Health inspection·August 24, 2023

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 45 was re-admitted to the facility on [DATE] with diagnoses which included polyneuropathy (malfunctioning of several nerves in the body which could cause numbness, weakness and pain) per the facility's admission Record. Residents Affected - Few A review of Resident 45's records was conducted. A Weekly Pressure Injury Evaluation, dated 7/18/23, indicated Resident 45 acquired a pressure injury (breakdown of skin integrity due to pressure) on the left heel. A Weekly Pressure Injury Evaluation, dated 7/25/23, indicated Resident 45 acquired a pressure injury on the right heel on 7/18/23. A Weekly Pressure Injury Evaluation, dated 7/26/23, indicated Resident 45 acquired a pressure injury on the medial upper right buttock. A Nutritional Evaluation for a Significant Change of Condition was conducted by the Registered Dietitian (RD) on 8/18/23. On 8/24/23 at 9:31 A.M., an interview with LN 5 was conducted. LN 5 stated a newly acquired pressure injury was considered a change of condition. LN 5 stated the RD should have done an assessment definitely not a month after it was acquired. On 8/24/23 at 10:44 A.M., an interview with the DON was conducted. The DON stated when a resident developed new pressure ulcers, the RD had to assess within the week they were acquired. On 8/24/23 at 3:06 P.M., an interview with the RD was conducted. The RD stated the resident needed to be assessed within the week of a change of condition which included new pressure ulcers. Per the facility's policy and procedure titled, Nutritional Intervention for Pressure Injuries dated 12/13/16, .Procedures: 4 .There is an expectation that recognized .nutrition recommendation will be given to individuals at risk for pressure injuries which should be taken into consideration in assessment and developing the care plan . Based on interview and record review, the facility failed to ensure care/treatment was provided according to professional standards of practice for two of 15 sampled residents (Resident 3 and 45) when: 1. Licensed nurses (LN) did not respond to Resident 3's low blood glucose reading (a value less than 70 mg/dl [milligrams/deciliter]) by assessing the resident for signs and symptoms of hypoglycemia (low blood glucose/sugar) and notifying the resident's physician. In addition, LN did not clarify Resident 3's physician order related to a low blood glucose parameter. Page 1 of 21 555806 555806 08/24/2023 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0658 2. A response to a change of condition related to nutritional assessment was not conducted in a timely manner. Level of Harm - Minimal harm or potential for actual harm As a result, there was the potential risk to the residents' health and well-being. Residents Affected - Few Findings: 1. A review of Resident 3's admission Record indicated the resident was readmitted on [DATE] with diagnoses to include diabetes mellitus (the body's inability to regulate blood sugar) and dementia (a condition characterized by impairment of at least two brain functions, such as memory loss and judgment). A review of Resident 3's medication administration record for August 2023, indicated the resident had the following blood glucose readings: 65 mg/dl on 8/6, 67 mg/dl on 8/16, 58 mg/dl on 8/19, and 53 mg/dl on 8/22. A review of Resident 3's physician order for injectable insulin (hormone used to regulate blood glucose) dated 2/9/23, did not have a parameter for addressing a low blood glucose reading. On 8/23/23 at 2:51 P.M., a joint interview and record review was conducted with LN 1. LN 1 stated it was a professional standard of nursing practice to assess a resident for signs and symptoms of hypoglycemia (such a sweating or loss of consciousness) when a blood glucose reading was less than 70 mg/dl. LN 1 reviewed Resident 3's clinical record and stated the resident's blood glucose readings on 8/6, 8/16, 8/19, and 8/22 were lower than 70 mg/dl and the resident should have been assessed by the registered nurse. LN 1 stated there was no documentation that an assessment for hypoglycemia had been done on those dates. LN 1 further stated for blood glucose levels to be 53 and 58 mg/dl that It's pretty low. LN 1 stated the standard of practice was to notify the resident's physician when a blood glucose reading was less than 70 mg/dl. LN 1 stated there was no documentation Resident 3's low blood glucose readings had been reported to the resident's physician. LN 1 stated since Resident 3's insulin order did not have a parameter for low blood glucose, the physician should have been called for clarification of the order. LN 1 stated low blood glucose levels were dangerous with a possibility of the resident losing consciousness and slipping into a diabetic coma (unable to wake). On 8/23/23 at 3:05 P.M., a joint interview and record review was conducted with the director of nursing (DON). The DON stated it was a professional standard of nursing practice to assess a resident having a blood glucose reading less than 70 mg/dl in order to check for signs and symptoms of hypoglycemia. The DON stated it was her expectation that the LN assessment be documented, and the physician notified when a resident's blood glucose reading was less than 70 mg/dl. The DON reviewed Resident 3's clinical record and stated this should have been done when the resident's blood glucose readings were less than 70 mg/dl. The DON stated Resident 3's insulin order should have been clarified to provide a parameter for a low blood glucose reading. The DON further stated the facility did not have a policy or procedure to guide diabetes and insulin management. The DON stated she expected the standard of practice to be followed. According to the American Nurses Association (professional organization for nursing standards) and the American Nurses Credentialing Center, undated, at https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process, the first step in the nursing process is assessment. According to Lippincott Nursing Center (professional guidance and procedures for nursing practice), 555806 Page 2 of 21 555806 08/24/2023 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Managing Acute Diabetic Complications dated November 2022, .The blood glucose level that defines hypoglycemia varies in each patient, a less than 70 mg/dl . is considered hypoglycemia in patients with diabetes .Hypoglycemic management protocol . A standardized nurse-initiated hypoglycemic treatment protocol to immediately address blood glucose levels less than 70 mg/dl . Reassessment of the insulin treatment plan if blood glucose drops below 70 mg/dl .Tracking and documentation of each episode in the medical record . 