Health inspection·May 15, 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. Based on observation, interview, record review, and facility policy review, the facility failed to provide healthcare in a dignified manner when Resident #265 was left exposed during the provision of incontinence care and staff stood while they fed Resident #39. These deficient practice affected 2 (Resident #39 and Resident #265) of 2 sampled residents reviewed for dignity. Findings included: 1. An undated facility policy titled, Quality of Life - Dignity indicated, 10. Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. A Resident Face Sheet indicated the facility admitted Resident #265 on 04/22/2025. According to the Resident Face Sheet, the resident had a medical history that included a diagnosis of end stage renal disease. An admission Minimum Data Set (MDS), with an Assessment Reference Date of 04/28/2025, revealed Resident #265 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident was dependent on staff for toileting hygiene and was frequently incontinent of bowel and bladder. Resident #265's Care Plan included a problem statement initiated 04/30/2025 that indicated the resident was frequently incontinent of bowel and always incontinent of urine. Interventions directed staff to clean and dry the resident's skin after each incontinent episode (initiated 04/30/2025). During an observation on 05/14/2025 at 8:43 AM, Certified Nursing Assistant (CNA) #6 removed Resident #265 from the nurses' station and tool the resident to their room to change the resident's incontinence brief. The door to Resident #265's room was left opened and the resident was noted with their pants and incontinence brief down and their buttocks exposed to the hallway. CNA #6 then left the resident's room and returned with two clean incontinence briefs in his hand. During an interview on 05/14/2025 at 9:02 AM, CNA #6 stated he was trained to provide privacy and dignity during the provision of resident care, to include the pulling of the privacy curtain and the closure of the resident's room door. CNA #6 stated he realized that he left Resident #265's room door opened and the privacy curtain was not pulled around the resident's bed. According to CNA #6, he left Resident #265s's room to go and use the restroom and retrieve supplies. CNA #6 stated he should have pulled the resident's privacy curtain around the resident's bed and closed the room door. CNA #6 stated he knew what he needed to do but was rushing. Page 1 of 7 555754 555754 05/15/2025 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 During an interview on 05/14/2025 at 9:04 AM, Resident #265 stated CNA #6 told them he was going to change their incontinence brief. Resident #265 stated they turned to their right and held onto the siderail, then CNA #6 left them for more than five minutes, while they had their pants down. Resident #265 stated they did not like that and that CNA #6 should have pulled their privacy curtain around their bed or closed their room door so that people who walked by could not see them with their pants down. Residents Affected - Few During an interview on 05/14/2025 at 9:10 AM, the Director of Staff Development stated if a staff member was providing care to a resident and had to leave, the resident should be left in a dignified manner and have their privacy curtain pulled around the resident's bed, the resident room door closed, and some type of covering placed over the resident. During an interview on 05/14/2025 at 11:22 AM, Licensed Vocational Nurse #2 stated if a staff member had to leave a resident in bed to get supplies, the staff member should leave the resident in a low bed, with their call light within reach, and the resident should be covered to promote dignity. During an interview on 05/15/2025 at 9:43 AM, the Director of Nursing stated a resident should never be left in a bed exposed with their privacy curtain not pulled and their room door opened. During an interview on 05/15/2025 at 9:46 AM, the Administrator stated a resident's privacy curtain should have been pulled around the resident's bed and their door closed to provide dignity to the resident. The Administrator stated he expected staff to provide proper healthcare in a dignified manner. 2. An undated facility policy titled, Assisting the Resident to Eat indicated, 11. Assist the resident as necessary. If the resident needs to be fed: a. Sit at eye level in front of the resident. A Resident Face Sheet indicated the facility admitted Resident #39 on 09/09/2016. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side and dementia. Resident #39's Care Plan included a problem stated initiated 07/20/2017, that indicated the resident had impaired communication. Interventions directed staff to position themselves where the resident could visualize their face (initiated 07/20/2017). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 04/13/2025, revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 2, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was dependent on staff for eating. During an observation on 05/14/2025 at 8:18 AM, Certified Nursing Assistant (CNA) #7 stood to the right of Resident #39 while she fed the resident, who was in bed, breakfast. CNA #7 was noted to bend to offer the resident food and/or drink and Resident #39 had to turn their head to receive the food and/or drink from CNA #7. During an interview on 05/14/2025 at 8:28 AM, CNA #7 stated she was trained to sit next to the resident to feed them. CNA #7 confirmed she did not sit when she fed Resident #39 because there was not chair in the resident's room. During an interview on 05/14/2025 at 8:39 AM, Licensed Vocational Nurse (LVN) #1 stated Resident 555754 Page 2 of 7 555754 05/15/2025 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 #39 had to be fed by the staff. According to LVN #1, staff should be seated when they fed the resident for the resident's dignity and