 2023, at 11:30 AM Level of Harm - Minimal harm or potential for actual harm June 26, 2023, at 11:30 AM Residents Affected - Some During an interview with Registered Nurse (RN 1) on June 28, 2023, at 6:44 PM, RN 1 reviewed the MAR with missing documentation of blood glucose, and stated there was no documentation found in their system. During an interview on June 29, 2023, at 11:03 AM, with Director of Nursing (DON), DON stated that when this was brought to her attention, she looked for the documentation regarding these missed doses and could not find any nurses notes in the records. Her expectation is that it's supposed to be done and documented. The DON further stated, The facility's policy is that for sliding scale insulin orders, the blood glucose should be documented, and the insulin orders should be given per doctor's order. DON stated that she was going to create a QAPI (Quality Assessment Performance Improvement- a plan to correct any possible negative outcomes related to resident's care) to in-service the nurses. During a review of the facility's policy and procedure titled Insulin Administration dated September 2014, the policy and procedure indicated Preparation 4. The nurse shall notify the Director of Nursing Services and Attending Physician of any discrepancies before given the insulin .Documentation 1. The resident's blood glucose result, as ordered .2. The dose and concentration of the insulin injection. DON acknowledged that their nurses failed to follow the insulin administration policy. 2. During an observation on June 26, 2023, at 10:00 AM, in Resident 54's room, Resident 54 was on her back on an air mattress, her eyes were closed. She was on oxygen via nasal canula (a device used to deliver supplemental oxygen). During an interview on June 26, 2023, at 12:13 PM, with the Restorative Nurse Assistant 1 (RNA 1), RNA 1 stated, she checks the weight of the resident according to the dietician's verbal instruction. RNA 1 stated she never document the weight in the electronic record. RNA 1 stated, she documents the weight on a paper, then attach it to the resident's hard chart. During an interview on June 26, 2023, at 12:30 PM, with the Licensed Vocational Nurse 6 (LVN 6), LVN 6 stated, if there is an order for a weekly weight, the RNA will be notified by the dietician and the order will be carried out. LVN 1 further stated she was not aware about the standing order for weekly weight check and the reason why the order was not carried out. A review of Resident 54's face sheet (patient demographics) indicated that Resident 54 was admitted on [DATE], with the diagnoses that included heart disease (a condition affecting the normal functioning of the heart), muscle wasting (weakening and loss of muscle) and atrophy (a condition in thinning of the muscle). During a review of Resident 54's physician's order, dated April 21, 2023, indicated Weight weekly and notify RD. During a review of Resident 54's clinical record, weight was not done and not documented for the following dates: 1. Week of May 8,2023 555521 Page 6 of 18 555521 06/29/2023 Rancho Mesa Care Center 9333 LA Mesa Dr Alta Loma, CA 91701

F 0684 2. Week of May 15,2023 Level of Harm - Minimal harm or potential for actual harm 3. Week of May 22,2023 4. Week of June 5,2023 Residents Affected - Some 5. Week of June 12,2023 6. Week of June 19,2023 During a concurrent interview and record review on June 29, 2023, at 10:30 AM, with the Director of Nursing (DON), the physicians order dated April 21, 2023, was reviewed. The DON stated, if the doctor's order was to check weight weekly it should be carried out as ordered. The DON further stated, and she was not aware about the weekly weight order not being followed. During a review of Resident 54's care plan dated April 20,2023, the care plan indicated weigh weekly x 4 weeks and notify RD. Based on observation, interview and record review, the facility failed to ensure three (Residents 10, 54, and 64) of five sampled residents received care in accordance with the facility's policy and procedure. 1. For Resident 10 and 64, the facility failed to ensure their blood sugar levels were monitored and documented prior to administering insulin (medication used to lower blood sugar) according to physician's order. 2. For Resident 54, the facility failed to ensure weekly weights monitoring were carried out per physician's order. These failures had the potential to result in harm or death of the resident from medical complications caused by elevated or decreased blood sugar levels and resident harm from complications of nutritional deficiencies. Findings: 1. During a review of Resident 10's Face Sheet (a summary of medical and demographic data) dated June 27, 2023, the Face Sheet indicated, Resident 10's admitting diagnosis on April 17, 2023 included; Type 2 diabetes mellitus with diabetic neuropathy (insulin-dependent diabetes resulting in nerve pain), unspecified protein-calorie malnutrition (chronic lack of protein and calories), muscle wasting and atrophy (weakened and shrinking muscles), hypertensive heart disease (heart disease caused by high blood pressure) with heart failure , morbid (severe) obesity, and chronic kidney disease. During a review of Resident 10's Physician Orders dated April 17, 2023, indicated, 1. Diet order; regular diet, mechanical soft small portions. 2. humulin R (regular, short acting insulin [used to regulate blood sugar level] )100 U/ml (unit per milliliter) - inject QAC (before meals) and QHS (at bedtime) R/T DM (related to diabetes mellitus), per sliding scale: (a variable amount of insulin based on blood sugar levels) 0-150= 0 Units, give orange juice, 151-200=2 Units, 201-250=4 Units, 251-300=6 Units, 301-350=8 Units, 351-400=10 Units, 401-999=12 Units, Notify MD. 555521 Page 7 of 18 555521 06/29/2023 Rancho Mesa Care Center 9333 LA Mesa Dr Alta Loma, CA 91701

