Casa De Las Campanas

F-F802

Findings:

1. During an observation and interview on [DATE REDACTED] at 3:10 P.M. with the facility contractor (FC) in the health facility kitchen, the FC stated does maintenance cleaning every month for the facility's ice machines in the kitchens and on the units. FC demonstrated how he cleaned the Health center kitchen ice machine and stated I remove the spout from the ice machine or the top, and clean with a cleaning solution. Per the FC, he uses about 12 ounces of water in a bowl to dissolve a sanitizer solution packet, then pours the mixture in the top of the ice making part. Next, he stated he pours delime wash solution in the top, then flushes it with water x3 times to catch the dirty water. Finally, he stated he runs another sanitizer/water mixture through the machine for 30 minutes to make sure the drain is clean and before new water is turned on to make ice. The FC stated he used a clean rag from the red sanitizer bucket to wipe down the outside of the ice machine, along with the side filter, and inner condenser.

A record review on [DATE REDACTED] at 9:53 A.M. of the health center kitchen's ice machine maintenance log titled [Facility Name] ICE MACHINE LOG UNIT ID: [NAME] KITCHEN MAINTANANCE, indicated the last cleaning date started [DATE REDACTED]. The maintenance log recorded filters due on [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], and [DATE REDACTED]. Per

the maintenance log indicated filters would need to be cleaned twice a month.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 27 555362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555362 B. Wing 06/07/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Casa DE Las Campanas 18655 W. Bernardo Drive San Diego, CA 92127

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 During a main production kitchen observation and interview tour on [DATE REDACTED] at 3:30 PM with the Executive Chef (EC), Dietary Supervisor (DS), Food and Beverage Director (FBD), and the FC, the ice machine had Level of Harm - Minimal harm or some yellow pinkish colored spots on the inside left and right side corner wall touching the baffle (a part in potential for actual harm the ice machine that is used to catch formed ice to land smoothly to the ice machine bin). The FC then lifted

the ice machine bin door and there was small black speckled sized debris visible inside five ice cubes siting Residents Affected - Some at the top of the pile of ice. When the FC opened the top ice machine cover, the ice machine curtain had black and grayish colored mold looking spots on the top edges. The FC demonstrated how he cleaned the ice machine and stated he removed the curtain (front panel that is used as an insulation) and water tray of

the ice machine, then would pour a cup of water mixed with three ounces of ice machine delime cleaning solution in the top ice making part of the machine to run through the grid. The filters connected to the ice machine had a label that stated installed ,d+[DATE REDACTED] without a replacement date. Per the FC, the [Contractor Business Name] does not clean the baffle inside the ice bin or change out the water filters. The DS, FSB, and EC each acknowledged all the dirty areas with discolored debris in the ice machine, including the ice cubes with black speckles inside them, and the expired water filters attached to the ice machine.

Per the 2022 Federal Food and Drug Administration (FDA) Food Code, Section ,d+[DATE REDACTED].11 titled Equipment Food-Contact Surfaces and Utensils, .Ice bins and components of ice makers need to be cleaned: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to prevent the accumulation of slime, mold, or soil residues that may contribute to an accumulation of microorganisms .

During a review of the facility policy titled, FOOD STORAGE dated 2013, the policy indicated .9. All refrigeration equipment is thoroughly scrubbed weekly and cleaned daily .

2. During the initial kitchen tour observation of the health center kitchen on [DATE REDACTED] at 8:45 AM, the ice machine air gap system was piped directly through a food production sink pipe underneath the sink station.

During an initial tour observation on [DATE REDACTED] at 9:38 AM of the main production kitchen ice machine air gap, a white narrow PVC (polyvinyl chlorinated) pipe attached to the ice machine was extended into a floor sink drain next to the ice machine.

During a main production kitchen observation and interview on [DATE REDACTED] at 3:49 PM with the DS and FBD of

the main production kitchen ice machine air gap system, the DS and FBD acknowledged the white PVC pipe was pushed down into the floor sink drain. The FBD stated it should be raised higher.

During an observation in the main kitchen of the dish machine air gap system on [DATE REDACTED] at 11:24 AM, the dish machine had a copper pipe extended directly from the back of the machine into the left-side floor sink drain.

During an observation in the nurse's station 2 nourishment room ice machine air gap system on [DATE REDACTED] at 2:24 PM, the ice machine had a long white PVC extended directly from the back of the machine into the front right side floor sink drain.

