Health inspection·November 8, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for one out of 35 sampled residents (Resident 62) when Resident 62's comfort care was not care planned. This failure has the potential for Resident 62 to not receive person-centered services. Findings: Review of Resident 62's medical record, indicated, admitted on [DATE] with diagnosis including Seizure/Brain Injury. During an observation of Resident 62 on 11/4/24 at 11 AM, resident in bed, with oxygen via nasal cannula. Opened eyes when name was called. Not verbally responsive. During a concurrent interview and record review on 11/6/24 at 1:30 PM, with NM1 (Nurse Manger), per NM1 Resident 62 is on comfort care. Review of HCA (Health Care Advance Directive) indicates DNR/DNI. Review of ACP (Advanced Care Planning) dated 10/26/24, by Physician, indicated, The GOC (Goals Of Care) are Comfort base, without escalation off S4, unless minor and reversible circumstances. Code Status: is DNR/DNI. Review of resident care plan, no care plan found on comfort care. Per NM1, it should be care planned and did not find one. Review of facility policy and Procedure, Resident Care plan (RCP), Resident Care Team (RCT) & Resident Care Conference (RCC), dated 2/13/24, indicated, Purpose: It is the policy of LHH to develop and implement a comprehensive person- centered care plan for each resident, consistent with the patient's rights, that includes measurable objectives and timeframes to met their medical, nursing, mental and psychosocial needs . 4. Comprehensive Care Plan: v. Address other important considerations, such as advance care planning and palliative care. Page 1 of 10 555929 555929 11/08/2024 Laguna Honda Hospital & Rehabilitation Ctr D/P Snf 375 Laguna Honda Blvd. San Francisco, CA 94116

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 Based on interview and record review, the facility failed to follow the speech language pathologist's (SLP, a health care professional who assesses, diagnoses, and treats speech, language, and swallowing disorders in people) recommendations in one out of 6 sampled residents (Resident 78) when SLP 1 recommended a special diet for Resident 78 until reassessment of Resident 78's swallowing ability after esophageal dilation (a procedure that widens the tube connecting the mouth to the stomach to make it easier to swallow), but Resident 78 was continued onto a regular diet without reassessment by a SLP. Residents Affected - Few This failure has the potential for Resident 78's swallowing ability to be inaccurately assessed leading to a high risk of aspiration (the accidental inhalation of food, liquid, or other material into the lungs) or choking. Findings: A review of a physician progress note, dated 11/01/24, indicated that Resident 78 had multiple medical issues including paraplegia (loss of movement and/or sensation, to some degree, of the legs) and schizophrenia (a mental illness that is characterized by disturbances in thought). During a concurrent interview and record review on 11/07/24 at 1:05 PM with SLP 2, SLP 1's evaluation titled DYSPHAGIA [difficulty swallowing] EVALUATION ONLY, dated 06/20/23, was reviewed. SLP 1's evaluation indicated that Resident 78 is at risk of aspiration . MD [medical doctor] reported that pt [Resident 78] has esophageal dilation scheduled in August. She is recommended to continue with a puree diet [a soft, smooth diet of ground, pressed, or strained foods for people who have trouble chewing, swallowing, or digesting solid foods] and thin liquids [watery liquids that are easy to pour and are the most common liquids people drink] until then . Please re-refer pt for a swallow eval after esophageal dilation. SLP 2 stated that this was the most current evaluation done by an SLP at the facility and Resident 78 did not have a swallow evaluation after this one. A review of a procedure note, titled Op Note, dated 08/11/23 indicated that Resident 78 underwent an esophagogastroduodenoscopy (EGD, a procedure that allows a doctor to examine the inside of the upper gastrointestinal tract) in which the esophagus was dilated (widened). A review of Resident 78's care plan, titled Problem: Swallowing difficulty, dated 06/29/24, indicated a goal of Will tolerate enteral nutrition [a way of sending nutrition right to the stomach or small intestine] without swallowing difficulty. The care plan further indicated interventions including Staff continue to educate [Resident 78] .to notify RD [Registered dietician], MD, SLP, or RCT [resident care team, a collaborative group of people involved in a resident's care] members if she has trouble chewing or swallowing with current regular diet textures ( .[Resident 78] accepts risk of aspiration while on regular diet, see treatment plan note 08/23/24). A review of physician's document, titled Treatment Plan, dated 08/23/24 indicated that MD 1 met with Resident 78 and Discussed diet texture. Wants to continue regular diet despite risks of aspiration. 555929 Page 2 of 10 555929 11/08/2024 Laguna Honda Hospital & Rehabilitation Ctr D/P Snf 375 Laguna Honda Blvd. San Francisco, CA 94116