555806 Page 3 of 21 555806 08/24/2023 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure the nutritional status was monitored and acceptable parameters were maintained for one of one resident, (Resident 23), with unintended, unplanned severe weight loss of 16.43% in six months (9/4/22-2/4/23) when: Residents Affected - Few 1) The resident's nutritional status was not reassessed, the laboratory values were not drawn, or the interventions were modified after five, ten, or fifteen percent of weight loss occurred, according to facility policy and standards of practice. 2) The resident was not placed on weekly weights from 9/1/2022-3/31/2023 to monitor weight status after a loss of five or ten percent of body weight, according to policy. 3) The resident's meals and snack/nourishment consumption were not monitored to determine the resident's actual food intake in order to evaluate nutrition status, according to facility policy. These failures had the potential to result in Resident 23 experiencing further functional decline, loss of lean body mass (the body weight that includes muscles, bones, and organs and excludes fat) and reduce the risk of developing chronic conditions such as diabetes (inability to manage blood sugar) and heart disease. The facility census was 57. Findings: According to the Academy of Nutrition & Dietetics, Nutrition Care Manual, dated 2022, Treatment of unintended weight loss is imperative to ensure optimal outcomes for the older adult. Unintended weight loss is linked to increased mortality (death) among older adults . residents in long-term-care facilities who continue losing weight have a higher mortality rate compared with those who stop losing weight. Weight loss of 5% or more within 30 days is associated with a tenfold increase in the likelihood of death. Unintended weight loss often results in protein-energy undernutrition (low protein or calorie intake resulting in insufficient nutrient absorption), as the older adult loses critical lean body mass and is more prone to pressure ulcers (injuries to the skin and underlying tissue due to consistent pressure), infections (when a virus or bacteria enters the body and causes harm), immune dysfunction (when the body's system does not fight off infections or illness), anemia (low levels of oxygen in the blood), falls resulting in hip fractures (breaks or tears), and other conditions. Per the facility's admission Record, dated 8/23/23, Resident 23 was admitted on [DATE] with diagnoses of hypertension (high blood pressure), depressive disorder (condition of sadness), and hyperlipidemia (high concentration of fat content in the blood). During an observation and interview on 8/21/23, at 11:12 A.M., Resident 23 was sitting in his room in a wheelchair. The resident looked physically thin. Resident 23 stated he has lost at least 40 pounds since he has been at the facility and thinks he needs a special diet but stated they won't 555806 Page 4 of 21 555806 08/24/2023 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0692 listen to me. Level of Harm - Actual harm During an observation and interview on 8/21/23, at 12:23 P.M., of the lunch meal service in the dining room, Resident 23 was sitting in the dining room and received an entrée of two Harissa marinated chicken breasts fillets chopped, 2 slices of Boston cream pie, a 4-ounce cup of cranberry juice, and a 4-ounce cup of milk. Resident 23 stated he did not like the lunch meal and gave it a thumbs down. Resident 23 consumed ½ of his soup, ¾ of his chopped grilled chicken breast, and 2 slices of dessert pie. Resident 23 drank ¼ cup of milk and ½ cup of cranberry juice. Resident 23 gave the dessert a thumbs up and stated, it tasted good. Residents Affected - Few During a review of Resident 23's physician's ordered diet, dated 1/14/23, the diet order indicated Regular diet, Regular texture, mildly thick liquids. On 1/21/23, the diet order was updated to include Health shakes three times a day with meals. During a review of Resident 23's Weights and Vitals Summary, dated 8/22/23, the weight report indicated the following weights: 8/6/22- 152.6 pounds 9/4/22- 152.2 pounds* 10/1/22- 152.8 pounds 11/6/22- 149 pounds 12/3/22- 146 pounds 12/31/22- 137.6 pounds 1/8/23 - 137.4 pounds 2/4/23- 127.4 pounds* 3/4/23 - 130.3 pounds 4/1/23 - 131 pounds 5/6/23 - 130.7 pounds 6/3/23 - 130.2 pounds 7/1/23 - 126 pounds 8/5/23 - 126.3 pounds During a review of Resident 23's Physician's Progress Notes dated 6/3/23, the progress note indicated, Resident 23 .Diagnosis .poor fluid intake, Unexplained weight loss .5. Cognitive (related to thinking and reasoning) status .appears to have capacity to make his own medical and financial decisions. 