During an interview on [DATE REDACTED] at 11:07 AM with the Director of Plant Operations (DPO), the DPO reviewed

the photos or air gaps in the main kitchen and health center kitchen. The PO agreed that there needed to be

an air gap space between the floor sink drain and the pipes. Ice machine in main kitchen. He said he expects all equipment to be working operationally and on a preventive maintenance cleaning schedule.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 27 555362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555362 B. Wing 06/07/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Casa DE Las Campanas 18655 W. Bernardo Drive San Diego, CA 92127

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Per the 2022 Federal FDA Food Code, section ,d+[DATE REDACTED].13 titled Backflow Prevention, Air, .An air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE, EQUIPMENT, Or Level of Harm - Minimal harm or nonfood EQUIPMENT shall be at least twice the diameter of the water supply inlet and may not be less than potential for actual harm 25 mm (1 inch).

Residents Affected - Some 3. During an observation and interview in the health facility kitchen on [DATE REDACTED] at 9:25 A.M. with the DS and EC, the reach-in refrigerator door gasket had two lines of brown sticky grime and debris along the left, right, and top of the gasket. The DS and EC acknowledged the dirty grime on the gasket inner door, and both stated it should be cleaned.

During an observation on [DATE REDACTED] at 9:41 AM in the main production kitchen's reach-in refrigerator, the door gasket had brown and black sticky grime on each side and several black and grayish spots on the inside door panel. The DS and EC acknowledged the dirty grime on the gasket inner door, and both stated it should be cleaned.

During an interview on [DATE REDACTED] 2:36 P.M., with the DS and RD, the RD stated that sanitation audits were started in [DATE REDACTED] by the DS. The RD stated she was unaware of the kitchen cleaning and sanitation concerns identified in both the health center kitchen and the main production kitchen. The DS stated all the reach-in refrigerator door gaskets should have been on both kitchens' daily and weekly cleaning schedules.

During a record review of a health center kitchen staff in-service titled SHOWTIME, dated [DATE REDACTED], the policy indicated .refrigerators the inside and outside, at the same time refrigerators gaskets needs to be clean .

The facility's cleaning schedules and logs for the main production kitchen and health center kitchen reach-in refrigerators was requested but not provided.

During a review of the facility policy titled; FOOD STORAGE dated 2013 indicated .1. Food storage areas shall be clean at all times [sic] . 2. All exposed foods should be tightly covered.9. All refrigeration equipment is thoroughly scrubbed weekly, and cleaned daily .

4. During a production kitchen observation on [DATE REDACTED] at 9:34 A.M. with the DS, FDB and EC, the health center food prep station had a rack with twelve multi-colored rubber cutting boards stored underneath the counter. There were four green, three white and three red cutting boards stored with heavily worn deep knife cuts and groves, along with large white discoloration in the center of the boards. The FDB, DS, and EC acknowledged the discoloration on the cutting boards and heavily worn areas and stated it was from the sanitizer in the high temperature dish machine. The FDB and DS stated the cutting boards needed to be replaced.

Per the 2022 Federal Food Code, Section ,d+[DATE REDACTED].11, titled Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch .

During a review of the facility policy titled, FOOD STORAGE dated 2013 indicated .1. Plasticware, China, and glassware that cannot be properly sanitized due to chips or cracks will be discarded .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 27 555362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555362 B. Wing 06/07/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Casa DE Las Campanas 18655 W. Bernardo Drive San Diego, CA 92127

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 5. During a production kitchen observation on [DATE REDACTED] at 9:45 A.M. with the DS and EC of the health facility reach-in refrigerator, a long metal tray with 20 individually sliced chocolate mini dessert cakes on separate Level of Harm - Minimal harm or plates stored uncovered on the 5th shelf row of the rack. The 6th shelf had a tray with additional slices of potential for actual harm uncovered. The FDB and DS stated that the mini-dessert cakes needed to be covered to prevent cross contamination. Residents Affected - Some

During an observation on [DATE REDACTED] at 3:49 P.M. at the elevator kitchen leading to the main production kitchen, two dietary aides (DAs) were seen pushing a food cart with a tray of uncovered cookies on the bottom shelf of the open food cart and additional desserts on another tray of uncovered on the cart. Both DAs stated they were in a rush to get the food item from the main production kitchen to the health center kitchen and declined

an interview.

During a review of the facility policy, titled FOOD STORAGE, dated 2013, the policy indicated .1. Food storage areas shall be clean at all times [sic] . 2. All exposed foods should be tightly covered .

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FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 27 555362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555362 B. Wing 06/07/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Casa DE Las Campanas 18655 W. Bernardo Drive San Diego, CA 92127

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48263 potential for actual harm Based on record review, observation, and interview, the facility failed to ensure implementation of their policy Residents Affected - Some regarding use and storage of foods brought in from the outside food to ensure safe and sanitary storage, handling, and consumption was followed.

