Health inspection·May 18, 2023

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 a physician's order for oxygen therapy was in place before administration for one of three sampled residents (Resident 113) with respiratory issues. Residents Affected - Few As a result, there was a potential Resident 113 did not receive the correct amount of oxygen. Findings: Resident 113 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (a type of lung disease which causes breathing-related problems) exacerbation. On 5/16/23 at 9:49 A.M., an observation of Resident 113 was conducted. Resident 113 was receiving two liters per minute (LPM) of oxygen through a nasal cannula. On 5/17/23 at 8:26 A.M., an observation of Resident 113 was conducted. Resident 113 was receiving two to three LPM of oxygen through a nasal cannula. On 5/17/23 at 8:29 A.M., an observation, interview and record review with Respiratory Therapist (RT) 1 were conducted. RT 1 stated there was a physician's order to administer oxygen two LPM to Resident 113 dated 5/17/23. RT 1 stated there was no prior order before 5/17/23. Resident 113's roommate, Resident 115, stated Resident 113 has received oxygen even before this date. On 5/17/23 at 8:45 A.M., an interview with Resident 113 was conducted. Resident 113 stated the staff had administered oxygen to her since admission and she has been using it at home for five years. On 5/17/23 at 1:23 P.M. an interview and record review with Licensed Nurse (LN) 1 were conducted. LN 1 stated the physician's order for oxygen therapy for Resident 113 was dated 5/17/23. LN 1 stated Resident 113 received oxygen before this date. LN 1 stated a physician's order was needed before oxygen administration. LN 1 stated if a resident was administered oxygen without a physician's order, this could cause consequences and a lot of problems for Resident 113 such as an exacerbation of her breathing problems. On 5/18/23 at 9:22 A.M., an interview with LN 2 was conducted. LN 2 stated oxygen therapy requires a physician order before administration. LN 2 stated Resident 113 had COPD and if she was given more than the prescribed oxygen, it could cause lethargy to Resident 113. Per the facility's policy and procedure titled Oxygen Protocol revised 3/18/21, III. TEXT: B. Page 1 of 6 555572 555572 05/18/2023 Grossmont Hospital D/P Snf 5555 Grossmont Center Drive LA Mesa, CA 91941

F 0695 Policy: 1. The Oxygen Protocol will be initiated on patients by a written order from the physician . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555572 Page 2 of 6 555572 05/18/2023 Grossmont Hospital D/P Snf 5555 Grossmont Center Drive LA Mesa, CA 91941

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to consistently monitor specific target behaviors and adverse side effects for the use psychotropic medications for two of three residents (3, 8) selected for unnecessary medication review. As a result, the residents were at increased risk for receiving unnecessary medication. 1. Resident 3 was admitted to the facility on [DATE] with diagnoses that included left humerus (arm) fracture, per the resident's demographic sheet. On 5/17/23, Resident 3's clinical record reviewed. A physician's progress note, dated 4/28/23, indicated Resident 3 also had diagnoses that included bipolar disorder and adjustment disorder. According to the physician's orders, on 2/1/23 Resident 3 was prescribed quetiapine (antipsychotic) 150 mg at bedtime for bipolar disorder. The order directed staff to monitor the resident for episodes of agitation every shift, and to monitor side effects of quetiapine every shift. Resident 3 was also prescribed sertraline (antidepressant) 200 mg daily for depression on 2/2/23. The physician's order directed staff to monitor the resident for episodes of depression every shift, and to monitor for side effects of sertraline every shift. A concurrent interview and record review was conducted with Licensed Nurse (LN) 2 on 5/18/23 at 11:01 A.M. The monitoring for Resident 3's quetiapine and sertraline were reviewed. There was no documentation of behavior or side effect monitoring for both quetiapine and sertraline on the following shifts: 5/1 day, 5/3 night, 5/6 day, 5/10 day, 5/10 night, 5/11 night, 5/14 night, and 5/16 night. LN 2 acknowledged the monitoring for behavior and side effects was missed. LN 2 stated, They [nursing] should be documenting every shift. According to the facility's policy, Monitoring of Antipsychotic Medications, dated 5/11/22, When antipsychotic therapy is initiated, the resident is monitored to determine the effectiveness of the medication and the presence of adverse reactions . 2. Resident 8 was admitted to the facility on [DATE] with a diagnosis of osteomyelitis (infection) of right hip, per the resident's demographic sheet. On 5/17/23, Resident 8's clinical record was reviewed. According to the physician's orders, on 3/8/23 Resident 8 was prescribed diazepam 5 mg three times a day for anxiety. The order directed staff to monitor the resident for episodes of anxiety every shift, and to monitor for side effects of diazepam every shift. A concurrent interview and record review was conducted with LN 2 on 5/18/23 at 10:36 A.M. The monitoring for Resident 8's diazepam was reviewed. There was no documentation of behavior or side effect monitoring for diazepam on the following shifts: 5/2 day, 5/9 day, 5/10 day, 5/10 night, 5/11 night, 5/14 day, and 5/15 day. LN 2 acknowledged the monitoring for behavior and side effects was missed. LN 2 stated, They [nursing] should be documenting once a shift. 555572 Page 3 of 6 555572 05/18/2023 Grossmont Hospital D/P Snf 5555 Grossmont Center Drive LA Mesa, CA 91941