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 10's Nursing Orders dated April 17, 2023, indicated May have finger stick blood sugar checks prior to insulin administration. During a review of Resident 10's Patient Care Plan: Diabetes Mellitus dated April 18, 2023, the care plan indicated, Goal is to maintain blood sugar <200 mg/dl (milligrams per deciliter) x 90 days. Monitor BS (blood sugar) per Physician's order and Medication/Insulin as ordered. During a review of Resident 10's Medication Administration Record (MAR), dated from April 18, 2023, through June 27, 2023, the MAR indicated, documentation of blood sugar checks and insulin administration were missing for 23 scheduled instances on 20 days as follows: April 18, 2023 at 11:30 AM April 25, 2023 at 11:30 AM May 06, 2023 at 11:30 AM May 12, 2023 at 06:30 AM May 16, 2023 at 06:30 AM May 17, 2023 at 06:30 AM May 18, 2023 at 06:30 AM May 24, 2023 at 11:30 AM May 29, 2023 at 11:30 AM May 30, 2023 at 11:30 AM May 30, 2023 at 09:00 PM June 04, 2023 at 11:30 AM June 06, 2023 at 11:30 AM June 10, 2023 at 11:30 AM June 11, 2023 at 11:30 AM June 11, 2023 at 04:30 PM June 11, 2023 at 09:00 AM June 17, 2023 at 11:30 AM June 18, 2023 at 11:30 AM 555521 Page 8 of 18 555521 06/29/2023 Rancho Mesa Care Center 9333 LA Mesa Dr Alta Loma, CA 91701

F 0684 June 22, 2023 at 06:30 AM Level of Harm - Minimal harm or potential for actual harm June 22, 2023 at 11:30 AM June 24, 2023 at 11:30 AM Residents Affected - Some June 27, 2023 at 11:30 AM During a review of Resident 10's Nursing Notes dated April 18, 2023, through June 27, 2023, indicated, no documentation was found regarding missed blood sugar checks or insulin administration. During a concurrent interview and record review on June 29, 2023, at 10:26 AM, with the Director of Medical Records, (MRD), the MRD reviewed Resident 10's MAR notes from April 18, 2023, through June 27, 2023, and verified that she could find no supporting documentation regarding rationale for the 20 days of missed blood sugars and insulin dose in the chart. During an interview on June 29, 2023, at 11:01 AM, with the Director of Nursing (DON), the DON stated, When this was brought to my attention today, I looked for documentation regarding these missed doses and could not find anything. The DON stated, the expectation is that it's supposed to be done, supposed to be documented. The DON further stated, their policy for sliding scale insulin orders, the blood glucose should be documented, and the dose of insulin should be given as per doctor's orders. The DON stated, that is the standard nursing practice and there is really no excuse, so they will take this as an opportunity to improve. During an interview on June 29, 2023, at 11:03 AM, with Registered Nurse 1 (RN 1), RN 1 reviewed the MAR with missing documentation of blood glucose and insulin and agreed this would be interpreted as not done; it would be an error. She further stated, she could not find any nursing notes, MAR notes, or any other documentation on the rationale for the missing blood sugars. RN 1 further stated, the expectation is that it should be done, and should be on the MAR. RN 1 further clarified, when you prepare to give insulin, it will prompt you for the blood sugar level and it has to be entered on the e-MAR for you to give the insulin. It is possible that maybe it was below 150 and did not require insulin but there is no way to know because it was not charted. RN 1 stated, this is not according to proper procedure, it should be measured and charted every time it is ordered. When asked if the sliding scale is considered an order to do a blood sugar check, RN 1 stated, Yes, the order for insulin includes checking the blood sugar, you cannot give insulin without it. During a review of the facility's policy and procedure (P&P) titled Insulin Administration dated September 2014, the P&P stated: Documentation 1. The residents blood glucose result, as ordered; 2. The dose and concentration of the insulin injection . 555521 Page 9 of 18 555521 06/29/2023 Rancho Mesa Care Center 9333 LA Mesa Dr Alta Loma, CA 91701