555806 Page 5 of 21 555806 08/24/2023 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0692 Level of Harm - Actual harm Residents Affected - Few During a review of Resident 23's Minimum Data Set (MDS- a federally mandated clinical assessment of all residents in Medicare or Medicaid insurance program), section C- Cognitive Patterns, dated June 5, 2023, the MDS indicated, Resident 23 had a BIMS (Brief Interview of Mental Status) score of 15, which is the highest total possible score (00-15), and indicated the resident had a high mental capacity, as well as able to make medical decisions. During a review of Resident 23's Lab Results Report, dated 1/4/23, the basic metabolic panel (blood sample test of eight chemicals that break down food into nutrients for energy) results indicated the following lab values: *Hemoglobin (hgb)- 12.4 g/dL (grams per deciliter) (low); (normal range= 13 g/dL - 17.7 g/dL) *Neutrophils - 8.8 (high); (normal= 1.4- 7.0) A low hemoglobin (red blood cells containing iron that transport oxygen) value and high value for neutrophils (white blood cells). Low hemoglobin values may indicate the body is unable to receive enough oxygen, and high levels of neutrophils may indicate the body is under stress, and unable to effectively fight against infections. A pre-albumin (protein made in the liver and helps control how the body uses energy and is a sign of malnutrition) or albumin (measure of protein in the blood and indication of liver and kidney function) lab test was not ordered for Resident 23 when the resident experienced a five or ten percent significant weight loss, which occurred from 9/4/2022 - 2/4/23; or through 8/23/23 according to standards of practice. During an interview on 8/23/23 at 3:40 P.M., with resident 23's physician (PHYS), the PHYS stated Resident 23 had been on the Remeron mirtazapine (a drug to manage unhappy mood) since August 2022. The PHYS also stated monitoring pertinent labs such as prealbumin and albumin were important to monitor a person's nutrition status, especially someone with significant weight loss. PHYS acknowledged Resident 23 did not have an albumin or prealbumin lab test and stated it would have been important for monitoring nutrition status, that may have likely prevented further weight loss. During a review of Resident 23's Nutritional Screening and Assessment, dated 6/3/22, completed by the facility's Registered Dietitian (RD) indicated that the resident's target weight goal range was 150 - 165 pounds. The estimated daily nutritional requirements indicated the calories 1886 - 2264/day, protein 76-91/day and fluid 1886 ml/day (milliliters - one thousandth of a liter per day). During a review of Resident 23's Nutritional Risk Review dated completed 12/1/22 by the facility's Registered Dietitian (RD) indicated that the resident target weight goal range was 150 - 165 pounds and No significant weight change in 3 months. During a review of Resident 23's Nutritional Risk Review dated 3/2/23 completed by the facility's Registered Dietitian (RD) indicated that the resident's target weight goal range was 150 - 165 pounds. Significant weight change, negative -9.7 pounds/7% in 1 month and negative -21 pounds/14% in 3 months. Continue present regimen, health shakes TID (three times a day). During an interview on 8/23/23 at 10:25 A.M., with the Registered Dietitian (RD), the RD stated residents are placed on weekly weights and discussed at interdisciplinary meetings to provide interventions. The RD stated Resident 23 should have been on weekly weights when the significant weight loss 555806 Page 6 of 21 555806 08/24/2023 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0692 Level of Harm - Actual harm Residents Affected - Few was identified early at five or ten percent weight loss. The RD stated, although the resident received health shakes three times a day with meals, his food preferences were not received or documented by the food and nutrition department staff, which may have led to modifying his weight loss interventions. The RD also stated weight loss interventions such as fortified foods (the addition of calories and protein rich foods such as butter, milk, and other foods at meals), larger food portions, and additional foods and snacks offered at meals may have helped prevent further weight loss, once it was identified. The RD further stated earlier interventions may have possibly prevented the significant/severe weight loss because any gaps between intake and assessment to help minimize or prevent any unplanned weight loss. During an interview on 08/24/23 with Certified Nurse Assistant (CNA 1) at 10:55 A.M., the CNA 1 stated Resident 23 usually drank half of his health shakes, but she did not have a way to enter the morning and lunch snacks or health shake consumption into the computer system. CNA 1 stated she was unaware of how Resident 23's snacks/nourishments intake was fully assessed. During a record review of Resident 23's Activities of Daily Living (ADL) Eating report dated 6/29/23-8/22/23, the ADL intake Eating report indicated Resident 23 ate 50-75% of his meals. During a record review of the Nutrition-HS (hour of sleep) Snack report, dated 6/1/23-8/22/23, the intake HS Snack report indicated Resident 23 accepted the snack but consumed 50-75% of the snack five times. During a review of the facility's policy and procedure (P&P) titled, Weight Loss/Gain- A Change in Condition, dated 11/2010, the P&P indicated, Significant unplanned weight loss .is considered a change in condition when the intervention is tried and fails .5. Those residents who continue to have unplanned significant weight loss for 2 weeks are considered to have a change in condition .6. A change in condition precipitates a new MDS and a change in condition Nutritional Risk Review by the Dietary Manager or .Registered Dietitian. 7. Continue every nutritional intervention possible and continue weekly weights until the weight loss stabilizes over a 30-day period . During a review of the facility's policy and procedure (P&P) titled, Weight Management Guidelines, dated 2016, the P&P indicated, .Residents with significant weight variance should be identified and appropriate interventions implemented .8. Nursing should notify the physician and family of significant or severe weight loss .9. All .unplanned, and unavoidable weight loss should be care planned and have nutritional goals and approaches. The Dietitian, resident, and family must approve the weight loss .14. Follow best practice guidelines for interventions. Obtain resident preferences regarding interventions and individualize. Try food first 16.Closely follow the resident's .labs, skin, and other factors . During a review of the facility's policy and procedure (P&P) titled, Special Nutrition Program, dated 2018, the P&P indicated, .The Special Nutrition Program (SNP) is a fortified program that should provide for the increased nutritional requirements of residents who are underweight .experiencing significant weight loss, have poor intake and/or have low albumin .SNP breakfast, noon meal, evening meal .Approx. 