F 0758 Level of Harm - Minimal harm or potential for actual harm According to the facility's policy, Monitoring of Anxiolytic Medications, dated 5/11/22, When anxiolytic therapy is initiated or the dosage changed, the resident is monitored to determine the effectiveness of the medication . Residents Affected - Few 555572 Page 4 of 6 555572 05/18/2023 Grossmont Hospital D/P Snf 5555 Grossmont Center Drive LA Mesa, CA 91941

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the kitchen staff were knowledgeable of the proper chemical sanitation range values. As a result, there was a potential for spread of food-borne illness. Findings: On 5/17/23 at 10:50 A.M., a review of the 3 Compartment Sink and Sanitizer Log was conducted. The required sanitizer range value was indicated to be 272-700 parts per million (PPM). On 5/17/23 at 10:56 A.M., a joint observation and interview of Food and Nutrition Services Staff (FAN) 1 was conducted with the Executive, Nutrition and Services ([NAME]). FAN 1 was unable to state the required chemical sanitation values for the three-compartment sink. On 5/17/23 at 11:11 A.M., a joint observation and interview of Kitchen Supervisor (KS) 1 was conducted with the [NAME]. KS 1 was unable to state the required sanitation values for the three-compartment sink. On 5/17/23 an interview with the Manager of Nutrition Services (MNS) was conducted. The MNS stated the kitchen staff did not understand the meaning of the required chemical sanitation values for the three-compartment sink. The MNS stated it was important for the staff to know these to keep the patients safe. Per the facility's policy and procedure titled Infection Prevention for Food & Nutrition Services, revised 8/31/21, .III .B. EDUCATION AND TRAINING .2. Effectiveness of education is monitored . 555572 Page 5 of 6 555572 05/18/2023 Grossmont Hospital D/P Snf 5555 Grossmont Center Drive LA Mesa, CA 91941

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the kitchen staff consistently documented accurate final rinse temperature of the dishwashing machine. As a result, there was a potential the final rinse temperatures were not in the required range. Findings: On 5/16/23 at 8:32 A.M., a concurrent interview and record review of the document titled, Dishwashing/Warewashing Machine Temperature Log was conducted with the Manager of Nutrition Services (MNS) and Kitchen Supervisor (KS) 1. The log indicated the following temperature requirements: Wash 150F, Rinse 160F and Final Rinse 180F. The final rinse temperatures were not consistently documented accurately from 5/1/23. The MNS stated the kitchen staff were not looking at the correct gauge, which was the blue gauge for the final rinse temperature. The MNS stated the staff were instructed by the Executive, Nutrition Services ([NAME]) to check the green gauge for the final rinse temperature. KS 1 stated the staff was instructed by the [NAME] to check the green gauge and record the readings for the final rinse temperatures. On 5/16/23 at 8:34 A.M., an interview with the [NAME] was conducted. The [NAME] stated the green gauge was not the final rinse temperature gauge but the PSI [Pounds Per Square Inch], which was part of the final rinse validation. The [NAME] stated the staff should have recorded the final rinse temperature and the PSI. On 5/17/23 at 10:42 A.M., an interview with the [NAME] was conducted. The [NAME] stated the kitchen staff did not use the new and correct temperature log form which was implemented in August 2022. The [NAME] stated the staff needed retraining. The [NAME] stated if the staff recorded the wrong temperatures, the kitchen would have switched to disposables as part of infection control. Per the facility's policy and procedure titled Infection Prevention for Food & Nutrition Services, revised 8/31/21, .TEXT: E. EQUIPMENT/SANITATION 1. Proper temperature of dishwashers is maintained and recorded daily: The facility's document titled Food Safety Management System, revised 4/1/22, .D-8 Cleaning and Sanitizing Food Contact Surfaces .A high temperature dish machine must have a minimum final rinse temperature of 180 F .must be verified .Dish machine temperatures must be checked and recorded . 555572 Page 6 of 6