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview and record review, the facility failed to give a clinical rationale (specific reason a medication or procedure is done) for a PRN (given as needed or requested) medication order beyond 14 days of a psychotropic drug (any drug that affects brain activities associated with mental processes and behavior) in one of five sampled residents (Resident 1) when Resident 1 was prescribed Ativan (a sedating medication) for 90 days. This failure has the potential for Resident 1 to be continued on psychotropic medications that may be unnecessary for their care or physical, mental, functional, and psycho-social well-being. Findings: A review of a facility policy and procedure, titled USE OF PSYCHOTROPIC MEDICATIONS, last revised 08/08/23, indicated that PRN non-antipsychotic medications shall be limited to 14 day unless a longer time frame is deemed appropriate by a physician and there is documentation of their rationale and the duration of the PRN order in the medical record. A review of a physician progress note, dated 10/01/24, indicated that Resident 1 was admitted in 2019 and has clinical problems including Paraplegia [loss of movement and/or sensation, to some degree, of the legs], Epliepsy [a chronic brain disorder that causes seizures, which are brief episodes of abnormal electrical activity in the brain], and Insomnia [trouble falling asleep or staying asleep]. A review of a Pharmacy 30 day Med Review, titled LHH Medication Review Attestation, dated 10/25/24, indicated that Pharmacist 1 noted that PRN orders for psychotropic drugs have been limited to 14 days or less, unless an explicit reason has been provided . During a concurrent interview with record review on 11/07/24 at 2:25 PM with Pharmacist 1, Resident 1's medication order for Ativan, dated 10/15/24, was reviewed. The medication order indicated that Resident 1 was prescribed one milligram (mg, metric unit of measurement, used for medication dosage and/or amount) of Ativan Bedtime PRN for sleep. The medication order further indicated that it was ordered for 90 days as it was necessary to manage breakthrough seizure episodes. Pharmacist 1 stated that the clinical rationale on this medication order is likely a typo [an error in the typing or entry of words]. When asked if there was a specific reason this medication was prescribed by the doctor for more than 14 days, Pharmacist 1 stated, I don't know if I can find one. During a concurrent interview with record review on 11/08/24 at 8:48 AM with Medical Doctor (MD) 1, Resident 1's medication order for Ativan, modified on 11/07/24, was reviewed. The modified medication order indicated that Resident 1 was prescribed one mg of Ativan at Bedtime PRN for sleep. The medication order further indicated that it was ordered for 90 days as Resident with chronic insomnia with fluctuating (changing) frequency thus prn order is appropriate for > [greater than] 14 days . Poor sleep can impede overall health and mood; the benefit of quality rest outweigh the risk of this PRN medication. MD 1 stated that he changed this order yesterday to document the clinical rationale for the PRN order of Ativan. 555929 Page 3 of 10 555929 11/08/2024 Laguna Honda Hospital & Rehabilitation Ctr D/P Snf 375 Laguna Honda Blvd. San Francisco, CA 94116