This failure had the potential to contaminate residents' outside food stored at the facility, which may result in foodborne illness. The facility census was 50.

Findings:

During a concurrent interview and observation on [DATE REDACTED] at 4:24 P.M. with Certified Nursing Assistant (CNA) 1, at nursing station 2, CNA 1 stated outside food or food brought in by family members for residents is stored in the nursing station nourishment room in the fridge. CNA 1 stated food items must be labeled with

the resident's name and date on the container to identify who the items belong to. The CNA stated that outside food items should not be kept more than a week. An observation of the nourishment room refrigerator with CNA 1 indicated a large 32-ounce bottle of unopened orange juice labeled with a room number, and best if used by ,d+[DATE REDACTED]. CNA 1 stated the orange juice was not correctly labeled and was expired.

During an interview on [DATE REDACTED] at 10:29 A.M. with the Director of staff Development (DSD), the DSD stated outside food items brought in for residents should be signed, dated, and discarded after 72 hours. The DSD stated she did not specifically provide in-service trainings to the nursing staff regarding outside food and/or food brought in by family members. The DSD stated, I agree that we should have an in-service on our outside food policy it should be discarded within 72 hours and not one week. The DSD was notified regarding

a bottle of expired orange juice was left in the nourishment fridge that was only labeled with a resident's room number. The DSD stated she would not have thrown away the orange juice if it was sealed.

During an interview with the Director of Nursing (DON) on [DATE REDACTED] at 03:59 P.M., the DON stated outside foods brought in by family for residents should not be stored at the fridge by the nursing station and should be in the dining room in a separate resident nourishment fridge. The DON stated they need to update their policy to reflect the correct practice to prevent cross contamination with items that should not be stored in the nursing fridge. The DON stated her expectations for expired food items is it should be treated like medications and thrown away to prevent food-borne illnesses. The DON stated nursing staff should know to discard any outside food items within 72 hours.

During a review of the facility policy and procedure (P&P) titled Foods Brought in by Family/Visitors dated 2013, the P&P indicated .Foods that must be kept under refrigeration must be labeled with the resident's name, room number, and date. These food items should be stored in the nurses' refrigerator. Foods will be discarded within 72 hours .

During a review of the facility policy and procedure (P&P) titled Outside Food dated 2015, the P&P indicated . 5. Food items will not be stored in the medication refrigerators .

38924

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 27 555362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555362 B. Wing 06/07/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Casa DE Las Campanas 18655 W. Bernardo Drive San Diego, CA 92127

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 45063 potential for actual harm Based on observation, interview and record review, the facility failed to ensure a staff adhered to proper Residents Affected - Few infection control practice for one of 13 residents (Resident 1) when the staff did not perform hand hygiene (HH- washing hands with soap and water or use of hand sanitizer to kill microorganisms) before entering a resident's room.

This failure had the potential for cross contamination (spread of germs and bacteria) and infection to residents, staff and visitors.

Findings :

On 6/4/24 at 9:24 A.M., an observation was conducted inside of Resident 1's room. The Medical Records Staff (MRS) entered Resident 1's room to answer the call light. The MRS did not perform HH before entering

the Resident 1's room.

On 6/4/24 at 9:30 A.M., an interview was conducted with the MRS. The MRS stated she should have performed HH before entering Resident 1's room.

On 6/6/24 at 8:35 A.M. an interview was conducted with the Director of Staff Development (DSD). The DSD stated the MRS should have performed HH before entering Resident 1's room. The DSD further stated all staff should perform HH before entering a resident's room to prevent risk of cross contamination.

On 6/6/24 at 11:25 A.M., an interview was conducted with the Infection Preventionist (IP). The IP stated the MRS should have performed HH before entering Resident 1's room to prevent cross contamination.

On 6/7/24 at 9:30 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the MRS should have performed HH before entering Resident 1's room. The DON further stated HH before entering the resident room was important to prevent cross contamination and to protect the residents.

A review of the facility's policy and procedure titled Handwashing/Hand Hygiene revised 10/2023 indicated Policy: .2. All personell are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents and visitors.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 27 555362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555362 B. Wing 06/07/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Casa DE Las Campanas 18655 W. Bernardo Drive San Diego, CA 92127

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Keep all essential equipment working safely.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48263 potential for actual harm Based on observation, staff interviews, and policy review, the facility failed to ensure kitchen equipment was Residents Affected - Few maintained in safe operating condition when two reach-in refrigerators and an ice machine were not maintained according to standards of practice and facility policy.