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure secure storage of medications when: 1. The central supply medication storage cabinet was found open and unattended on June 26, 2023, at 9:55 AM. 2. The medication storage room was found open and unattended on June 26, 2023, at 10:01 AM and June 27, 2023, at 12:42 PM. 3. The treatment cart #3 was left unlocked and unattended on June 26, 2023, at 11:30 AM. These failures had the potential for medications to be accessed and dispersed by an unauthorized person, in a vulnerable population of 56 residents. Findings: 1. During a concurrent observation and interview, on June 26, 2023, at 9:55 AM, in the Central Supply Room, with the Central Supply Supervisor (CSS), the central supply medication storage cabinet was found open and unattended. The CSS verified the finding and stated it should be not be unlocked and unattended. The CSS further stated she would put a lock on it right away. 2. During a concurrent observation and interview, on June 26, 2023, at 10:01 AM, in front of the Medication Storage Room, with the Infection Preventionist Nurse (IPN), the medication storage room was found open and unattended. The IPN verified the finding and stated the room should be always locked. During a follow-up observation and interview on June 27, 2023, at 12:42 PM, in front of the medication storage room, with the Case Manager (CM), the medication storage room remained open and unattended. The CM verified the findings and stated the room should be locked. 3. During an observation on June 26, 2023, at 11:28 AM, the treatment cart #3 was parked in front of room [ROOM NUMBER]. It was left unlocked and unattended. During an interview on June 26, 2023, at 11:30 AM, with the Treatment Nurse (TN 1), the TN 1 verified she left the treatment cart #3 unlocked and unattended. The TN 1 stated she forgot to lock it. During a concurrent interview and record review, on June 29, 2023, at 9:09 AM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Storage of Medications, revised April 2007, was reviewed. The P&P indicated, .7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals (diverse group of medicines that includes vaccines) shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. The DON stated the P&P was not followed. The DON further stated the expectation was for all rooms, cabinets, and carts to be locked. 555521 Page 10 of 18 555521 06/29/2023 Rancho Mesa Care Center 9333 LA Mesa Dr Alta Loma, CA 91701

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interview and record review the facility failed to designate a qualified Director of Food Services to provide oversight of the dietary department which includes, implementing menus, purchasing food, training of staff, and ensuring compliance with all state and federal regulations. This failure had the potential to result in a lack of effective oversight in the operations of the dietary department and supervision which could lead to poor quality of services in the dietary department. Findings: During an interview on June 28,2023, at 1:38 PM, the Dietary Services Supervisor (DSS) stated, she is waiting to take her exam to become a Certified Dietary Manager. During a review of facility's document titled FNS (Food and Nutrition Services) JOB DESCRIPTION dated, 2018, indicated, .for QUALIFICATIONS .3. Must meet the qualifications of FNS Director as stated under State & Federal Regulations. During an interview with the Administrator (Admin) on June 29, 2023, at 2:18 PM, the Admin acknowledged that the DSS did not meet one of the state qualifications for a dietary supervisor, she stated she thought that she was qualified because she worked at other health care facilities as a dietary supervisor. 555521 Page 11 of 18 555521 06/29/2023 Rancho Mesa Care Center 9333 LA Mesa Dr Alta Loma, CA 91701

