Health inspection·February 7, 2020

F 0552 Level of Harm - Minimal harm or potential for actual harm A review of Resident 9's Verification of Resident Informed Consent, dated 5/15/19, for Psychotherapeutic Drugs (drugs that control thoughts, mood, or behavior) Classification of Drug . Depakote 500 mg (a psychotherapeutic drug) . The box was checked next to .I have reviewed with the resident the following material information . and was signed by MD 1 for obtaining informed consent. The form was also signed by the DON for verifying consent was obtained by the physician. Residents Affected - Few A review of Resident 9's physician orders, dated 5/15/19, indicated the resident received Depakote 500mg to treat schizophrenia. On 2/7/20 at 8:09 A.M., a joint interview and record review was conducted with the DON. The DON reviewed Resident 9's Verification of Resident Informed Consent, dated 5/15/19 for Depakote 500 mg. The DON stated MD 1 did not explain the risks and benefits of the medication to Resident 9 because the resident did not have the mental capacity to understand or make decisions. The DON stated she signed that consent had been verified knowing the physician did not obtain consent. The DON stated psychotherapeutic medications were an important part of a resident's medical care. The DON stated there should have been a bioethics committee conducted to discuss the medication risks and benefits and whether or not Resident 9 should be treated with Depakote. The DON stated there should have been a bioethics committee conducted with all required members as per facility policy. The DON stated, we messed up on this one. On 2/7/20 at 3:51 P.M., a telephone interview was conducted with MD 1. MD 1 stated the risks and benefits of Depakote 500 mg were not explained to the resident since the resident lacked capacity. MD 1 stated he continued what the previous physician ordered, and had not obtained consent. MD 1 stated he was not part of a bioethics committee to discuss and make the decision to use Depakote for Resident 9. MD 1 stated he could not recall being part of a bioethics committee for any residents of the facility. Per the facility's undated policy titled Resident Rights Bioethics Committee/Epple Bill, .When situations arise that involve complex bioethical decisions, a Bioethics committee/IDT shall meet to address the issues . possible Bioethics Committee/IDT involvement include: . D. To act as surrogate decision maker for residents who are incapable of making their own decisions and have no responsible party or interested person . 3. The Bioethics committee/IDT is composed of: Facility administrator, director of nursing services, medical director/attending physician at SNF, social services director/designee, LTC Ombudsman Per the facility's policy titled Informed Consent-CA, revised May 2018, .2. A physician's orders related to the use of psychotherapeutic drug should have an informed consent obtained by the physician within 72 hours . Procedures . 2. To use the Verification of Informed Consent form, facility staff shall: a. Confirm that the physician who obtained Informed Consent has provided all necessary and required information relative to the drug/treatment/procedure FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555596 If continuation sheet Page 2 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555596 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkside Health and Wellness Center 444 W Lexington El Cajon, CA 92020 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. 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 protect resident belongings for one of 15 residents (27) reviewed for personal property. Residents Affected - Few This failure resulted in a potential for resident to resident altercation between Resident 27 and Resident 35. Findings: Resident 27 was admitted to the facility on [DATE], with diagnoses which included, anxiety disorder (a long standing mental disorder with persistent worry and fear that interfere with daily activities) and schizophrenia (a mental disorder of thinking and behavior that impairs daily functioning), per the facility's admission Record. On 2/4/20, at 3:35 P.M., an interview and observation with Resident 27 was conducted. Resident 27 was sitting on his bed and stated his roommate, Resident 35, was stealing his clothes. Resident 27 stated the SSD was informed a week ago about the incident and told Resident 27 that his closet would have to be locked. Resident 27 stated, nothing had been done and felt frustrated because there were no locking devices on Resident 27's closet door. On 2/6/20 at 9:02 A.M., a concurrent observation and interview with CNA 30 was conducted. CNA 30 stated Resident 27 informed CNA 30 that Resident 35 had his clothes, and told CNA 30, Just don't let him (Resident 35) touch my stuff. When CNA 30 opened Resident 27's closet, there was no locking device. CNA 30 stated Resident 35 had the tendency to grab clothes and go into Resident 27's closet, and redirection did not work. CNA 30 further stated, LN 30 was informed of the incident. CNA 30 stated anyone could easily access Resident 27's closet. On 2/6/20, a review