This failure had the potential to expose the facility's 50 residents to potential contaminants that could cause widespread foodborne illness.

Cross Reference 812

Findings:

1. During an initial kitchen tour observation on 6/4/24 at 9:41 A.M. in the health facility, a reach-in refrigerator door gasket (a gasket helps to create a vacuum and air-tight seal, forming a barrier for the cool inside your refrigerator and freeze) was worn, with tears at the top and bottom right corners and detaching on the sides.

During an observation and interview on 6/4/24 at 2:45 P.M., with the Dietary Supervisor (DS) and the Food and Beverage Director (FBD) in the health facility kitchen, the DS and FBD acknowledged the torn and detached reach-in refrigerator door gasket and stated it needed to be replaced.

During an observation and interview in the main production kitchen facility on 6/5/24 at 9:55 A.M. with the DS and FBD, the reach-in refrigerator used for the health facility had a heavily worn door gasket with pieces torn off the sides and detaching from the top right and bottom corners. The DS and FDB acknowledged the worn and detached door gasket on the reach-in refrigerator and the FBD stated it will be replaced.

Per the 2022 Federal Food and Drug Administration (FDA) Food Code, sections 4-601.11, and Annex 4-602. 13, .non-food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Additionally, the presence of food debris or 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 .

Per the 2022 Federal FDA Food Code, section 4-202.16, titled Nonfood-Contact Surfaces,

Non-FOOD-CONTACT SURFACES shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance.

2. During an initial kitchen tour on 6/4/24 at 9:41 A.M., an ice machine in the main kitchen had a broken plastic missing piece on the outer right corner bin door that left a large gaping hole opening. There rubber seals in the right and left upper corners of the ice bin exterior were covered with white calcium-like deposits and were torn and detaching. The inside of the ice machine baffle (a part in the ice machine that is used to catch formed ice to land smoothly to the ice machine bin) showed some yellowish and black spotted discoloration.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 27 555362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555362 B. Wing 06/07/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Casa DE Las Campanas 18655 W. Bernardo Drive San Diego, CA 92127

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 During a record review on 6/4/24 at 9:53 A.M. of the facility's ice machine maintenance log titled [Facility Name] ICE MACHINE LOG UNIT ID: [NAME] KITCHEN MAINTANANCE, date started 1/16/23. The Level of Harm - Minimal harm or maintenance log recorded filters due on 6/25, 8/21, 12/15, and 5/31. potential for actual harm

During an observation and interview on 6/4/24 at 3:19 P.M., with the DS and FBD of the ice machine in the Residents Affected - Few main production kitchen, the FBD acknowledged the broken plastic piece on the ice bin and hole in the right corner, the worn rubber seals and the calcium-like deposits on the bin exterior. The FBD and the DS agreed

the ice machine needed to be fixed or replaced.

During an interview on 6/6/24 at 11:07 A.M., with Director of the Plant Operations (DPO). The DPO stated he expected all equipment to be working operationally and on a preventive maintenance cleaning schedule.

Per the 2022 Federal FDA Food Code, section 4-602.11 titled Equipment Food-Contact Surfaces and Utensils, Ice bins and components of ice makers need to be cleaned: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold .

Per the 2022 Federal FDA Food Code, .Ice makers and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms.

During a review of the facility policy titled, Equipment Maintenance dated 2013, the policy indicated .It is the policy of the community to maintain the equipment according to manufacturer's instructions .1. All food service equipment will be operated, maintained, serviced and cleaned according to manufacturer's directions

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FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 27 555362

F-F804

Findings:

During a concurrent observation and interview on 6/6/24 starting at 9:11 A.M of the facility's emergency food and water supplies, the AADM (Acting Administrator), the STD (Safety and Transportation Director), Dietary Supervisor (DS), Food and Beverage Director (FBD), Executive Chef (EC), and Sous Chef (SC) stated the facility did not have a therapeutic menu for three days to feed the facility 50 residents. The AADM, DS, and SC the facility abides with the regulations to have a 3-day food supply. The AADM stated the skilled nursing facility-health center's 3-day food supply was combined with all the emergency foods for the entire senior residential care community buildings. There were 11 pallets of 60 cases per pallet with 12 units of one-liter (1L) containers of water. There were 15 per tier and 12 per box of rehydrated (dried foods that require water to turn into a nutritious food) meals. The AADM and DS acknowledged the meal count needed to be calculated for health center facility beds, and the water supply needed to be calculated for the residents and enough to rehydrated meals. The DS stated there need to have 873 meals to feed 97 residents, three meals per day, for 3 days.