positioning. LVN #1 stated she observed Resident #39 being fed at an angle while CNA #7 stood, but noted she did not correct the staff's position. LVN #1 stated if there was not a chair in the resident's room, CNA #7 should have asked for one. During an interview on 05/14/2025 at 9:10 AM, the Director of Staff Development stated staff should be seated when they feed a resident who is in bed to provide dignity in the dining experience. During an interview on 05/15/2025 at 9:43 AM, the Director of Nursing (DON) stated staff should not stand over a resident to assist with dining but sit next to the resident at eye level to make the resident feel comfortable. The DON stated it was very intimidating to a resident to have someone stand over them and that it was not a dignified dining experience. The DON said it was a dignified dining experience when staff were seated so that the resident did not feel rushed. The DON stated that if a staff member did not have a chair, they should get a chair or a stool and be seated. During an interview on 05/15/2025 at 9:46 AM, the Administrator stated he expected staff to feed residents at eye level to provide proper healthcare assistance in a dignified manner. 555754 Page 3 of 7 555754 05/15/2025 Village Square Healthcare Center 1586 W. San Marcos Blvd San Marcos, CA 92078

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, record review, and facility policy review, the facility failed to assess a resident for their ability to self-administer their medication for 1 (Resident #171) of 25 sampled residents. Residents Affected - Few Findings included: An undated facility policy titled, Self-Administration of Medications indicated, 2. If a resident desires to participate in self-administration, the interdisciplinary team will assess the ability of the resident to participate, by completing a Resident Self Administration of Medication assessment. A Resident Face Sheet revealed the facility admitted Resident #171 on 02/22/2025. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease (COPD) and pneumonia. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/09/2025, revealed Resident #171 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #171's Physician Order Report for the timeframe 05/01/2025 - 05/31/2025, revealed an order dated 03/05/2025, for budesonide suspension 0.5 milligram per 2 milliliter (ml), inhale 2 ml once a day for COPD. The Physician Order Report did not specify the resident was able to self-administer their budesonide inhaler. During a concurrent observation and interview on 05/13/2025 at 9:48 AM, the surveyor noted an inhaler on Resident #171's bedside table. Resident #171 stated the inhaler was for their COPD and emphysema. Per Resident #171, yes they know I have it. Resident #171 stated they used the inhaler whenever they needed it. During an interview on 05/14/2025 at 1:28 PM, Certified Nursing Assistant #8 confirmed Resident #171 kept their inhaler at their bedside and she saw the resident self-administer the inhaler. During an interview on 05/14/2025 at 2:00 PM, Licensed Vocational Nurse (LVN) #10 stated there was a form that had to be completed and approved by a doctor before a resident was allowed to self-administer their medication. LVN #10 stated if Resident #171 wanted their inhaler, they were supposed to call the nurse so that the nurse would administer the medication. Per LVN #10, she had never seen Resident #171 with an inhaler. During an interview on 05/15/2025 at 8:44 AM, Registered Nurse (RN) #9 stated a resident would need to have an assessment, along with a physician's order before they were allowed to self-administer or keep any of their medication. RN #9 stated she was not familiar with Resident #171 but if the resident did not have an order or an assessment, the resident should not have an inhaler in their possession. During an interview on 05/15/2025 at 9:16 AM, the Director of Nursing (DON) confirmed the albuterol inhaler was removed from Resident #171's possession and stated the facility would provide an all hands education regarding self-administration of medications. The DON stated it was her expectation that prior to self-administration, residents were assessed and a physician order was obtained. 555754 Page 4 of 7 555754 05/15/2025 Village Square Healthcare Center 1586 W. San Marcos Blvd San Marcos, CA 92078

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 facility policy review, the facility failed to ensure dietary staff covered their facial hair during meal preparation, cold food items were held on the tray line at temperature of 41 degrees Fahrenheit (F) or below, expired food items were discarded, and items in the walk-in freezer were stored in a manner to prevent freezer burn. These deficient practices had the potential to affect all residents who received food from the kitchen. Findings included: 1. A facility policy titled, Personal Hygiene dated 2018, indicated, 6. Beards and or mustaches should be covered during meal preparation and service. During an observation on 05/12/2025 at 8:55 AM, [NAME] #3 prepared fish with his facial hair uncovered. During an observation on 05/12/2025 from 11:38 AM until 11:46 AM, [NAME] #3 took the temperature of the food on the lunch tray line and plated food while their facial hair was not covered. During an observation on 05/13/2025 at 11:50 AM, [NAME] #3 served hot lunch food items and his facial hair was not covered During a concurrent observation and interview on 05/13/2025 at 2:05 PM, [NAME] #4 placed dinner rolls on a sheet pan and his facial hair was uncovered. [NAME] #4 stated he was trained to cover his facial hair but forgot to put on a face cover on. During an interview on 05/13/2025 at 2:07 PM, the Dietary Director (DD) stated staff with facial hair should wear a face cover to protect their hair from getting in the food. The DD stated she expected staff with facial hair to wear a face cover or be clean shaven. During an