of Resident 27's medical record was conducted. There was no documentation in the nursing progress notes, or in the social worker notes, related to Resident 27's missing personal clothing items. On 2/6/20, at 10:48 A.M., a record review and interview with the SSD was conducted. The SSD stated Resident 35 had a behavior of wandering and opening closets. The SSD recalled last week she was informed by CNA 31 of Resident 35 opening closets. The SSD stated there was no documentation of the incident or follow-up. On 2/6/20, at 11 A.M., a record review and interview with the MA was conducted. The MA stated the Maintenance Log book was used to communicate requests between staff and the MA. There was no work request found in the maintenance log to install locks on Resident 27's closet. On 2/7/20, at 2:43 P.M., an interview with the DON was conducted. The DON stated, the issue with Resident 27's closet being accessed by Resident 35 was not communicated effectively between the nursing staff, the SSD and the MA, when it should have been. The DON stated, the nursing staff, the SSD, and the MA did not intervene immediately to protect Resident 27's belongings. The DON stated this could have caused an altercation between Resident 27 and Resident 35. A review of the facility's policy titled, Personal Property, Resident's, revised May 2007, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555596 If continuation sheet Page 3 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555596 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkside Health and Wellness Center 444 W Lexington El Cajon, CA 92020 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0602 indicated, .it is the policy of this facility to provide .safety for resident's personal property Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555596 If continuation sheet Page 4 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555596 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkside Health and Wellness Center 444 W Lexington El Cajon, CA 92020 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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 ensure wound treatments were consistently provided as ordered to one of 15 residents (31), reviewed for quality of care. In addition, a physician's wound treatment order was not carried out, or clarified by nursing staff. Residents Affected - Few These failures had the potential to negatively impact Resident 31's wound healing and to impede the coordination of care. Findings: Resident 31 was admitted to the facility on [DATE] with diagnoses to include diabetes mellitus (inability to control blood sugar) with foot ulcer (open wound) and atherosclerosis (narrowing via the build-up of fats/plaques) of native arteries of left leg with ulceration of other part of foot, per the facility's admission Record. 1a. On 2/4/20 at 9:40 A.M., an observation and interview was conducted with Resident 31. Resident 31 was sitting in bed and his right foot was wrapped in a pressure-offloading boot. Resident 31 stated he had wounds on his feet. Resident 31 stated his bandages were supposed to be changed daily. Resident 31 stated he was lucky if they (nursing staff) change it three times a week. Resident 31 stated he did not refuse wound treatments. Resident 31 stated nursing staff just never came. Resident 31's clinical record was reviewed. Resident 31's MDS assessment (an assessment tool) Section C, dated 9/17/19, indicated the resident scored 15 on the BIMS (a score of 13-15 indicated cognition was intact). Resident 31's TAR was reviewed as follows: September 2019- daily treatment to right great toe (cleanse with NS, apply medihoney (ointment), apply cutimed (dressing), apply hydrofoam blue (antibacterial dressing), apply duoderm (dressing), cover with island dressing, and cover site with rolled gauze). The TAR was blank on 9/6/19 and 9/17/19. October 2019- daily treatment to right foot (cleanse with NS, apply antiseptic gel, cover with gauze, and apply compression with rolled gauze). The TAR was blank on 10/17/19 and 10/24/19. November 2019- daily treatment to right foot and heel ulcer (cleanse with NS, apply wet hydrofoam blue, and cover with gauze). The TAR was blank on 11/20/19 and 11/27/19. December 2019- daily treatment to left heel (cleanse with NS, apply betadine, wrap with rolled gauze). The TAR was blank on 12/29/19. -daily treatment to left lateral foot, right lateral foot, and right heel (Cleanse with NS, apply medihoney, soak gauze with Dakin's solution (medicated solution), cover with dressing and wrap with rolled gauze). The TAR was blank on 12/29/19. January 2020- daily treatment to left lateral foot, right lateral foot, and right heel (Cleanse with NS, apply medihoney, soak gauze with Dakin's solution, cover with dressing and wrap with rolled gauze). The TAR was blank on 1/23/20, 1/25/20, and 1/26/20. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555596 If continuation sheet Page 5 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555596 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkside Health and Wellness Center 444 W Lexington El Cajon, CA 92020 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few - daily treatment to left heel (cleanse with NS, apply betadine, wrap with rolled gauze). The TAR was blank on 1/23/20, 1/25/20, and 1/26/20. On 2/5/20 at 3:12 P.M. a joint interview and record review was conducted with LN 1. LN 1 stated Resident 31 required daily treatment to the wounds on his feet. LN 1 stated adherence to wound treatment was very important as Resident 31 was diabetic and diabetic wounds could easily become infected. LN 1 stated nurses were required to sign the TAR after treatment was provided to a resident. LN 1 reviewed Resident 31's TARs and stated the TAR was blank on 9/6/19, 9/17/19, 10/17/19, 10/24/19, 11/20/19, 11/27/19, 12/29/19, 1/23/20, 1/25/20, and 1/26/20. LN 1 stated there was no documentation Resident 31 refused wound treatment or was out of the facility on those days. LN 1 stated if the wound treatment was left blank in the TAR then the treatment was not provided to Resident 31. LN 1 stated Resident 31 should have received regular and consistent wound treatments. Multiple attempts were made to interview the main wound treatment nurse and the wound physician. The facility failed to provide the requested information. On 2/7/20 at 2:30 P.M., an interview was conducted with the DON. The DON stated Resident 31's TAR should not have unsigned treatments. The DON acknowledged if the treatment was not signed, then the treatment was not done. 1b. Resident 31's clinical record was reviewed. Wound Physician Notes dated 12/23/19, 1/2/20, 1/6/20, 1/13/20, 1/20/20, 1/27/20, and 2/3/20 indicated, Assessment and Plan: . to right foot x 2 (two wounds) and left foot . 5. Use cutimed sorbact with honey on Friday dressing change and no dressing change on the weekend . On 2/6/20 at 8:35 A.M., a joint interview and record review was conducted with LN 1. LN 1 reviewed Resident 31's clinical record and Wound Physician Notes. LN 1 stated there was no order to use cutimed sorbact with honey on Friday dressing change and no dressing change on the weekend. LN 1 stated the wound physician's assessment and plan was considered an order and should have been followed. LN 1 stated nursing had not carried that order out or asked the physician for clarification. LN 1 stated this should have been done. LN 1 further stated nursing was supposed to read the physician's wound documentation and make note of any recommendations or changes to the treatment plan. Multiple attempts were made to interview the main wound treatment nurse and the wound physician. The facility failed to provide the requested information. On 2/7/20 at 2:23 P.M., an interview was conducted with the DON. The DON stated a recommendation from the wound physician was considered an order and was expected to be carried out. The DON stated there should have been better coordination of care and communication between the wound physician and nursing. On 2/7/20 at 4:17 P.M., an interview was conducted with the DON. The DON stated the facility did not have a policy related to coordinating care or communication between physicians and nursing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555596 If continuation sheet Page 6 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555596 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkside Health and Wellness Center 444 W Lexington El Cajon, CA 92020 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer tube feedings (places food and fluids directly into the stomach through a tube inserted in the abdomen) consistent with a physician's order for one of two residents (26) reviewed for tube feeding. This failure had the potential for Resident 26 to be placed at risk for altered nutrition related to inadequate caloric intake. Findings: Resident 26 was admitted on [DATE] with diagnoses which include dysphagia (difficulty swallowing) and adult failure to thrive (loss of appetite) per the facility's admission Record, dated 2/7/20. A record review of Resident 26's Order Summary Report, dated 1/31/20, indicated Resident 26 had a physician's order, dated 1/1/20, to receive 1120 milliliters (mls) of tube feeding, starting at 6 P.M. to run 14 hours daily. A record review of Resident 26's Medication Administration Records (MARs), dated 1/1/20-1/31/20, and 2/1/20-2/29/20, indicated LNs documented the completed amounts of tube feeding for Resident 26 as follows: 1/2/20-1/9/20, 1200 mls daily, 1/10/20-11/13/20, 960 mls daily, 1/14/20, 920 mls, 1/15/20-1/17/20, 1160 mls daily, 1/18/20, 1440 mls, 1/19/20, 1200 mls, 1/20/20-1/22/20, 1160 mls daily, 1/25/20-1/26/20, 880 mls daily, 1/27/20, 960 mls, 1/28/20, 1040 mls, 1/30/20-1/31/20, 880 mls daily, 2/1/20-2/3/20, 960 mls daily, and 2/4/20, 1200 mls. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555596 If continuation sheet Page 7 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555596 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkside Health and Wellness Center 444 W Lexington El Cajon, CA 92020 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 2/7/20 at 9:15 A.M., a concurrent interview and record review with LN 18 was conducted. LN 18 stated nurses were to take the completed amount indicated by the feeding pump (pump that delivers continuous tube feeding), calculate the amount provided for their shift, and document the amount. LN 18 stated nurses should continue the tube feeding until the ordered amount was given. LN 18 reviewed Resident 26's MARs and stated nurses were documenting too much or too little of tube feeding, and not as ordered by the physician. LN 18 stated 1120 mls of tube feeding was the physician's order and should be followed to prevent complications. On 2/7/20 at 10:30 A.M., an interview with the RD was conducted. The RD stated Resident 26 was on tube feeding to prevent weight loss. The RD stated tube feeding orders should be followed to maintain adequate nutrition and hydration to prevent any decline in disease processes. On 2/7/20 at 2:13 P.M., an interview with the DON was conducted. The DON stated nurses should be following physician's orders and providing the correct amount of tube feeding to meet the appropriate caloric intake, prevent dehydration, and prevent weight loss. According to the facility's policy, titled Infection Control Policy/Procedure: Subject Tube Feeding ., revised June 2007, .It is the policy of this facility to assure safe practice in providing tube feedings .2.according to the physician's order .3. Stop the pump. Check volume control for amount infused and record intake. Clear the volume control .6. Document feeding on tube feeding record . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555596 If continuation sheet Page 8 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555596 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkside Health and Wellness Center 444 W Lexington El Cajon, CA 92020 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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 practices that mitigated the risk of resident food contamination were followed, when: Residents Affected - Some 1. Dishware and utensils were stored while wet. In addition, wet water pitchers were air dried outside of the kitchen next to soiled linen barrels. 2. Resident dishware and kitchen equipment were stored with dirt, debris, and objects resembling rat feces on them. 3. Spoiled produce was stored amongst unspoiled produce. 4. Clean dishware and utensils had food debris on them. 5. Glassware had cracks and a food scoop had a melted handle. These failures to mitigate potential food contamination may result in foodborne illness (illness caused from consumption of contaminated or toxic food). Findings: 1. On 2/4/20 at 8:15 A.M., a joint kitchen observation and interview was conducted with the DDS. Five plastic water pitchers and two plastic food prep tubs were wet when stored in the cabinet. Two wet food scoops were stored in the drawer above the cabinet. The DDS stated clean dishes and utensils should not have been put away wet as this could lead to contamination. The DDS stated dishware should be air dried first and then stored for next use. On 2/4/20 at 8:50 A.M., a joint kitchen observation and interview was continued with the DDS. Five plastic water pitchers and two plastic food prep tubs were observed air drying on a portable food cart outside of the kitchen. The sun was shining directly on the dishware. The cart with drying dishware was placed approximately four feet away from several barrels labeled soiled linen. Weeds, dirt, leaves, and a soiled mop and bucket surrounded the food cart and drying dishware. The DDS stated I have no room to dry them inside. The DDS stated the dishware could become dirty and contaminated when air drying outside of the kitchen. On 2/6/20 at 10 A.M., an interview was conducted with the facility's RD. The RD stated dishes and utensils should not be put away wet. The RD stated it was her expectation that dishware be air dried prior to being stored. The RD further stated it was not an acceptable practice to air dry dishware outside in the elements and next to soiled items. The RD stated I've never seen anything like that. Per the facility's policy titled Dish Washing, dated 2018, . 5. Dishes are to be air dried in racks before stacking and storing 2. On 2/4/20 at 8:50 A.M., a joint kitchen observation and interview was conducted with the DDS. Two portable outside kitchen storage areas were inspected. The DDS stated dishware used for residents and kitchen equipment were stored within the portable storage sheds. The first storage shed had shelves with dishware covered in a layer of dust. A food slicer and food processor was placed directly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555596 If continuation sheet Page 9 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555596 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkside Health and Wellness Center 444 W Lexington El Cajon, CA 92020 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some on the bottom of the storage unit. The food slicer and food processor were covered with a thick layer of dirt and leaves. The food slicer had small black objects resembling rat feces on it. The DDS stated the dishware and kitchen equipment in the first storage shed were dirty and the black objects looked like turds (feces). The DDS stated the condition of the outside storage shed was not acceptable. On 2/6/20 at 10 A.M., an interview was conducted with the facility's RD. The RD stated she was not aware kitchen equipment and dishes were stored in portable storage sheds outside. The RD stated the kitchen equipment in the outside storage shed should not have been stored directly on the bottom of the storage container. The RD stated the dishware and kitchen equipment should not have been visibly soiled with dust or dirt. The RD stated there should not have been anything resembling rat feces near kitchen equipment or dishware. Per the facility's policy titled Sanitation, dated 2018, .9. All utensils, counters, shelves and equipment shall be kept clean, . 