During a record review and interview on 6/6/24 at 3:17 P.M. with the RD and DS, both the RD and DS acknowledged the day 1 Emergency menu plan list of foods did not include the facility residents on therapeutic diets or clearly provide instructions for how to feed residents on therapeutic and textured diets with appropriate tools needs. The RD stated it was important to have a sufficient menu to meet the medical and therapeutic needs of the health center facility residents and include staff and visitors, in the event of an emergency.

Review of the untitled and undated facility document indicated In the event of a loss of utilities, water may be unavailable as it may be contaminated and in need to purification. In either case, the dietary department will need to have on hand an adequate supply of water. This water will be used for cooking, cleaning, and drinking by residents and staff. A minimum of three-day supply will be available. The quantity of water that is needed has been determined by the following calculation: MRE's (meals ready to eat) =48 oz of water per #10 can. We have 124 cans of MRE's total for Health Center. The total water requirement for MRE's will be 5, 952 ounces of water or 46.5 gallons. (176.28 liters). TOTAL NEED = 346.5 Gallons .

Review of the undated facility document titled Disaster indicated In the event of a disaster and the utilization of our disaster supply is needed, you will be expected to

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 27 555362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555362 B. Wing 06/07/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Casa DE Las Campanas 18655 W. Bernardo Drive San Diego, CA 92127

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 know what to do so we can continue to provide meals to the residents and staff onsite .

Level of Harm - Minimal harm or Review of the 2013 and 2015 facility policy and procedure (P&P) titled Menu Planning indicated It is the potential for actual harm policy of the community that menus be planned in advanced .4. All menus will be approved by the Consultant Dietitian. 5. Menus will be planned with consideration of cultural background and food habits of residents. 6. Residents Affected - Some All meal substitutions and menu changes will be documented on the dietary census . Guidelines .5. Therapeutic diets will be planned and served in accordance with the state-approved Diet Manual. Therapeutic diets must be prescribed by the attending physician. 6. A preplanned emergency menu will be available. These food items must be stored in a separate location and rotated with new product every 12 months .

Review of the 2015 facility policy and procedure (P&P) titled Therapeutic Menu Planning indicated .Purpose: Therapeutic diets are also called modified or special diets and indicate a change from a regular diet. Often times, there is a problem in providing adequate nutritional care for geriatric residents. As a result of many years of living (often years of abuse), there are changes that occur in organ systems of the geriatric resident.

These changes affect the planning of nutritional care for both the health center and independent residents .

48263

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 27 555362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555362 B. Wing 06/07/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Casa DE Las Campanas 18655 W. Bernardo Drive San Diego, CA 92127

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or 48263 potential for actual harm Based on observation, interview and record review, the facility failed to ensure food served was in a Residents Affected - Few palatable, flavorful manner that maintained the nutritional value of the menu items served.

This failure had the potential to decrease residents' meal intake and contribute to weight loss. The facility census was 50.

Findings:

During a dining observation on 6/4/24 at 12:00 P.M., the following resident food concerns occurred:

- One resident reported she did not like the food that was being served (Pizza and mashed potatoes).

- One resident stated, the salad sucks.

- One resident stated, the food is dry.

Review of the facility's Resident Council meeting minutes dated February 2024, March 2024, and April 2024

the following dietary concerns were identified:

.beef and pork at dinner to tuff [sic] to eat.

Soup is not good and meat to cook [sic] or under cook.

Need help with menus and get food I need [sic].

Food needs more flavor.

During an interview on 6/5/24 at 4:22 PM with the resident council president (Resident 3), Resident 3 stated

the meat items served at the facility seemed overcooked and tough to eat. Resident 3 stated concerns about food was often discussed during the meetings and the menus were confusing with words that were hard to pronounce or foods that were unfamiliar.

A review of Resident 3's admission Minimum Data Set (MDS, a standardized care screening and assessment tool), dated 5/5/24, indicated that Resident 3 made herself-understood or understood others, and had no cognitive (mental process involved in knowing, learning, and understanding things) deficits.