interview on 05/14/2025 at 11:13 AM, the Registered Dietitian stated she expected all staff with facial hair to wear a face cover, either a beard guard or a surgical mask, or be clean shaven, especially the cooks. During an interview on 05/15/2025 at 9:00 AM, [NAME] #3 stated he was never told to wear a cover for his facial hair. During an interview on 05/15/2025 at 9:43 AM, the Director of Nursing stated she expected dietary staff with facial hair to wear a face cover or to shave. During an interview on 05/15/2025 at 9:46 AM, the Administrator stated he expected staff with visible facial hair to wear a face cover like a beard guard or a surgical mask. 2. The 2022 Food Code published by the United States Food and Drug Administration, indicated, 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding, (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under [paragraph mark] (B) and in [paragraph mark] (C) of this section, Time/Temperature Control For Safety Food shall be maintained: (1) At 57 [degrees] C [Celsius] (135 555754 Page 5 of 7 555754 05/15/2025 Village Square Healthcare Center 1586 W. San Marcos Blvd San Marcos, CA 92078

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many [degrees] F [Fahrenheit] of above, expect roasts cooked to a temperature and for a time specified in [paragraph mark] 3-403.11(E) may be held at a temperature of 54 [degrees] C (130 [degrees] F) or above; or (2) At 5 [degrees] C (41 [degrees] F) of less. During a concurrent interview and observation of the lunch tray line on 05/13/2025 at 11:45 AM, [NAME] #3, in the presence of the Dietary Director (DD), took the food temperature of the tossed salad that contained lettuce and tomato and the temperature was 55 degrees F. At 11:46 AM, [NAME] #3 took the temperature of the peach yogurt and stated the temperature was 55 degrees F. Once the temperatures were taken, Dietary Aide (DA) #11 informed the Staffing Coordinator (SC) that the cart is ready. The surveyor asked that the temperature of the peach yogurt be taken again and the DD obtained the temperature and stated it was 51.7 degrees F, but it should be 41 degrees F or below. The DD stated she did not have an answer for that when asked why she did not intervene when it was brought to her attention that the food items were above 41 degrees F. During an interview on 05/13/2025 at 12:10 PM, [NAME] #3 stated he was trained that cold foods should leave the kitchen at 41 degrees F or below. When asked why he did not intervene when he obtained food temperatures that were above 41 degrees F, [NAME] #3 stated he did not have a reason. During an interview on 05/13/2025 at 2:07 PM, the DD stated if staff identified cold food items whose temperature was too high, the staff should get rid of the food item. During an interview on 05/13/2025 at 2:20 PM, the SC stated she did not see the cold food temperature monitoring. Per the SC, she expected staff to replace a food item if the temperature was too high with a new food item that had a temperature of 41 degrees F or below. During an interview on 05/14/2025 at 11:13 AM, the Registered Dietician stated she expected the dietary staff to keep cold food items at 41 degrees F or below on the tray line. During an interview on 05/15/2025 at 9:43 AM, the Director of Nursing stated she expected the dietary staff to follow the protocol for what is an appropriate cold/warm temperature for a food item to be served at. During an interview on 05/15/2025 at 9:46 AM, the Administrator stated he expected cold food items to leave the kitchen at a temperature of 41 degrees F or below. 3. During an observation on 05/12/2025 at 9:18 AM, there were nine pre-boiled eggs in the refrigerator in a plastic bag with a use-by-date of 05/11/2025. During an interview on 05/13/2025 at 2:41 PM, the Dietary Director stated staff were expected to monitor cold storage for expired items, and she monitored cold/frozen storage most every day. The DD stated that she checked cold/frozen storage for expired foods when she completed her food order and when foods were put away after delivery. During an interview on 05/15/2025 at 9:43 AM, the Director of Nursing stated she expected food stored in the refrigerator and freezer to be removed when expired. During an interview on 05/15/2025 at 9:46 AM, the Administrator stated he expected food stored in the refrigerator and freezer to be removed when expired. 555754 Page 6 of 7 555754 05/15/2025 Village Square Healthcare Center 1586 W. San Marcos Blvd San Marcos, CA 92078

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 4. A facility policy titled, Freezer Storage dated 2018, indicated, 5. All foods should be stored in an airtight moisture-resistant wrapper such as a plastic bag or freezer paper to prevent freezer burn. During a concurrent interview and observation of the walk-in-freezer on05/12/2025 at 9:25 AM, there was a 30-pound box of corn kernels in a plastic bag that was loosely rolled down and opened to air. The Dietary Director (DD) stated the bag and box of corn kernels should both have been sealed tightly so that the food was not left opened to air. Also noted in the walk-in freezer was a case of chick breasts stored in a plastic bag that was opened to air. The DD stated staff removed a few items from the box and did not close the bag back. The DD stated that the bag and box of chicken should both have been sealed tightly so that the food was not left opened to air. During an interview on 05/13/2025 at 2:41 PM, the DD stated staff should put items in a storage bag, wrap them in plastic wrap, or place them in a storage container that should be sealed. During an interview on 05/15/2025 at 9:43 AM, the Director of Nursing stated she expected food stored in the refrigerator and freezer to be stored covered. During an interview on 05/15/2025 at 9:46 AM, the Administrator stated he expected food stored in the refrigerator and freezer to be stored covered. 555754 Page 7 of 7