3. On 2/4/20 at 8:20 A.M., a joint kitchen observation and interview was conducted with the DDS. The reach-in refrigerator (#2) had a large uncovered plastic container with tomatoes and green bell peppers in it. Three green bell peppers had large black fuzzy areas the size of quarters resembling mold on them. The three green bell peppers had a slippery, slimy feel. The DDS stated the three bell peppers should not be there with the rest of the vegetables. The DDS stated the three bell peppers were spoiled and should have been thrown away. On 2/6/20 at 10 A.M., an interview was conducted with the facility's RD. The RD stated there should not be any spoiled produce mixed in with unspoiled produce. The RD stated the three spoiled bell peppers should have been removed from circulation. Per the 2017 US FDA Food Code, 3-302.11 Packaged and Unpackaged Food -Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by: .(7) Not Storing damaged, spoiled, or recalled FOOD .held in the FOOD ESTABLISHMENT as specified under § 6-404.11 . Per the facility's policy titled Storing Produce, dated 2018, 1. Check boxes of fruit and vegetables for rotten, spoiled items . Throw away all spoiled items .When storing vegetables .green peppers, . they will stay fresh longer if you place them in a sealed bag or container. 9. Remove the wilted or spoiled portions of lettuce, celery, and other fresh vegetables in the refrigerator often so they don't cause the rest of the vegetables to spoil 4. On 2/4/20 at 8:20 A.M., a joint kitchen observation and interview was conducted with the DDS. The dishware and utensil storage area was observed. Six food serving scoops used for puree, one ladle, and one pair of tongs had dried, caked on food debris. The DDS stated the scoops, ladle, and tongs had not been thoroughly cleaned. The DDS stated it was her expectation for dishware and utensils to be double checked to ensure they were thoroughly cleaned before storing them. On 2/6/20 at 10 A.M., an interview was conducted with the facility's RD. The RD stated the dishware and utensils should have been thoroughly cleaned before being stored. The RD stated clean utensils (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555596 If continuation sheet Page 10 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555596 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkside Health and Wellness Center 444 W Lexington El Cajon, CA 92020 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 should not have dried on food debris. Level of Harm - Minimal harm or potential for actual harm On 2/6/20 at 12:50 P.M., an observation of the dishwashing process was conducted with DA 1. DA 1 stated the dishes on the counter were clean and were air drying. Two glasses and the top and bottom container used to puree food was air drying with visible food debris on them. DA 1 stated clean dishes should not have food debris on them. DA 1 stated the dishes should have been checked to ensure they were thoroughly cleaned. Residents Affected - Some Per the facility's policy titled Dish Washing, dated 2018, .1. Gross food particles shall be removed by careful scraping and pre-rinsing in running water 5. On 2/4/20 at 8:20 A.M., a joint kitchen observation and interview was conducted with the DDS. The dishware and utensil storage area was observed. One food scoop used for puree had a melted handle that was cracked and had holes in it. The DDS stated the scoop should not be in circulation for use. The DDS stated the scoop should have been thrown out and replaced with a new one. On 2/6/20 at 10 A.M., an interview was conducted with the facility's RD. The RD stated kitchen utensils and dishware should be kept in good condition. On 2/6/20 at 12:50 P.M., an observation of the dishwashing process was conducted with DA 1. Plastic glassware was observed stored on a rack. DA 1 stated the glassware was clean and ready for use. Three plastic drinking glasses had cracks and chips along the bottom and top rim of the glasses. DA 1 stated cracked and chipped drinking glasses were supposed to be thrown away as cracks could harbor germs. Per the facility's policy titled Sanitation, dated 2018, . 9. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks and chipped areas. 10. Plastic ware, china and glassware that becomes unsightly, unsanitary or hazardous because of chips, cracks or loss of glaze shall be discarded FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555596 If continuation sheet Page 11 of 11