Review of the facility's menu dated 6/5/24 indicated the Regular Diet was served chilled pea and mint soup, barbequed (BBQ) chicken, collard greens, garlic paprika chickpeas, yogurt gelatin dessert, and milk. The Pureed Diet was served pureed chilled pea and mint soup, pureed BBQ chicken, pureed collard greens, mashed potatoes, yogurt gelatin and milk.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 27 555362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555362 B. Wing 06/07/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Casa DE Las Campanas 18655 W. Bernardo Drive San Diego, CA 92127

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 On 6/5/24 at 12:35 PM, a test tray observation and interview with the Dietary Supervisor (DS) and the Food and Beverage Director (FDB) were conducted. The regular diet BBQ chicken tasted dry, a little over cooked, Level of Harm - Minimal harm or and lacked flavor. The FDB and DS agreed the chicken was dry and the FDB stated it could have had more potential for actual harm seasoning.

Residents Affected - Few During an interview on 6/6/24 at 2:58 PM with the Registered Dietitian (RD) and the DS. The RD stated the residents have had mixed reviews about the facility foods and the meals were boring. The RD further stated

she heard concerns the meat was tough sometimes and confirmed one of the residents did state the chicken was dry. The DS stated she was unaware of the resident council's dietary and food concerns. The DS also stated an in-service should have been done with kitchen staff on ways to make the menu for more palatable.

The RD also agreed the residents on pureed diets who received the mashed potatoes instead of the quinoa for lunch, did not receive the same nutritionally equivalent meal as the residents on a Regular diet. The RD stated the diet meals should be the same.

During a review of the facility policy titled Test Trays/Meal Rounds, dated 2013, the policy indicated .It is the policy of the community to serve food that is palatable, attractive .4. Food complaints will be addressed as

they arise on an individual basis.

38924

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 27 555362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555362 B. Wing 06/07/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Casa DE Las Campanas 18655 W. Bernardo Drive San Diego, CA 92127

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48263

Residents Affected - Few Based on observation, interview, and record review the facility failed to follow the dietary recommendations for the finger food diet for an unsampled resident, (Resident 60), reviewed for weight loss. Note: The nursing home is disputing this citation. This failure had the potential to negatively impact Resident 60's food intake which could further impair nutrition status and lead to weight loss. The facility census was 50.

Findings:

A review of Resident 60's Admission Record indicated the resident was initially admitted to the facility on [DATE REDACTED] with diagnoses which included, paroxysmal atrial fibrillation (an irregular heart rhythm that cause symptoms of shortness of breath, pounding heart beats, and weakness).

A review of Resident 60's admission Minimum Data Set (MDS, a standardized care screening and assessment tool), dated 5/10/24, indicated that Resident 60 usually made herself-understood or understood others, and had moderate impairment in cognitive (mental process involved in knowing, learning, and understanding things) skills. Resident 60 required substantial or maximum (helper does MORE THAN HALF

the effort) assistance with eating.

A review of Resident 60's Nutritional Evaluation dated 5/9/24 completed by the facility's Registered Dietitian (RD), the evaluation indicated, .about 25%, poses high nutritional risk for continued weight loss as she has already lost 3.8# over the past 6 days. Labs reviewed reflective of anemia. Nutrition dx (diagnosis): At risk of involuntary weight loss RT (related to) poor intake and lack of self-feeding ability .

A review of Resident 60's dietary progress note dated 5/13/24 completed by the Dietary Supervisor (DS), the progress note indicated, .resident eats well when meals are finger food. Will update preference to encourage better meal intake .

During a dining observation of Resident 60's lunch meal tray on 6/5/24 at 12:12 P.M., Resident 60 received one 1/2 meat sandwich with lettuce, two chicken legs, a bowl of split pea and mint soup, a banana and 8-ounce carton of milk.

During an interview with CNA 2 on 6/5/24 at 12:15 P.M., CNA 2 stated Resident 60 can eat some foods without assistance but needs assistance for others like sandwiches.

During a concurrent interview and record review on 6/6/24 at 2:53 P.M. with the RD and DS, the DS stated Resident 60 preferred finger foods and was on a regular texture diet. The RD and DS reviewed the facility's Finger Food policy titled Finger Food Diet, dated 2009. The policy indicated, .Meats are sliced and placed between bread to serve as a sandwich cut into fourths prior to meal service . The RD and DS acknowledged that the sandwich served was not cut in fourths and the RD stated the resident should have received the food in the correct form to encourage food intake and prevent weight loss.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 27 555362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555362 B. Wing 06/07/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Casa DE Las Campanas 18655 W. Bernardo Drive San Diego, CA 92127

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 Per the Academy of Nutrition & Dietetics, Nutrition Care Manual, dated 2022, .Unintended weight loss is linked to increased mortality (death) among older adults . residents in long-term-care facilities who continue Level of Harm - Minimal harm or losing weight have a higher mortality rate compared with those who stop losing weight. Weight loss of 5% or potential for actual harm more within 30 days is associated with a tenfold increase in the likelihood of death . https://www. nutritioncaremanual.org/ Residents Affected - Few