880 to 1000 calories and 23 to 34 grams (unit measurement of mass) of protein .4.offer the resident one to two additional fortified foods per day per resident needs and preferences .each fortified food should furnish 200 calories or more and 6 grams of protein . During a review of the facility's policy and procedure (P&P) titled Criteria for Intervention with Abnormal Labs, dated 2017, the P&P indicated .they should be put on nutrition intervention list for 555806 Page 7 of 21 555806 08/24/2023 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0692 Level of Harm - Actual harm the Dietitian for intervention and documentation .a. Hgb less than 12 g/dl (grams per deciliter) .d. Albumin less than 3.5 g/dl or as indicated as low based on the lab used or prealbumin less than 15 .a. Labs which can be indicators for dehydration are increased .Albumin . Residents Affected - Few 555806 Page 8 of 21 555806 08/24/2023 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review, the facility failed to ensure that one of eight sampled residents (Resident 361) reviewed for medication administration, received the medication in accordance with the physician's orders. This failure had the potential for the for Resident 361 to experience unexpected medication side effects or decreased drug action. Findings: During an observation on 8/23/23 at 9:38 A.M., licensed nurse (LN) 2 gave Resident 361 Aspirin 81 (milligram) mg chewable using a plastic spoon. Resident 361 swallowed the medication and did not chew the chewable Aspirin. LN 2 did not provide instructions to Resident 361 and the resident did not chew the Aspirin before swallowing. An interview on 8/23/23 at 9:42 A.M., with LN 2 was conducted. LN 2 stated that Resident 361 should have been instructed that the Aspirin was chewable and needed to be chewed first before swallowing to help with absorption. A review of Resident 361's physician's order on 8/23/2023 indicated an order for Aspirin chewable 81 milligram 1 tablet daily. During an interview on 8/25/2023 at 2:00 P.M., with the Director of nursing (DON), the DON stated that the licensed nurse should have followed the Physician's order and provide instructions to Resident 361 before the resident took the medication. A record review of the facility's Policy and procedure titled, Medication Administration, dated 11/2027, indicated . I. transcribing of medication orders, medical records and medication administration, #4 Nursing must read and compare POS and MAR being given and charted each time medication are administered. #5 If directions on medication do not exactly match order on MAR, must clarify orders, and direction change sticker and notify pharmacy of changes . 555806 Page 9 of 21 555806 08/24/2023 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on observations, interview and record review, the facility failed to ensure overall systems were met for the Food and Nutrition Services in the kitchen when: a resident experienced an unplanned insidious severe weight loss of 16% in a six months; residents' food temperatures were not monitored for safety and palatability; kitchen staff did not perform tasks competently for food safety in food preparation, food storage, and sanitation for dishwashing and dish storage; kitchen staff did not monitor the temperatures in the dry storage room and emergency food supply room closet to ensure safe quality of the food supply; recipes were not followed for time and temperature control for food safety foods (TCS); and fruit fly pests were found in the kitchen. These failures placed all residents at risk for harm and exposure to contamination that had the potential to impair their nutrition and health status. The facility census was 57. Cross reference F692, F802, F803, F804, F812, F925 Findings: During the initial kitchen tour on 8/21/23 at 8:14 A.M., multiple observations and concurrent staff interviews were conducted in the kitchen for food safety, sanitation, cleanliness, and nutrition care, and food services delivery to residents. There were several deficient practices identified including a severe unplanned weight loss resident (Resident 23), menu and recipe compliance, dirty floors in the walk-in refrigerators and freezers, food debris on utensils, unchecked dish machine sanitation logs, unlabeled/misdated/expired foods in the refrigerators, and fruit fly pests in the dry storage and food preparation areas. During an interview on 8/23/23 at 12:16 P.M., with the Director of Food and Nutrition Services (DFS) and Registered Dietitian (RD), both the DFS and RD acknowledged the poor overall kitchen cleanliness, menu compliance, food safety and sanitation practices, and pest control practices, and stated the kitchen should be free of bugs and pests and kitchen staff need to keep the kitchen clean to avoid pests. The DFS stated the kitchen staff should have cleaned their areas and performed their job tasks correctly because they had received in-services this year. The DFS stated the Dietary Hitlist completed daily by the Lead [NAME] (LCK), identified the areas in the kitchen such as labeling and dating of refrigerated foods and dish machine logs incorrectly completed during July-August 2023. The DFS stated the staff know what they need to clean and how to follow menus and recipes but they may need to be reminded. The RD stated she worked an average of 16 hours a week in the facility. The RD further acknowledged there may have been alternative efforts to implement for the resident with severe unplanned weight loss, Resident 23, such as taking his food preferences within a couple of months of admission, and modifying the nutrition regimen within a few months when the significant weight loss was identified. The DFS and RD each stated they expect the food and nutrition services operations be carried out safely and effectively for the nursing home residents. According to the 2022 Federal FDA Food Code, section 2-103.11, titled Person in Charge, .