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to maintain a medication error rate below five percent. During the medication pass on 11/05/24 and 11/06/24, two medication errors were observed out of thirty-two opportunities for two out of seven residents, resulting in an error rate of 6%. This failure had the potential to result in harm in the health and safety of residents. Residents Affected - Few Findings: 1. A review on 11/05/24 of Elsevier, an online medical resource, provides the following instructions for administering subcutaneous injections: insert the needle quickly and firmly at a 90° angle, withdraw the needle quickly and smoothly, activate the safety device per the manufacturer's instructions for use, and gently place an antiseptic swab or gauze over the injection site. When administering insulin with a short needle, it is important to inject at a 90° angle to ensure proper delivery into the subcutaneous tissue, avoid injecting into muscle, and minimize discomfort. This technique helps to maintain predictable blood glucose levels and ensures safe, effective insulin administration. During a observation on 11/05/24 at 8:14 AM it was observed LVN 1, a licensed vocational nurse, administering medication to Resident 305. The nurse administered 4 units of NPH insulin. However, instead of injecting at the recommended 90° angle, the nurse injected the insulin at an angle of approximately 20°. During an interview LVN 1 confirmed that he had administered the subcutaneous insulin injection at an angle of approximately 20°. He acknowledged the need to improve upon his injection technique. 2. The American Diabetes Association (ADA) recommends that patients use a different site for each insulin injection, rotating within the same general area. Similarly, the American Association of Diabetes Educators (AADE) recommends that patients rotate insulin injection sites within the same body area to avoid lipodystrophy. Rotating injection sites helps to ensure consistent insulin absorption and reduces the risk of developing lipodystrophy, a condition characterized by the thickening or thinning of subcutaneous fat at the injection site. During an observation 11/05/24 at 1:05 PM, RN 1, and Resident 291, a resident with a blood sugar level of 334, was administered 1 unit of Lispro as a routine dose, and an additional 3 units of Lispro as a sliding scale dose, totaling 4 units in the right lower quadrant. During an interview on 11/05/24 at 1:15 PM RN 1 and reviewing the Resident 291's records, it was noted that the previous insulin injection had also been administered in the right lower quadrant. This finding indicates that RN 1 did not rotate the injection site for the insulin administration. The nurse confirmed that she had not rotated the injection site during the administration process. During an interview on 11/05/24 at 2:30 PM with the Nurse Educator, she stated that she was responsible for educating nurses on the appropriate administration procedures during medication pass. Additionally, she mentioned that she has a protocol in place, which includes ensuring proper rotation of 555929 Page 4 of 10 555929 11/08/2024 Laguna Honda Hospital & Rehabilitation Ctr D/P Snf 375 Laguna Honda Blvd. San Francisco, CA 94116

F 0759 injection sites by avoiding the area where the last dose was administered. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555929 Page 5 of 10 555929 11/08/2024 Laguna Honda Hospital & Rehabilitation Ctr D/P Snf 375 Laguna Honda Blvd. San Francisco, CA 94116

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. 5. During an observation on 11/4/24 at 10:18 AM, in Resident 569's room, an egg salad sandwich was on the overbed table. The label on the sandwich indicated, 11/3/24 Dinner. During a concurrent interview, Resident 569 confirmed the sandwich was served for dinner on 11/3/24. Resident 569 stated, Yes, it was for last night's dinner. During an interview on 11/4/24 at 10:43 AM, Nurse Supervisor (NS) 1 validated the sandwich was served for dinner on 11/3/24. NS 1 stated, He can have food poisoning. According to the 2022 Federal Food Code, a Time Temperature Control for Safety (TCS; foods designated to maintain specific temperature ranges within designated time frames to prevent the growth of harmful bacteria) food is to be discarded when within four hours from the point in time when the food is removed from temperature control. Based on observation, interview, and facility document review, the facility failed to ensure standards of practice for storing, preparing, and serving food were met when: 1. The kitchen floor in the steam jacket kettle area was not maintained resulting in cracked tiles and missing grout; 2. The ceiling above the manual dish washing area was not maintained free of dust build-up; 3. Steam jacket kettles were not sanitized as part of the cleaning process; 4. Frozen food items were not covered when stored in the freezer; and 5. An egg-salad sandwich available for a resident (Resident 569) at bedside, was not discarded within an appropriate time frame. These failures had the potential to result in contamination of food, utensils, and equipment; and/or promote the harborage of pests for at least 385 residents who received food from the kitchen out of a census of 417. Findings: 1. 555929 Page 6 of 10 555929 11/08/2024 Laguna Honda Hospital & Rehabilitation Ctr D/P Snf 375 Laguna Honda Blvd. San Francisco, CA 94116

