Health inspection·May 10, 2024

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review, the facility failed to ensure the menu was followed as planned during lunch tray line (a system of food preparation in which trays move along an assembly line) when 2 residents (Resident 18 and 32) small portion diet were not followed. This failure had the potential not to meet the nutritional needs as planned to maintain normal body weight and acceptable nutritional values of residents. Findings: During a concurrent observation with the Dietary Manager (DM) on 5/06/24 at 11:58 a.m., of the lunch meal service in the kitchen steam table, part of the menu for the day (5/06/24),were cheesy mashed potatoes, carrots,and turkey. For the cheesy mashed potatoes, the scoops prepared for meal serving were #8 scoop (=1/2 cup) and a #16 scoop (=1/4 cup). For the diced and minced turkey, a 3-ounce spoodle was in place. During a concurrent observation and interview on 5/06/24 at 12:19 p.m., with the [NAME] (CK), in the kitchen, the meal cards for Residents 8 and 32 indicated ,small portion diet and 2 ounces of meat. CK was noted using scoop #8 (1/2 cup) for the potatoes served on the meal plates of Residents 8 and 32, in addition to 3 ounces of diced /minced turkey. When the meal carts were about to leave the kitchen, surveyor asked the Dietary Manager (DM) to check the meal plates of Residents 8 and 32. The DM, confirmed the meal plates of Residents 18 and 32, had 1/2 cup of mashed potatoes ( # 8 scoop), instead of 1/4 cup mashed potatoes as ordered prepared by using scoop # 16 for small portion diet and 3 ounces of diced/minced turkey. During an interview on 5/06/24 at 12:23p.m., with the CK, and with the DM translating the questions, CK stated, not being aware the scoop used for Residents 8 and 32 , for the small portion diet was #8 scoop , instead of scoop #16. Both residnets were also served 3 ounces of diced /minced turkey , instead of just 2 ounces as ordered. This was verified by CK, upon checking of the meal spreadsheet . During a review of the facility's DCC (Danish Care Center) Spring/Summer 2024 Diet Spreadsheet menu, dated 5/03/24, showed three ounces of roasted thyme turkey, 1/2 cup of cheesy potatoes, 1/2 cup (#8 scoop) sliced carrots for the regular diet, small bite size (SB6) diet and minced and moist (MM5) diet. It showed under the small portion diet 2 ounces roasted thyme turkey and 1/4 cup cheesy potatoes. Page 1 of 5 555554 555554 05/10/2024 Coastal Oaks Special Care Center 10805 El Camino Real Atascadero, CA 93422

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. Based on record review and interview, the facility failed to maintain medical records for three of 3 sampled residents (Resident 46, 38 and 44) and for one unsampled resident (Resident 47) were in accordance with professional standards and practices when: 1). Resident 46, physician ordered supplement intakes were not documented in the medical record. 2). Resident 38, Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage ((SNFABN) notice of Medicare coverage ending) signature of resident representative was not legible or identified. 3) . Resident 44, Resident-Facility Arbitration Agreement ((RFAA) opting for a private dispute resolution procedure instead of going to court agreement) signature of resident representative was not legible or identified. 4). Resident 47, SNFABN date of notification was omitted. These failures had the potential to eflect a resident's progress towards achieving their person-centered plan of care objectives and goals and the improvement and maintenance of their clinical, functional, mental and psychosocial status Findings: During a review of the facility's policy and procedure (P&P) titled, Resident Records-Identifiable Information, Clinical Records, no date, the P&P indicated, Clinical records are complete, accurately documented, readily accessible and systematically organized. 1) During a review of Resident 46's May 2024 Physician Order Sheet, dated 4/01/2024, the Physician Order Sheet indicated Resident 46 to have house supplement (120cc) oral BID (twice a day) at lunch and dinner. During a review of Resident 46's ADL [activity of daily living] Verification Worksheet, date range 4/01/24 through 5/08/24, the ADL Verification Worksheet had only nine days with recorded intakes by the Certified Nursing Assistant (CNA). During a review of the facility's policy and procedure (P&P) titled, High Calorie/High Protein Supplements, dated 2022, the P&P indicated, Nursing staff will supervise the delivery and consumption of all supplements and record appropriately in the medical record, meal intake reporting records, and/or the medication administration record. During an interview on 05/08/24 11:49 a.m. with CNA1, CNA1 stated I have worked here almost 5 years, in charge of documenting breakfast, lunch and dinner, when we document the meal there is a section for supplements like the mighty shake. It is always the CNAs that document the meals. During an interview on 05/08/24 11:55 a.m. with the Director of Staff Development (DSD), DSD stated, after each meal the CNAs will document meals and supplements, supplements yes or no, then it will ask how much, the CNA will write the point system like the percentage, CNA training would be done on initial hire, chart audits, on the tray card will verify that it is on the meal ticket, or if they 555554 Page 2 of 5 555554 05/10/2024 Coastal Oaks Special Care Center 10805 El Camino Real Atascadero, CA 93422

