Health inspection·February 28, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to promote dignity for one of 10 sampled residents (Resident 9) when Certified Nursing Assistant (CNA) 1 was observed standing over Resident (9) while assisting in bed to eat. This deficient practice had the potential to not promote dignity and respect for Resident 9 to cause emotional distress. Findings: A review of Resident 9's admission Record indicated, Resident 9 was admitted to the facility on [DATE] with diagnoses which included history of schizoaffective disorder (a mental health disorder with a mix of hallucinations and delusions). A record review of Resident 9's minimum data set (MDS - a federally mandated resident assessment tool) dated 12/18/24 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 15 points out of 15 possible points which indicated Resident 9 did not have cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 2/26/25 at 1:11 P.M., an observation was conducted inside of Resident 9 ' s room. CNA 1 was standing over Resident 9 at the side of the bed while feeding Resident 9 in bed. Resident 9 later threw a pitcher across the room toward her roommate ' s side of the room which landed on the floor, and rolled outside of Resident 9 ' s room. On 2/26/25 at 1:13 A.M., an interview was conducted with Licensed Nurse (LN) 2. LN 2 stated Resident 9 is alert but will make non-sensical statements and say random things while talking to her and usually not able to answer questions fully. LN 1 stated CNA 1 should be sitting down at eye-level while feeding Resident 9 to promote dignity and respect. On 2/28/25 at 10:53 A.M., an interview was conducted with CNA 1, in the conference room. CNA 1 stated she was also an restorative nurse assistant (RNA) and does RNA exercises with Resident 9. CNA 1 stated she was helping Resident 9 because Resident 9 had a hard time getting food on her spoon. CNA 1 stated while Resident 9 was eating she was talking about peasants and that did not make sense. CNA 1 stated Resident 9 can also get physical with staff. CNA 1 stated she should have gotten a chair when she was feeding Resident 9 to be at an eye-level which promoted dignity and better communication. Page 1 of 6 555754 555754 02/28/2025 Village Square Healthcare Center 1586 W. San Marcos Blvd San Marcos, CA 92078

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 2/28/25 at 11:40 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated standing over a resident while feeding them can be intimidating for any resident. The DON stated her expectations were for the nursing staff to promote dignity while feeding residents by not standing over them and making eye-contact to promote dignity and respect. A review of the undated facility ' s policy and procedure titled, ASSISTING THE RESIDENT TO EAT indicated, .If the resident needs to be fed: a. Sit at eye level in front of the resident . 555754 Page 2 of 6 555754 02/28/2025 Village Square Healthcare Center 1586 W. San Marcos Blvd San Marcos, CA 92078

F 0694 Provide for the safe, appropriate administration of IV fluids 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 follow the physician ' s order to infuse the intravenous fluid [IVF] (IV- plastic tube inserted in the vein to deliver hydration, medications or nutrition) within 20-hour time for one of 10 residents (Resident 2) receiving an IVF. As a result, Resident 2's IV fluid was consumed over 26 hours. In addition, the IV tubing was not labeled with date and time it was used. Residents Affected - Few This deficient practice had the potential for Resident 2 to experience IV related complications and infections that would impact resident's health and well-being. Findings: A review of Resident 2's admission Record indicated; Resident 2 was admitted to the facility on [DATE] with diagnoses which included history of heart failure (when the heart muscle doesn't pump blood as well as it should). A record review of Resident 2's minimum data set (MDS - a federally mandated resident assessment tool) dated 2/2/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 15 points out of 15 possible points indicated, Resident 2 did not have cognitive (pertaining to memory, judgement and reasoning ability) deficits. A review of Resident 2 ' s physician's orders dated, 2/26/25 indicated, .sodium chloride 0.9 % parenteral solution; amt: 50 ml [milliliters]/[per] hr [hour]; intravenous Special Instructions: 1 liter for HYPERKALEMIA [high potassium: a mineral that is essential to the human body] . On 2/26/25 at 2:10 P.M., a concurrent observation and interview was conducted with Resident 2, in Resident 2 ' s room. Resident 2 had an IV on his left hand with Sodium Chloride 0.9% via IVF controlled by a flow regulator. Resident 2 stated the IVF was started in the morning. Resident 2 had a remaining IVF of approximately 700 ml in the bag. The IV tubing was not labeled with date and time it was used. On 2/27/25 at 12:05 P.M., an observation was conducted on Resident 2 ' s IVF, in Resident 2 ' s room. Resident 2 ' s IVF contained approximately 300 ml of fluid remaining in the bag. On 2/28/25 at 11:11 A.M., an interview and record review was conducted with Licensed Nurse (LN) 1, in the conference room. LN 1 stated she was the IV nurse for Resident 2. LN 1 stated Resident 2 had an order for IVF dated 2/26/25 for 1 litter (1000 ml) of Sodium Chloride 0.9% at 50 ml/hr. LN 1 stated the IVF should have been infused within 20 hours. LN 1 stated that Resident 2 ' s IVF was started at 9:45 A.M. and should have been completed by 5:45 A.M. on 2/27/25 during the night shift. The IVF had been running over 26 hours. LN 1 stated Resident 2 ' s IV site and IVF should have been monitored for complications such as IV site pain, redness, inflammation (immune response to infection or irritation), third spacing caused by IV not being in the vein, or IV tubing/line blockages. LN 1 stated an IVF that has been on for too long or too slow of a flow could lead to irritation and infection on Resident 2 ' s hand and an inadequate IVF to be administered as prescribed. LN 1 further stated that Resident 2 ' s IV tubing 555754 Page 3 of 6 555754 02/28/2025 Village Square Healthcare Center 1586 W. San Marcos Blvd San Marcos, CA 92078