(Q) Written procedures and plans, where specified by this Code and as developed by the Food Establishment .are maintained and implemented as required. During a review of the facility job description titled Food and Nutrition Services Director, dated April 2021, the job description indicated, .The Food and Nutritions Services Director is primarily 555806 Page 10 of 21 555806 08/24/2023 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many responsible for providing effective food and nutrition services in the skilled nursing facility .Assures efficiency of food serving; compliance with local, state, and federal standards; sanitation, and hygiene . During a review of the facility job description titled Dietitian, dated April 2014, the job description indicated, .7. Through observation and evaluation, promote food production and services procedures that conserve nutritive value, flavor, appearance, quality, and are attractively served at the proper temperature . 555806 Page 11 of 21 555806 08/24/2023 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0802 Level of Harm - Minimal harm or potential for actual harm Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observations, interview and record review, the facility failed to ensure kitchen staff competently carried out the functions of the food and nutrition services department when: Residents Affected - Many 1. A Kitchen staff did not correctly label and date TCS (Time/Temperature Controlled for food safety) foods in a walk-in refrigerator and did not monitor the dry storage room by correctly labeling, dating, and checking the quality of the food supply. 2. A Lead [NAME] (LCK) did not prepare the tuna salad correctly using the cool down process for ambient temperature foods. 3. A Dishwasher did not enter the dish machine wash and rinse temperatures on a log in a timely manner. These failures placed all residents at risk of cross contamination and the potential to acquire food-borne illnesses. The census was 57. Cross reference F800, F804, F812 Findings: 1. During the initial kitchen tour on 8/21/23 at 8:25 A.M., an observation of the walk-in refrigerator and interview with the Executive Chef (EXC) was conducted. There was a metal tray of soup ingredients on the first two shelves that included sliced tomatoes, sliced white onions and sliced green bell peppers. These were not labeled or dated. There was a large black plastic bin with spoiled green bell peppers and a large bin with red bell peppers. Each bin had three bell peppers with black and gray mold spots on them, and they were dated 8/18/23. Additionally, there was a case of asparagus uncovered, dated 8/19/23. The EXC stated the case of asparagus should had been covered with plastic wrap, and the molded bell peppers should have been thrown out. The EXC further stated, the kitchen staff member pours the new produce on top of the existing food items when they receive deliveries but they should have checked them first to prevent them from developing mold. During an interview on 8/21/23 at 8:45 A.M., with LCK, LCK stated these tray of soup ingredients should have been dated and labeled to prevent being used past the expiration date. During the initial kitchen tour on 8/21/23 at 9:05 A.M., an observation of the kitchen's dry storage room was conducted. There was a medium sized clear plastic uncovered container with a white sugar label on it and no date. There was also a metal canister with vinegar, without a date and clear plastic wrap stuffed in the opening. 555806 Page 12 of 21 555806 08/24/2023 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview on 8/23/23 at 12:08 P.M., with the DFS, the DFS stated the expectation is for the kitchen staff to complete all labeling and dating of foods by the end of the day. According to the 2017 Federal FDA Food Code, Section 3-602.11 Food Labels.(A) Food packaged .shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling .and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement .and date. During a review of the facility's policy and procedure (P&P) titled Labeling and Dating for Safe Storage of Food, dated 3/6/2020, The P and P indicated, . labeling and dating are critical in order to promote food safety .all products should be dated upon receipt . During a review of the facility's policy and procedure (P & P) titled Food Storage, dated 1/12/16, the P & P indicated, .1. Fresh vegetables should be checked and sorted for ripeness .4. Fresh vegetables .should be left in cartons .paper wrapping . it retards spoilage and loss of moisture .5. Rotate so that oldest produce is used first 2. During the initial kitchen tour on 8/21/23 at 9:45 A.M., an observation of kitchen was conducted. LCK was observed preparing tuna salad for the residents. During an interview on 8/21/23 at 9:46 A.M., with LCK, LCK stated he made the tuna salad this morning. LCK stated he made the tuna salad using a large can of tuna from the dry storage, chopped celery, mayonnaise and relish from the refrigerator. LCK stated he and did not do the cool down process for the tuna, because it came from a can. During an interview on 8/23/23 at 12:16 P.M., with the Director of Food and Nutrition Services (DFS) and Registered Dietitian (RD), the RD stated the tuna salad should have been prepared using food safe practices by following the recipe to chill the tuna down to 41 degrees before serving it. During a review of the facility's policy and procedure ( P&P) titled, Standardized Recipes, dated 12/2013, indicated standardized recipes will be used for all products .7. HACCP (Hazard Analysis Critical Control Points) controls are also noted on recipes .Albacore Tuna salad Sandwich . 2. Combine tuna, mayonnaise, celery and relish: chill under refrigeration (41 degrees F) . According to the Federal Food and Drug Administration (FDA) Food Code 2022, Section 3-501.14, titled Cooling, .