During a review of the facility's policy titled Scope of Service dated 2013, the policy indicated, .2. The staff is Note: The nursing home is adequately trained and educated in food preparation and service . disputing this citation. 38924

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 27 555362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555362 B. Wing 06/07/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Casa DE Las Campanas 18655 W. Bernardo Drive San Diego, CA 92127

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48263

Residents Affected - Some Based on observation, interview, and record review, the failed to ensure food safety and sanitation practices

in dietary services were maintained for food storage according to standards of practice when:

1. Two ice machines were not cleaned and maintained according to manufacturer's instructions.

2. Three ice machines and one dish machine did not have a proper air gap system to adequately prevent backflow of contaminated fluids.

3. Two reach-in refrigerators used to store facility resident food contained a brownish colored sticky grimy debris on the door gasket (inner rubber sealant that helps to create a vacuum and air-tight seal, forming a barrier to cool the inside of the refrigerator and freezer); and one reach-in refrigerator door had several black and grayish spots on the inside door panel.

4. Four green, three white and three red rubber cutting boards had white discoloration and severely worn with large cuts and groves in the center.

5. Multiple food items including individual desserts, were left uncovered during transport from the production kitchen to the health center kitchen for facility residents.

These failures had the potential to cause widespread food borne illness among all 50 residents who receive food from the kitchen.

Cross reference

F-F812.

Findings:

1. A) During the initial Skilled Nursing Facility (SNF) Health center kitchen tour on 6/4/24 at 8:56 AM, a Dishwasher Dietary Aide (DA 1) was observed using a low temperature (a dishwasher machine that uses a low heat of 140 degrees Fahrenheit in the rinse cycle) dish machine. DA 1 demonstrated how to test the chlorine solution levels needed to sanitize dishes in the dish machine with a chlorine test strip. DA 1 dipped

the test strip inside the top end opening of the dish machine door. DA 1 also took a strip and dipped it inside

the tank holding the dish machine solution. DA 1 stated both methods will give an accurate test of the sanitizer solution.

B) During a food production kitchen tour on 6/05/24 at 11:07 A.M., an observation and interview was conducted with DA 2 at the health center section food prep area. DA 2 demonstrated how he tested the sanitizer in the red buckets. DA 2 dipped an ammonia test strip a red sanitizing bucket with ammonia solution for 16 seconds then pulled it out and stated the reading was 300-400 ppm. DA 2 stated he used the red buckets with sanitizer to wipe food prep counter surfaces, food carts, and the food production sink. DA 2 stated he does not write down the test results on a log sheet in the kitchen and did not know where the results are logged. DA 2 stated he only logged the sanitizer test levels for the residential dining areas when

he works there.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 27 555362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555362 B. Wing 06/07/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Casa DE Las Campanas 18655 W. Bernardo Drive San Diego, CA 92127

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 C) During a food production kitchen tour on 6/5/24 at 11:32 A.M., DA 3 was observed in the dishwashing station at the three compartment sink cleaning pots and pans. DA 3 stated that he needed to check the Level of Harm - Minimal harm or sanitation levels at the beginning of his task and throughout the day at about every two hours. DA 3 potential for actual harm demonstrated strip testing with results at 300. DA 3 stated that it should be a 200 and stated that he would need to tell management because it was not at the level it should be. Residents Affected - Some

During an interview on 6/6/24 at 3:30 P.M., with the Dietary Supervisor (DS) and Registered Dietitian (RD),

the DS stated that a Contractor/Vendor did an in-service with the kitchen staff on the use of test strips for testing the sanitizer solution. The DS stated the kitchen staff were taught to use the appropriate process when testing sanitizer levels in for the dish machine and red the buckets. The DS and RD stated they expected the kitchen staff to follow the correct process for testing the sanitizer levels in the dish machine and

the red sanitizer buckets.

According to the 2022 Federal Food and Drug Administration (FDA) Food Code, section 4-501.116, titled Warewashing Equipment, Determining Chemical Sanitizer Concentration, .Concentration of the sanitizing solution shall be accurately determined by using a .other device .

During a review of the facility's sanitation log document titled POTS AND PANS DISHWAHER MACHINE SANTITZING SOLUTION STRENGTH LOG, dated June 2024, the sanitation testing was not recorded or signed during the AM shift on 6/5/24. The 6/1/24 through 6/4/24 red bucket sanitizer test results were recorded as 200 parts per million (ppm).