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to store and serve food that conserved flavor and appearance when: Residents Affected - Few 1. Five packages of flour tortillas were found dry and had expired 10 days ago. This failure had the potential to cause food-borne illness (stomach issues from expired and contaminated food) and less palatable. Findings: 1.During an observation on June 26, 2023, at 8:35 AM with the Dietary Services Supervisor (DSS) in the dry storage room area on the top shelf five packages of flour tortillas were found dry and had expired 10 days ago. During an interview with the DSS on June 26, 2023, at 8:35 AM, the DSS acknowledged that the flour tortillas were found expired and dry, and they should not be used. During a record review of facility's policy and procedure titled DRY GOODS STORAGE GUIDELINES dated, 2018, indicated Do check expiration dates on boxes of foods to be sure the length of time is correct. 555521 Page 12 of 18 555521 06/29/2023 Rancho Mesa Care Center 9333 LA Mesa Dr Alta Loma, CA 91701

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: Residents Affected - Many 1. Three oranges and seven onions with mold were found in the kitchen inside of a plastic box. 2. A box of 14 yellow squash was wet and leaking inside of the refrigerator, that was stored in the central supply room. 3. Thirty two ounces (unit of weight) of plain yogurt container found inside the refrigerator expired. 4. The ice machine was found dusty outside and inside with dark black stain seen on both sides of the ice maker tray. 5.A shelf storing clean water pitchers were stored in the Central Supply room, near the laundry room. These failures had the potential to contaminate resident's food and cause food -borne illness to a population 56 medically compromised residents who receive food from the kitchen. Findings: 1. During a concurrent observation and interview on June 26, 2023, in the kitchen at 8:06 AM, there were three oranges with mold inside a plastic box inside at the bottom of a stainless steel shelf. Dietary Staff Aid 2 (DA 2) stated the oranges should be thrown away because they have mold. During a concurrent observation and interview on June 26, 2023, at 8:11AM, in the kitchen, there were seven onions with mold found inside a plastic box on the bottom of a stainless shelf. DA 1 stated the onions should be thrown away because they have mold. During an interview on June 27, 2023, at 8:20 AM, Dietary Services Supervisor (DSS), acknowledged the mold and stated, they should be thrown away. During a record of the facility's policy and procedure titled PRODUCE STORAGE GUIDELINES, dated 2018, indicated, May use longer if no signs of spoilage are visible. 2. During an observation on June 26, 2023, at 9:09 AM, in the Central Supply Room Area, there was a box of 14 yellow squash that was wet and leaking inside of the refrigerator. During an interview with the DSS on June 26, 2023, at 9:10 AM, DSS acknowledged the wet yellow squash, and stated the refrigerator should be fixed. During a review of the FDA Federal Food Code 2022, 3-305.11 indicated, (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) in clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; Pathogens can contaminate and/ or grow in food that is not stored properly. Drips of condensate and drafts of 555521 Page 13 of 18 555521 06/29/2023 Rancho Mesa Care Center 9333 LA Mesa Dr Alta Loma, CA 91701