(B) Time/temperature control for safety food shall be cooled within 4 hours to 41 degrees F or less if prepared from ingredients at ambient temperature such as reconstituted foods and canned tuna. According to the Federal Food and Drug Administration (FDA) Food Code 2022, chapter 3 Annex section 3-501.16, Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature Danger Zone of 41 degrees F to 135 degrees F for too long. 3. During the initial kitchen tour on 8/21/23 at 8:40 A.M., an observation of the kitchen dishwashing area was conducted. The Dishwashing temperature log was already filled up for Breakfast and Lunch time. 555806 Page 13 of 21 555806 08/24/2023 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0802 Level of Harm - Minimal harm or potential for actual harm During an interview on 8/21/23 at 8:41 A.M. with Dishwasher (DW) 1, DW 1 stated he usually put the dishwashing temperature in the log after every meal. During an observation on 8/22/23 at 8:45 A.M., an observation of the kitchen dishwashing area was conducted. The Dishwashing temperature log was not filled up for 8/22/23. Residents Affected - Many During an interview on 8/22/23 at 8:48 A.M., with DW 2, the DW 2 stated the dishwashing temperature log should have been filled up by the second dishwasher assigned for the day by this time. During an interview on 8/23/23 at 12:17 P.M. with DFS, the DFS stated dishwashing temperature logs must be completed daily, after each meal to ensure that the dishwashing machine is working and monitored. During a review of the facility's policy and procedure (P&P) titled Recording of Dishmachine Temperatures, dated 1/31/2017, the policy and procedure indicated 8.a. To ensure that the wash and rinse temperatures are properly monitored and controlled, a log must be completed by those who are directly involved in the dishwashing process. Entries must be made for each meal . 555806 Page 14 of 21 555806 08/24/2023 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure residents received foods that retained nutritive value and were served at an appetizing temperature when holding temperatures on the steam table and resident trays were below acceptable range. Residents Affected - Few These failures had the potential to result in decreased food intake and further compromise the nutritional status of medically vulnerable residents in the facility. The facility census was 57. Cross reference F692, F800, F802, F803 Findings: During a kitchen observation and interview on 8/21/23 at 11:48 A.M., with [NAME] 1 (CK1) and the EXC of the steam table, the temperature of lunch meal main entrée Harissa Marinated Chicken was at 153 degrees F. CK1 stated the temperature of the chicken entrée was 165 degrees F right after cooking, but she never re-checks it or logs the final cooking temperature. CK 1 stated she takes the temperature again when the food is on the steam table. The EXC stated CK 1 should have checked to ensure the holding temperature was safe to make sure it was at the steam table. During a record review on 8/22/23 at 11:20 A.M., of the resident council meeting minutes, seven residents (10, 39, 18, 47,43, 356, 35) attended. Residents complained hot foods being served at lukewarm temperatures and not hot enough, especially food in the dining room. During a test tray observation on 8/22/23 at 11:25 A.M., with the Registered Dietitian (RD), the Director of Food and Nutrition Services (DFS) and the Executive Chef (EXC), the lunch meal regular diet and pureed diet trays were tested for temperature, taste, and palatability. Once all residents on the unit received their trays and were eating at 11:43 A.M., the temperatures were taken of the foods by the DFS and two Surveyors using the facility thermometer and compared with the Surveyor's thermometer. The temperatures were within three degrees of each other. The regular diet meal food temperatures from the Surveyor's thermometer included: Beef Tenderloin 120.3 degrees Fahrenheit (F); [NAME] Red Potatoes 111 degrees F; Brussels sprouts 114 degrees F; Chicken soup 141 degrees F. The puree diet temperatures were as: beef puree 133.7 degrees F; mashed potatoes 132 degrees F; brussels sprouts puree 119 degrees F; chicken pureed soup 124.1 degrees F. The temperatures of the regular and pureed diet food items varied between warm and lukewarm. The DFS, EXC and RD also tasted each food item with the surveyors. The pureed food items were not flavorful and according to the DFS, tastes grindy and not like the regular diet foods. The pureed brussels sprouts did not have the taste and flavor of brussels sprouts. The DFS stated the pureed brussels sprouts could use more seasoning to improve palatability. The temperature of the apple juice was at 71.6 degrees F. The DFS stated the juice should have been cooler before it is served to the residents. According to the 2022 US Food and Drug Administration (FDA) Food Code, Section 3-403.11, titled Reheating for Hot Holding, When food is held, cooled, and reheated in a food establishment, there is an increased risk from contamination caused by personnel, equipment, procedures, or other factors. If food is held at improper temperatures for enough time, pathogens can multiply to dangerous numbers. Proper reheating provides a major degree of assurance that pathogens will be eliminated. It is especially effective in reducing the numbers of Clostridium perfringens that may grow in meat, poultry, or gravy if these products were improperly cooled. 555806 Page 15 of 21 555806 08/24/2023 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few According to the 2022 Federal FDA Food Code, Annex section 3-501.16, Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature Danger Zone of 41 degrees F to 135 degrees F for too long. During a review of the facility's policy and procedure (P & P) titled, Food temperatures, dated 2014, the P & P indicated, .Foods should be served at proper temperature to insure food safety and palatability .3. Record reading on food temperature Chart at beginning of tray line and end of tray line .4. Acceptable serving temperatures are: .Meat, entrees greater than or equal to 140 degrees F (Fahrenheit), potatoes greater than or equal to 140 degrees F, Vegetables greater than or equal to 140 degrees F, and Milk, juice less than or equal to 41 degrees F . 8. Palatability of foods determines appropriate temperature at bedside or tableside food Resident's surveys will determine their acceptability. 555806 Page 16 of 21 555806 08/24/2023 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