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many It would be the standard of practice to ensure the materials for indoor floor, wall, and ceiling surfaces under conditions of normal use are maintained to ensure they are smooth, durable, and easily cleanable. Additionally, pooling of liquid wastes could attract pests such as insects and rodents or contribute to problems with certain pathogens. (US Food Code, 2022). During the Initial Tour of the kitchen on 11/04/24 at 10:45 a.m., an observation showed the floor in the steam jacketed kettle (a large, deep pot mounted on legs to stand on the floor. The pot uses steam to cook food) area was wet and had several cracked tiles. When pressure was placed on the cracked tiles, water came out from beneath the tiles. In addition, there was missing grout which created long divots between several tiles. During a concurrent interview with the Food Service Director (FSD) on 11/4/24 at 10:45 a.m., FSD stated a work order was placed two to three weeks ago to fix the cracked tiles and missing grout. FSD stated Facilities was in the kitchen since the work order was placed to fix floor tiles in the kettle area. A document review showed two work orders were created on 10/18/24 for Broken tile in front of Steamer # [number] 4; and Broken tile and missing grouts in between kettle #1 and #2. During an interview and concurrent observation in the kitchen on 11/6/24 at 3:35 p.m., the Director of Facilities (DOF) confirmed broken tiles and missing grout under the steam jacket kettles. DOF stated he resurfaced the tile floor under the steam jacket kettles on 10/20/24. DOF stated it was a very wet area and the grout was disrupted easily. DOS stated the area needed to be resurfaced with a better material that did not degrade so quickly when wet. 2. It would be the standard of practice to ensure the materials for indoor ceiling surfaces under conditions of normal use are maintained to ensure they are easily cleanable. Additionally, the presence dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. (US Food Code, 2022). On observation and concurrent interview with FSD on 11/4/24 at 1:00 p.m., showed a significant amount of a gray, fuzzy substance on the ceiling in the warewashing room, mainly in the area of the manual warewashing sinks. FSD stated the substance was likely dust. FSD stated the dust build-up on the ceiling was likely due to moisture in that area. FSD stated a cleaned the ceiling about once a year, but it could be cleaned more often by facility staff. FSD stated he thought the ceiling was last cleaned by the company in April. Review of the facility Kitchen Registers & Oven Cleaning Project Report for service dates 5/28 - 5/31/2024, showed HVAC (heating, ventilation, and air conditioning) registers (vents) and adjacent ceiling tiles were cleaned. 3. Review of the facility Policy and Procedure (P&P) titled General Cleaning and Sanitizing work Surfaces and Kitchen or Galley Equipment revised 7/2024, showed cleaning is the process in which a food service worker is removing food and other types of soil from a surface. Sanitizing is the process in 555929 Page 7 of 10 555929 11/08/2024 Laguna Honda Hospital & Rehabilitation Ctr D/P Snf 375 Laguna Honda Blvd. San Francisco, CA 94116

F 0812 Level of Harm - Minimal harm or potential for actual harm which a food service worker uses a sanitizer on the same surface that was previously cleaned, to reduce the number of micro-organisms to a safe level. To be effective, the food service worker must conduct a two-step process, cleaning and sanitizing. Surfaces must be first cleaned and rinsed before sanitizing. All food-contact surfaces must be washed, rinsed, and sanitized. For sanitizing the surface, use a clean cloth with sanitizer and allow the surface to air dry. Residents Affected - Many Review of the undated facility document titled Nutrition Services Department Job Description, showed a responsibility for Job Number 15 was to ensure food service machinery was clean and sanitized. For large pieces of equipment, wash, rinse, sanitize, and airdry. An observation in the kitchen and interview with a Food Service Worker (FSW) and FSD on 11/4/24 at 10:50 a.m., showed an area with six steam jacket kettles (two 50-gallon, and four 100-gallon) ad some were in use for cooking food. Food Service Worker (FSW) stated she was position number 15 and was responsible for cleaning the kettles. FSW stated she was about to clean a kettle filled with food residue. FSW stated the cleaning process included draining the kettle, then scrubbing the inside surface with a brush, soap, and hot water, and lastly rinsing the inside surface with water. FSD confirmed there should be a sanitizing step. Then FSW stated if she used a sanitizer, she would drain the kettle, scrub the inside surface with soap and water, wipe the inside surface with a sanitizing solution, and lastly rinse the inside surface again. FSD stated the kettle should not be rinsed after sanitizing. 4. It would be the standard of practice to ensure food is be protected from cross contamination by storing the food in packages, covered containers, or wrappings. (US Food Code, 2022). During the Initial Tour of the kitchen on 11/4/24 at 10:30 a.m., an observation of food stored in walk-in freezer number one was conducted. Due to boxes from the morning food delivery stacked in the middle of the freezer, the majority of the freezer was inaccessible. A spot check was done for food stored on racks close to the freezer entrance The spot check revealed multiple foods stored on the racks were not covered including plant based chicken breast, pureed carrots, plant based vegan (no animal product ingredients) patties, and plant based sausage patties. These foods were in opened boxes and the plastic wrapping around the food within the boxes did not cover the food. During a concurrent interview with FSD on 11/4/24 at 10:30 a.m., FSD confirmed multiple frozen foods were stored and not covered. FSD stated we can do a better job. when asked how the frozen foods should be stored. 555929 Page 8 of 10 555929 11/08/2024 Laguna Honda Hospital & Rehabilitation Ctr D/P Snf 375 Laguna Honda Blvd. San Francisco, CA 94116