F 0812 unfiltered air can be sources of microbial contamination for stored food. Level of Harm - Minimal harm or potential for actual harm 3. During a concurrent observation and interview on June 26, 2023, at 9:12 AM, with the DSS in the Central Supply Room Area, there was a 32 ounces (2 pounds) plain yogurt container that was expired in Refrigerator 3. The DSS acknowledged that the yogurt was expired and should not be used. Residents Affected - Many During a review of the facility's policy and procedure titled REFRIGERATED STORAGE GUIDE, dated 2019, indicated, .Yogurt .follow expiration date or 7 days after opening, whichever comes first. 4. During an observation on June 26, 2023, at 9:31 AM, the ice machine was found with dry, chalky dust like particles outside and inside with dark black stains seen on both sides of the ice maker tray. During an interview with the Maintenance Supervisor (MS) on June 26, 2023, at 9:42 AM, in the Central Supply room, he acknowledged that the ice machine was found dusty. During a record review of facility document titled Ice Machine Cleaning Log, indicated Frequency of Cleaning: Monthly .PROCEDURE FOR CLEANING STORAGE COMPARTMENT OF ICE MACHINE .1. The ice machine storage compartment will be cleaned monthly .7. The outside of the machine is cleaned weekly or wiped down as need with clean cloth and approved cleaning agent. During a record review of facility document titled, Invoice from [Company Name] dated, September 30, 2022, indicated Last ice Machine Maintenance was performed on September 30, 2022 nine months ago. During a review of the FDA Federal Code, dated 2022, 4-602.11 indicated Ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. 5. During an observation on June 26, 2023, at 10:43 AM, a shelf, storing clean water pitchers was stored in the Central Supply Room. During an interview on June 26, 2023, at 10:45AM, with the Housekeeper Supervisor (HKS) stated the pitchers should not be there. During a review of the FDA Federal Food Code 2022, 4-903.11 indicated, (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination;. In addition, Clean equipment and multiuse utensils which have been cleaned and sanitized, laundered linens, and single-service and single-use articles can become contaminated before their intended use in a variety of ways such as through water leakage, pest infestation, or other unsanitary condition. The improper storage of clean and sanitized equipment, utensils, laundered linens, and single-service and single-use articles may allow contamination before their intended use. Contamination can be caused by moisture from absorption, flooding, drippage, or splash. It can also be caused by food debris, toxic materials, litter, dust, and other materials. The contamination is often related to unhygienic employee practices, unacceptable high-risk storage locations, or improper construction of storage facilities 555521 Page 14 of 18 555521 06/29/2023 Rancho Mesa Care Center 9333 LA Mesa Dr Alta Loma, CA 91701

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure their infection control practices were implemented in accordance with their policy and procedure when: Residents Affected - Many 1. One of the kitchen sink air gaps (a form of backflow prevention device) had black, brown grime. 2. Two bar guns (a device used to serve types of carbonated drinks and non-cabonated drinks) were found to contain red residual fluid and were not clear. These failures had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi, or parasite) to 56 medically compromised residents and staff in the facility. Findings: 1. During a concurrent observation and interview on June 27, 2023, at 12:55 PM, with the Dietary Aide (DA 3), the kitchen sink air gap had black, brown grime. The DA 3 verified the air gap and stated it was the Maintenance Supervisor responsibility to clean the air gap. During an interview with the Maintenance Supervisor (MS), on June 29, 2023, at 9:02 AM, the MS acknowledged the air gap and stated it is the responsibility of the kitchen staff to clean the kitchen sink's air gap. During an interview with the Dietary Services Supervisor (DSS) on June 29, 2023, at 10:01 AM, the DSS acknowledged the air gap and stated it is the responsibility of the Maintenance Supervisor to clean the kitchen sink's air gap. During a review of document titled, Weekly Cleaning Schedule, dated May 28, 2023, through June 4, 2023, the weekly cleaning schedule did not indicate the air gap was part of the cleaning schedule. During a concurrent interview and record review with the Administrator (Admin), on June 29, 2023, at 1:45PM, the Admin reviewed the Cal Code Official Inspection Report invoice dated January 11, 2022 and acknowledged the report which indicated, All plumbing and plumbing fixtures shall be installed in compliance with local plumbing ordinances, shall be maintained so as to prevent any contamination, and shall be kept clean, fully operative, and in good repair. The Admin acknowledged the air gap was not clean. 2. During an observation of the kitchen, on June 27, 2023, at 12:55 PM, two bar guns were observed to contain a red residual liquid inside. During a concurrent observation and interview on June 27, 2023, at 12:59 PM, with the DA 3, the bar guns were run with drinkable water and emptied into a basin. The drinkable water appeared pink in color. The DA 3 stated the bar guns are cleaned every night and last maintenance was done about two months ago. The DA 3 further stated he would not drink the water if served to him. During a review of invoice titled, [Company Name], dated December 3, 2022, the invoice indicated, Changed water filter, water is crystal clear, bar guns needs new O rings. During a concurrent interview and record review with the DSs, on June 29, 2023, at 10:15 AM, the 555521 Page 15 of 18 555521 06/29/2023 Rancho Mesa Care Center 9333 LA Mesa Dr Alta Loma, CA 91701