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 food safety and sanitation practices were met in the kitchen according to standards of practice when: Residents Affected - Many 1. An ice scooper was left inside the ice machine. 2. The kitchen's clean dish storage area had dirty serving utensils and debris in tray with clean dishes. 3. A Lead cook (LCK) did not prepare the tuna salad correctly using the cool down process for ambient temperature foods. 4. The floor in the walk-refrigerator and freezer had dirty label, brown stains, trash and other debris on the floor. 5. Fruit flies were in the flying around uncovered food in the kitchen and dry storage area. These failures exposed residents to contaminated food and unsanitary practices, which had the potential to place them at risk of developing foodborne illness. The facility census was 57. Cross- reference F800, F802, F925 Findings: 1. During an initial kitchen tour on 8/21/23 at 8:25 A.M., an ice machine scooper was found inside the ice machine. During an interview on 8/21/23 at 8:30 A.M., with the Director of Food and Nutrition Service (DFS), The DFS stated he did not know which kitchen staff left the ice scooper inside the ice machine, but stated it should not have been left there because that was unsanitary. According to the 2022 Federal FDA regulations, ice needs to be stored and handled like food, and that means ice machines need to be regularly cleaned. Food Law . Chapter 4 specifies the ice machines and scoops must be cleaned and sanitized . 2. During an initial kitchen tour on 8/21/23 at 8:50 A.M., an observation the kitchen's clean dish storage area was conducted. The clean area with serving utensils, colored serving scoopers were 555806 Page 17 of 21 555806 08/24/2023 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0812 observed to have small brown debris and residues. Level of Harm - Minimal harm or potential for actual harm During an interview on 8/21/23 at 8:52 A.M., with the Executive Chef (EXC) and Director of Food and Nutrition Service (DFS), the EXC stated the serving utensils, scoopers, and eating utensils should not have debris and residues after washing them. The DFS stated the kitchen staff should have checked them before they were stored with clean dishes. Residents Affected - Many According to the 2022 Federal FDA Food Code, section 4-601.11, .it is the standard of practice to ensure non-food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris. According to the 2022 Federal FDA Food Code, section 4-602.11, titled Clean-Food Contact Surfaces, Equipment food contact surfaces of shall be cleaned at any time during the operation when contamination may have occurred. During a review of the facility's policy and procedure ( P&P) titled, Dry Storage- Dishes and Utensils, dated 2012, the P&P indicated .1.Spoon, knives, and forks shall be stored in containers .or shall be covered. 2. Storage areas should be cleaned and sanitized . During a review of the facility's policy and procedure (P & P) titled, Dish and Utensil Procedure dated 7/1/2014, the P & P indicated 9. Any dish, tray or utensil with debris should not be used. Send back to the dish room to be properly washed and sanitized 3. During the initial kitchen tour on 8/21/23 at 9:45 A.M., an observation of kitchen was conducted. Lead [NAME] (LCK) was observed preparing tuna salad. During an interview on 8/21/23 at 9:46 A.M., with LCK, LCK stated he made the tuna salad this morning. LCK stated he made the tuna salad from a canned tuna, celery, mayonnaise and relish. LCK stated he did not do the cool down process for the tuna, because it came from a canned tuna. During a review of the facility's policy and procedure ( P&P) titled, Standardized Recipes, dated 12/2013, indicated standardized recipes will be used for all products .7. HACCP (Hazard Analysis Critical Control Points) controls are also noted on recipes .Albacore Tuna salad Sandwich . 2. Combine tuna, mayonnaise, celery and relish: chill under refrigeration (41 degrees F) . According to the Food and Drug Administration (FDA) Food Code 2022, Section 3-501.14, titled Cooling, .(B) Time/temperature control for safety food shall be cooled within 4 hours to 41 degrees F or less if prepared from ingredients at ambient temperature such as reconstituted foods and canned tuna. According to the 2022 Federal FDA Food Code, Annex section 3-501.16, Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature Danger Zone of 41 degrees F to 135 degrees F for too long. During an interview on 8/23/23 at 12:16 P.M., with the Director of Food and Nutrition Services (DFS) and Registered Dietitian (RD), the RD stated the tuna salad should have been prepared using food safe practices by following the recipe to chill the tuna down to 41 degrees before serving it. 555806 Page 18 of 21 555806 08/24/2023 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 4. During the initial kitchen tour on 8/21/23 at 8:45 A.M., an observation of the walk-in refrigerator and freezer floor and interview with the EXC was conducted. The floors in both walk in areas were dirty with stains, food debris, labels, and paper throughout. The EXC stated the walk-in refrigerator and freezer floors should be cleaned at all times. During an interview on 8/23/23 at 12:16 P.M., with the Director of Food and Nutrition Services (DFS) and Registered Dietitian (RD), both the DFS and RD stated the walk-in freezer and refrigerator floors in the kitchen should have been clean. 