F 0694 should have been labeled for infection control measures. Level of Harm - Minimal harm or potential for actual harm On 2/28/25 at 11:58 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated the RNs could have identified any IVF flow issues or complications such as inadequate fluid delivery, phlebitis [inflammation of the vein, and/or infiltration [leaking from the vein in surrounding tissues] and infection. The DON stated Resident 2 ' s IV tubing should have been labeled with date and time to determine when to replace the tubing to prevent infection control issues. The DON stated Resident 2 ' s IV fluid should have been completed timely and discarded appropriately as prescribed within 20 hours (5:45 A.M. on 2/27/25) and not over 26 hours (12:05 P.M. on 2/27/25). Residents Affected - Few A review of the facility ' s policy and procedure titled IV THERAPY undated indicated, .Once started, completely use all parenteral fluids within 24 hours, or discard . 555754 Page 4 of 6 555754 02/28/2025 Village Square Healthcare Center 1586 W. San Marcos Blvd San Marcos, CA 92078

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow the physician ' s order to infuse the intravenous fluid [IVF] (IV- plastic tube inserted in the vein to deliver hydration, medications or nutrition) within 20-hour time for one of 10 residents (Resident 2) receiving an IVF. As a result, Resident 2's IV fluid was consumed over 26 hours. In addition, the IV tubing was not labeled with date and time it was used. Residents Affected - Few This deficient practice had the potential for Resident 2 to experience IV related complications and infections that would impact resident's health and well-being. Findings: A review of Resident 2's admission Record indicated; Resident 2 was admitted to the facility on [DATE] with diagnoses which included history of heart failure (when the heart muscle doesn't pump blood as well as it should). A record review of Resident 2's minimum data set (MDS - a federally mandated resident assessment tool) dated 2/2/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 15 points out of 15 possible points indicated, Resident 2 did not have cognitive (pertaining to memory, judgement and reasoning ability) deficits. A review of Resident 2 ' s physician's orders dated, 2/26/25 indicated, .sodium chloride 0.9 % parenteral solution; amt: 50 ml [milliliters]/[per] hr [hour]; intravenous Special Instructions: 1 liter for HYPERKALEMIA [high potassium: a mineral that is essential to the human body] . On 2/26/25 at 2:10 P.M., a concurrent observation and interview was conducted with Resident 2, in Resident 2 ' s room. Resident 2 had an IV on his left hand with Sodium Chloride 0.9% via IVF controlled by a flow regulator. Resident 2 stated the IVF was started in the morning. Resident 2 had a remaining IVF of approximately 700 ml in the bag. The IV tubing was not labeled with date and time it was used. On 2/27/25 at 12:05 P.M., an observation was conducted on Resident 2 ' s IVF, in Resident 2 ' s room. Resident 2 ' s IVF contained approximately 300 ml of fluid remaining in the bag. On 2/28/25 at 11:11 A.M., an interview and record review was conducted with Licensed Nurse (LN) 1, in the conference room. LN 1 stated she was the IV nurse for Resident 2. LN 1 stated Resident 2 had an order for IVF dated 2/26/25 for 1 litter (1000 ml) of Sodium Chloride 0.9% at 50 ml/hr. LN 1 stated the IVF should have been infused within 20 hours. LN 1 stated that Resident 2 ' s IVF was started at 9:45 A.M. and should have been completed by 5:45 A.M. on 2/27/25 during the night shift. The IVF had been running over 26 hours. LN 1 stated Resident 2 ' s IV site and IVF should have been monitored for complications such as IV site pain, redness, inflammation (immune response to infection or irritation), third spacing caused by IV not being in the vein, or IV tubing/line blockages. LN 1 stated an IVF that has been on for too long or too slow of a flow could lead to irritation and infection on Resident 2 ' s hand and an inadequate IVF to be administered as prescribed. LN 1 further stated that Resident 2 ' s IV tubing 555754 Page 5 of 6 555754 02/28/2025 Village Square Healthcare Center 1586 W. San Marcos Blvd San Marcos, CA 92078

F 0880 should have been labeled for infection control measures. Level of Harm - Minimal harm or potential for actual harm On 2/28/25 at 11:58 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated the RNs could have identified any IVF flow issues or complications such as inadequate fluid delivery, phlebitis [inflammation of the vein, and/or infiltration [leaking from the vein in surrounding tissues] and infection. The DON stated Resident 2 ' s IV tubing should have been labeled with date and time to determine when to replace the tubing to prevent infection control issues. The DON stated Resident 2 ' s IV fluid should have been completed timely and discarded appropriately as prescribed within 20 hours (5:45 A.M. on 2/27/25) and not over 26 hours (12:05 P.M. on 2/27/25). Residents Affected - Few A review of the facility ' s policy and procedure titled IV THERAPY undated indicated, .Once started, completely use all parenteral fluids within 24 hours, or discard . 555754 Page 6 of 6