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many DSS reviewed the [Company Name] invoice dated December 3, 2022, and acknowledged the invoice was the most recent. The DSS stated she placed an emergency service request to the company to repair the juice guns. The DSS further acknowledged the juice guns were not running clear in between juice dispensing. During an interview with the DSS, on June 29, 2023, at 10:20 AM, the DSS stated that the company had canceled her emergency service request. The DSS stated she would provide documentation. The documentation requested was not provided by the DSS. During a review of facility's policy and procedure (P&P) titled, Infection Prevention and Control in LTC, undated, the P&P indicated, .Proper environmental service management is essential to resident quality of life and for infection prevention and control. 555521 Page 16 of 18 555521 06/29/2023 Rancho Mesa Care Center 9333 LA Mesa Dr Alta Loma, CA 91701

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review, the facility failed to ensure the antibiotic stewardship program (a program to measure and improve how antibiotics are prescribed by clinicians and used by patients) was implemented in accordance with facility policy when the monitoring of antibiotic usage and resistance data (monitoring the effectiveness of the antibiotics) were not documented for two consecutive months (May and June 2023). Residents Affected - Few This failure had the potential to inaccurately monitor the use of antibiotics for 56 residents. Findings: During a review of the Antibiotic Stewardship binder, undated, was conducted on June 28, 2023, at 3:50 PM, the binder forms Nursing Center Infection Control Summary Report (a monthly report of the infections and the facility's plan to address) and Infection Prevention and Control Surveillance Log (log of infections, the signs/symptoms, organism on culture, treatment and comments) were not filled out for the months of May and June 2023. During a concurrent interview and record review with the Infection Prevention Nurse (IPN) and the Consultant Infection Preventionist (CIP), on June 28, 2023, at 11:30 AM, the IPN reviewed the Antibiotic Stewardship binder and acknowledged the binder was not completed for the months of May and June 2023. The IPN stated she started to fill out the binder but was not sure how to fill out the binder. The CIP stated the facility has an antibiotic stewardship program; however, it has not been implemented recently due to turnover in the IPN position. During further interview and record review with the IPN and the Administrator (Admin), on June 29, 2023, at 8:44 AM, the facility's policy and procedure (P&P) titled, Antibiotic Stewardship, dated revised December 2016, was reviewed. The P&P indicated, Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program .1. The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. The Admin stated the P&P was not followed. 555521 Page 17 of 18 555521 06/29/2023 Rancho Mesa Care Center 9333 LA Mesa Dr Alta Loma, CA 91701

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure equipment was maintained in safe operating condition when: Residents Affected - Few One of three refrigerators observed, had condensation (water) dripping from the top of the refrigerator to the bottom area. This failure had the potential for the refrigerator to not function properly to cool the food and/or contamination of the food stored inside the refrigerator which could cause foodborne illnesses to a population of 56 medically compromised residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview with the Dietary Services Supervisor (DSS), on June 26, 2023, at 9:05 AM, one of the three refrigerators located inside of the Central Supply room area, had condensation dripping from the top of the refrigerator area to the bottom. The refrigerator was storing boxes of vegetables. An open box of yellow squash under the refrigerator was wet from the dripping water. DSS stated that the refrigerator should be fixed and remove the contaminated vegetables. During an interview on June 29, 2023, at 11:55 AM, with Maintenance Supervisor (MS), acknowledged the dripping water and stated his expectations is to get it fixed. During a review of the FDA Federal Code, dated 2022, 4-501.11 indicated Proper maintenance of equipment to manufacturer specifications helps ensure that will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk. For example, refrigeration units in disrepair may no longer be capable of properly cooling or holding time/temperature control for safety foods at safe temperatures. 555521 Page 18 of 18