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 observation, interview, and facility document review, the facility failed to ensure the kitchen was free of pests when fruit flies were consistently present. Residents Affected - Many This failure had the potential for contamination of food and food contact-surfaces leading to the transmission of disease to 385 residents who received food from the kitchen out of a census of 417. Findings: It would be the standard of practice to ensure premises are maintained free of insects, rodents, and other pests. Insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. Effective measures must be taken to eliminate their presence in food establishments. (US Food Code, 2022). Review of the facility Policy and Procedure titled Pest Control Policy dated August 2022, showed the purpose of the policy was to provide a pest free, clean, healthy environment for residents, staff, and visitors. The Food Service Department will be treated once per week when the Department is not in operation. Supplemental service to the facility must be requested by completing an Environmental Services Department work order. During the initial tour of the kitchen on 11/4/24 at 10:05 a.m., an observation showed small flies on the ceiling in the warewashing room, above where the trash and compost bins were stored. There were also small flies, flying in the area. An observation and concurrent interview with the Food Service Director (FSD) on 11/4/24 at 12:50 p.m., showed small flies on the ceiling in the kitchen warewashing room above where the trash and compost bins were stored. FSD confirmed the presence of the flies and stated a pest control technician provided service every Thursday. FSD stated a work order for flies in the kitchen was submitted last week. An observation on 11/6/24 at 11:14 a.m., showed small flies on the ceiling in the warewashing room above where the trash and compost bins were stored. On 11/4/24 the last three months of pest reports were requested. Pest reports from 8/1/24 to 10/3/24 were provided. Review of . Pest Inspection Report from 8/1/24 to 10/3/24, showed the presence of fruit flies in the kitchen in all 10 reports. The dates of the reports were 8/1/24, 8/8/24, 8/15/24, 8/22/24, 8/29/24, 9/5/24, 9/12/24, 9/19/24, 9/26/24, 10/3/24. During an interview and concurrent document review with the Environment Services Director (ESD) and FSD on 11/6/24 at 2 p.m., ESD stated she received a work order for flies in the kitchen on 10/28/24. ESD stated the purpose of a work order was to alert the technician of problem areas. Review of the undated work order (number 19064) showed Gnats/fruit flies in the kitchen and the status of the work order was Complete. FSD confirmed the work order was not dated and said there was also an email to confirm the date of the work order. The pest control reports were reviewed and FSD confirmed the presence of fruit flies were documented consistently on the pest reports. Review of the email dated 10/28/24 showed a work order request for work order 19064 and the description of the request was Gnats/fruit flies in the kitchen. The status of the request showed pending 555929 Page 9 of 10 555929 11/08/2024 Laguna Honda Hospital & Rehabilitation Ctr D/P Snf 375 Laguna Honda Blvd. San Francisco, CA 94116

F 0925 environmental service. Level of Harm - Minimal harm or potential for actual harm During an interview with the Pest Control Technician (PCT) on 11/7/24 at 10:10 a.m., PCT stated he serviced the kitchen one a week, and usually saw fruit flies in the warewashing room and near the food chopper area. PCT explained the presence of breeding material promoted the presence of fruit flies, and clarified breeding material in the kitchen was food residue. PCT stated only physical treatment which he stated was non-chemical, was done in the kitchen. PCT stated even though the flies were vacuumed today, more flies might appear tomorrow from the floor drains and hand sinks. PCT stated the facility needed to take additional steps to eliminate fruit flies by scheduling an additional service which included adding a pesticide to drains, and/or increase service in the kitchen to twice a week. PCT stated this extra service needed to be requested by the facility for it to be scheduled. Residents Affected - Many 555929 Page 10 of 10