During a review of the facility's policy and procedure (P&P) titled, SANITATION, dated 2013, the P&P indicated .4. Food Service personnel will follow cleaning schedules and procedures in all areas for which

they are responsible .

During a review of the facility's policy and procedure (P&P) titled, DISHWASHING and SANITIZING, dated 2015, the P&P indicated .Proper dishwashing and sanitizing is necessary in the prevention of foodborne diseases .

2. During an interview in the production kitchen on 6/5/24 at 9:41 AM with [NAME] (CK) 1, CK 1 stated he does not always cook the meats but if he were to cook them, he would use the cool down process. CK 1 stated the cool down process was cooking the meat to 170 degrees then cool it down to 41 degrees in four hours. CK 1 stated he used a blast chiller machine to cool down foods but he did not know how long it took to cool down the foods. CK 1 stated if the blast chiller machine was not working he would have to use a cool down process.

During an interview on 6/6/24 2:36 P.M. with the DS and RD, both the DS and RD stated they expected the Cooks to know the proper methods to safely cook and cool down foods.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 27 555362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555362 B. Wing 06/07/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Casa DE Las Campanas 18655 W. Bernardo Drive San Diego, CA 92127

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 According to the 2022 Federal Food and Drug Administration (FDA) Food Code, section 3-501.14, titled Cooling, indicated .Bacteria rapidly grows between the temperatures of 40 degrees and 140 degrees Level of Harm - Minimal harm or Fahrenheit (F). Therefore, the cool down process is a method to prevent bacteria growth by safely reducing potential for actual harm the temperature of cooked and prepared foods for later consumption. The Federal FDA Food Code identifies cooling as an essential control measure for food safety, particularly after cooking meats or preparing Residents Affected - Some perishable foods with ingredients that are at ambient temperatures. When cooling cooked foods, after it reaches a safe minimum final internal cooking temperature (> than 145 degrees F), within two hours the temperature shall reach 70 degrees F or less, and within an additional four hours, it should reach 41 degrees F or less. For foods prepared with ingredients at ambient temperature, such as canned tuna, the food shall be cooled to a temperature of 41 degrees F or less within 4 hours.

During a review of the facility's policy and procedure (P&P), FOOD HANDLING GUIDELINES (HACCP) undated, indicated .Potentially hazardous food shall be cooled from 140*F (60*C) to 70 (21*C) as measured at its center within two hours from 70*F (21*C) to 41*F (5*C) within an additional four hours for a total cooling time of six hours .

3. During an interview on 6/5/24 at 11:35 A.M., with the Sous Chef (SC) in the 2nd floor kitchen dishwashing station. The SC stated an outside contractor [Contractor Name] was the one who does in-services and that

he also did in-service for kitchen sanitation. The SC stated he did not have a Certified Dietary Manager (CDM) credentials.

During an interview on 6/6/24 2:36 P.M., with the Registered Dietitian (RD), the RD stated the kitchen sanitation and food safety in-service trainings should be provided by a qualified kitchen staff member including a RD or CDM.

During an interview and record review on 6/6/24 2:40 P.M. with the DS, the DS acknowledged a document titled SHOW TIME dated 6/21/21 indicated .Refrigerators the inside and outside, at the same time refrigerator gaskets needs to be clean after lunch and dinner . The DS stated that that this was the in-service for refrigerator gaskets by the SC. The DS stated there was no documentation of specific kitchen staff in-services conducted between January 2021 and January 2024 on food safety and sanitation topics by a qualified kitchen staff member. The DS acknowledged the SC did not have the CDM credentials.

During a review of the facility's kitchen staff in-services binder, there was no documentation of in-services on food safety and sanitation to support in-services provided to staff from 6/21/19 until 4/24/24.

During a review of the facility policy titled, IN-SERVICE EDUCATION dated 2013 indicated .1. In-service education will be provided to all food service personnel at least monthly. 2. Topics will include, but not limited to, the following: a. Sanitation/Food borne illness .

38924

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 27 555362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555362 B. Wing 06/07/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Casa DE Las Campanas 18655 W. Bernardo Drive San Diego, CA 92127

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Level of Harm - Minimal harm or potential for actual harm 38924

Residents Affected - Some Based on observation, staff interview, and document review, the facility failed to ensure an emergency menu with the appropriate food and water supplies was developed to meet the nutritional and therapeutic needs of

the residents, according to facility policy and regulation standards.

This failure had the potential to result in further compromising the nutritional and health status of the facility's 50 medically vulnerable residents, or its 97 licensed beds.

Cross reference