F 0842 refused the supplement. I have a handout but not a policy. Level of Harm - Minimal harm or potential for actual harm 2) During a review of Resident 38's SNFABN, dated 2/6/24, the SNFABN indicated, Signature of Patient or Authorized Representative, signature was illegible and without identification for the signature. Residents Affected - Few During an interview on 5/8/24 at 10:50 a.m. with the Administrator (ADM), ADM reviewed the SNFABN and stated, the resident representative signature was illegible and should have been identified. 3) During a review of Resident 44's RFAA, dated 11/21/22, the RFAA indicated, Resident Representative/Agent Signature, signature was illegible and without identification for the signature. During an interview on 5/8/24 at 10;50 a.m. with ADM, ADM reviewed the RFAA and stated, the resident representative signature was illegible and should have been identified. 4) During a review of Resident 47's SNFABN, dated 2/6/24, the SNFABN indicated, Date, without a date. During an interview on 5/8/24 at 10:50 a.m. ADM, ADM reviewed the SNFABN and stated, the date the phone call was made should have been documented. 555554 Page 3 of 5 555554 05/10/2024 Coastal Oaks Special Care Center 10805 El Camino Real Atascadero, CA 93422

F 0848 Provide a neutral and fair arbitration process and agree to arbitrator and venue. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure three of three sampled residents (Resident 22, 44, and 46) binding arbitration agreements had clearly stated the selection of a neutral arbitrator agreed upon by both facility and resident or resident representative and clearly stated the selection of a venue that is convenient to both facility and resident or resident representative. Residents Affected - Few This failure had the potential to result in psychosocial harm in the event of an arbitration dispute. Findings: During a review of: Resident 22's RESIDENT-FACILITY ARBITRATION AGGREEMENT (RFAA), dated 7/8/21, the RFAA did not indicate the selection of a neutral arbitrator agreed upon by both facility and resident or resident representative and did not indicate the selection of a venue that is convenient to both facility and resident or resident representative. Resident 44's RFAA, dated 11/21/22, the RFAA did not indicate the selection of a neutral arbitrator agreed upon by both facility and resident or resident representative and did not indicate the selection of a venue that is convenient to both facility and resident or resident representative. Resident 46's RFAA, dated 4/7/23, the RFAA did not indicate the selection of a neutral arbitrator agreed upon by both facility and resident or resident representative and did not indicate the selection of a venue that is convenient to both facility and resident or resident representative. During an interview on 5/8/24 at 3 p.m., with the Administrator (ADM), ADM stated the required verbiage is not there. 555554 Page 4 of 5 555554 05/10/2024 Coastal Oaks Special Care Center 10805 El Camino Real Atascadero, CA 93422

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 maintain essential equipment and safe operating condition, when the refrigerator gasket was found to have been torn. Residents Affected - Few This failure resulted in the door not being able to seal appropriately and with potential to effect food temperatures. Findings: During a concurrent observation and interview on 05/08/24 at 02:46 p.m. of the snack shack refrigerator, the low-fat milk in the door was 48 fahrenheit (The standard scale used to measure temperature in the United States) when measured with the facility thermometer and verified by the Dietary Manager (DM) . The DM stated they took measurements to get a new refrigerator ordered. The DM Stated if they had seen the torn gasket then they would have notified maintenance about it for repair. During an interview and observation on 05/08/24 at 03:54 p.m. of the snack shack refrigerator, Facilities Manager (FM) stated he was not aware about the tear in the gasket. FM stated he would expect to be notified of this needing to be replaced by staff or in the maintenance logbook. During a review of the Maintenance Repair Log, dated 7/25/23 through 5/7/24, the Maintenance Repair Log did not indicate any reporting of the torn gasket for the snack shack refrigerator. During a review of the facility's policy and procedure (P&P) titled, Maintenance Preventative Maintenance Program, undated indicated, These goals are accomplished by detecting and correcting minor defects before they develop into serious problems and by performing the services necessary to prevent undue wear and subsequent breakdown. 555554 Page 5 of 5