5. During the initial kitchen tour on 8/21/23 at 8:25 A.M., There were more than three fruit flies observed flying around the tray line counter area with exposed food. During a concurrent observation and interview on 8/21/23 at 8:45 A.M., with the Director of Food and Nutrition Service (DFS), in the kitchen, three flies were observed flying around throughout the kitchen. The DFS acknowledged the flies and stated there should be no fruit flies in the kitchen, to prevent cross contamination. The DFS stated he will call the pest control company to take a look at it. During a concurrent observation and interview on 8/21/23 at 9:40 A.M., with the Executive Chef (EXC), in the kitchen dry storage room, there were four fruit flies observed flying around on a large metal can of vinegar. The metal can did not have a top on it and contained a piece of clear, thin plastic wrapped around the opening. The EXC acknowledged the fruit flies and stated they've been flying around for a while, but they should not be in the kitchen at all. The EXC stated he will follow up with the pest control company to spray again. During an interview on 8/23/23 at 12:16 P.M., with the Director of Food and Nutrition Services (DFS) and Registered Dietitian (RD), both the DFS and RD stated the kitchen should be free of bugs and pests and kitchen staff need to keep the kitchen clean to avoid pests. During a review of the pest company invoice records dated 8/23/2023, the invoices indicated a presence of drain flies in the kitchen, and Fruit flies come from specific sources .The two spices .were uncovered produce such as onions and the drains . During a review of the facility's policy and procedure (P & P) titled Pest Control, dated 3/1/18, the P and P indicated The Community shall implement a pest control program .1. Will help ensure that the community's residents .offers minimal risk of infection from unwanted insects. According to the 2022 Federal Food Code, section 6-501.111, stated .Controlling Pests .The premises shall be maintained free of insects, rodents and other pests . by . routinely inspecting the premises for evidence of pests . 555806 Page 19 of 21 555806 08/24/2023 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

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 ensure a visitor wore the proper personal protective equipment (PPE) while in contact with one of one sampled resident (Resident 8) on isolation precaution. Residents Affected - Few As a result, there was a potential for spread of infection. Findings: Resident 8 was re-admitted to the facility on [DATE] with diagnoses which included sepsis (blood infection) per the facility's admission Record. On 8/21/23 at 3:12 P.M., a joint observation with Certified Nurse Assistant (CNA) 4 was conducted. Resident 8's room had a sign indicating Resident 8 was on Enhanced Barrier Precautions (everyone must perform hand hygiene and wear gown and gloves for certain activities with the resident). Resident 8's family member was observed going inside the room and sat on the resident's bed without the proper PPE. CNA 4 stated she did not know if Resident 8's family member should be wearing PPE while sitting on the resident's bed. On 8/22/23 at 9:29 A.M., an interview with Resident 8 was conducted. Resident 8 stated her visitors did not wear PPE when they were inside the room. On 8/24/23 at 10:50 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated Resident 8's family member should not have sat on the resident's bed without the proper PPE due to the precautions in place. On 8/24/23 at 11:11 A.M., an interview with Infection Preventionist (IP) 1 was conducted. IP 1 stated Resident 8 was on enhanced barrier precautions due to the presence of a multi-drug resistant organism in the urine. IP 1 stated it would have been better if Resident 8's family member was wearing the proper PPE while she was sitting on the resident's bed. IP 1 stated the staff should have educated the family member not to sit on the bed [without PPE] in general. Per the facility's policy and procedure titled, Enhanced Standard Precautions Guidelines, dated 10/24/22, .High-Risk residents: Wear gowns and gloves .associated with the greatest risk for MDRO contamination .hands, clothes, and the environment: changing bed linens .contact with environmental surfaces . 555806 Page 20 of 21 555806 08/24/2023 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observations, interview and record review, the facility failed to ensure the kitchen and dry storage room was free of pests. Residents Affected - Few This failure had the potential to contaminate food stored in the kitchen which could lead to widespread foodborne illness. The facility census was 57. Cross- reference F800, F802, F812 Findings: During the initial kitchen tour on 8/21/23 at 8:25 A.M., there were three flies observed flying around the tray line counter area. During a concurrent observation and interview on 8/21/23 at 8:45 A.M., with the Director of Food and Nutrition Service (DFS), in the kitchen, three flies were observed flying around throughout the kitchen. The DFS acknowledged the fruit flies and stated there should be no fruit flies in the kitchen, to prevent cross contamination. The DFS stated he will call the pest control company to come out and look at it. During a concurrent observation and interview on 8/21/23 at 9:40 A.M., with the Executive Chef (EXC), in the kitchen dry storage room, there were four fruit flies observed flying around and an uncovered open 5-quart plastic bin with white sugar inside. The bin was unclosed with a red lid hanging off the top. The EXC acknowledged the fruit flies and stated they've been flying around for a while, but they should not be in the kitchen at all. The EXC stated he will follow up with the pest control company to spray again. During an interview on 8/23/23 at 12:16 P.M., with the Director of Food and Nutrition Services (DFS) and Registered Dietitian (RD), both the DFS and RD stated the kitchen should be free of bugs and pests and kitchen staff need to keep the kitchen clean to avoid pests. During a review of the pest company invoice records dated 8/23/2023, the invoice indicated the presence of drain flies in the kitchen, and Fruit flies come from specific sources .the two spices . find were uncovered produce such as onions and the drains . According to the 2022 Federal Food Code, section 6-501.111, .Controlling Pests .The premises shall be maintained free of insects, rodents and other pests . by . routinely inspecting the premises for evidence of pests . During a review of the facility's policy and procedure (P & P) titled Pest Control, dated 3/1/18, the Pest Control indicated .The Community shall implement a pest control program .1. Will help ensure that the community's residents .offers minimal risk of infection from unwanted insects. 555806 Page 21 of 21