Stanford Court Skilled Nursing & Rehab Center

F-F677

Findings:

Review of Resident 15's clinical record indicated Resident 15 was readmitted on [DATE REDACTED] with diagnoses which included a history of hemiplegia (one sided muscle weakness) and hemiparesis (inability to move one side of the body) following cerebral infarction affecting left dominant side (a brain attack known as a stroke that stops blood flow to the brain causing left sided weakness and movement to the body).

A record review of Resident 15's minimum data set (MDS- a nursing assessment tool) dated 7/18/24 indicated a, Brief Interview for Mental Status (BIMS- developed by reviewing the resident's mental status

during the prior seven-day period) score of 15 points out of 15 possible points which indicated Resident 15 had no cognitive (pertaining to memory, judgement, and reasoning ability) deficits.

A record review of Resident 15's MDS dated [DATE REDACTED], indicated that Resident 15's functional abilities status with personal hygiene (the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face, and hands) was dependent.

On 7/31/24 at 10:39 A.M., an observation and interview was conducted with Resident 15, in Resident 15's room. Resident 15 was seen lying in bed resting with a left-hand contracture without a hand splint. Resident 15's fingernails on both hands were long, thick, yellowish brown with brown dirt-like debris (accumulation of waste and/or dead skin) underneath her nailbeds with old chipped brownish red nail polish on the tip of the fingernails. Resident 15 stated her left hand required a splint due to the contracture (A permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) and was only able demonstrate opening her left hand enough to show the bottom half of her palm where the tip of her left fingernails rested. Resident 15 stated that the staff puts on her hand splint only when they think of doing so. Resident 15 stated she did not remember the last time they put on the hand splint or provided nail care.

On 8/1/24 at 8:53 A.M., an observation and interview was conducted with Resident 15, in Resident 15's room. Resident 15 was observed with a hand splint to her left contracted hand. Resident 15's fingernails on both hands were unchanged from 7/31/24 observation and were still long, thick, yellowish brown with brown dirt-like debris underneath her nailbeds with old chipped brownish red nail polish on the tip of the fingernails. Resident 15 stated the nursing staff did not provide nail care for her.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 27 555290 Department of Health & Human Services Printed: 09/17/2025 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 555290 B. Wing 08/02/2024

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

Stanford Court Skilled Nursing & Rehab Center 8778 Cuyamaca Street Santee, CA 92071

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 0684 On 8/1/24 at 2:02 P.M., an interview and record review was conducted with restorative nursing assistant (RNA: nursing staff providing rehabilitation [rehab] exercises for range of motion [ROM] as per Physician's Level of Harm - Minimal harm or order) 1. RNA 1 stated Resident 15 has an order for a palm guard (hand splints) and that passive range of potential for actual harm motion (PROM: exercises to help improve movement with assistance from staff to physically move the joints) and active range of motion (AROM: exercises to help movement without assistance). RNA 1 stated that Residents Affected - Few Resident 15's orders included the palm guard was ordered for four to six hours as tolerated. RNA 1 stated Resident 15's palm guard care to include making sure the splints are not on too tight, providing hand hygiene to include nail care and checking the skin for skin breakdown before and after splint use. RNA 1 stated that it was charted that the splint was applied at 10:15 A.M., on 7/31/24 and hand hygiene for Resident 15's hands should have been done. RNA 1 stated her [Resident 15] fingernails are dirty, and I would not leave her like that. I would clean and clipped them for sure.

On 8/1/24 at 2:25 P.M., an observation and interview was conducted with RNA 1 and Resident 15, in Resident 15's room. Resident 15 stated that it was yesterday in the morning shift after her shower that her left-hand splint was put on by the nursing staff and denied having the left-hand splint removed. RNA 1 removed Resident 15's hand splint and stated she would be providing hand hygiene and gathered supplies for Resident 15. Resident 15's left hand was a mildly reddened on the inside palm. Resident 15's fingernails

on both hands remained the same that were still long, thick, yellowish brown with brown dirt-like debris underneath her nailbeds with old chipped brownish red nail polish on the tip of the fingernails. Resident 15 stated, Hurting a bit when RNA 1 moved her hand to remove the splints. RNA 1 stated Resident 15's left hand splint should have been removed per MD order within four to six hours as tolerated and not kept on until the next day.

On 8/1/24 at 2:57 P.M., an interview and record review was conducted with the Director of Staff Development (DSD). The DSD stated that splints required Physician's orders and need to be followed. The DSD reviewed Resident 15's RNA orders for the left hand splint that indicated RNA: 5X/Wk [five times per week] FOR L [left] PALM GUARD 4-6 [sic] HRS [hours] AS TOLERATED; OFF FOR GROOMING AND HYGIENE. The DSD reviewed Resident 15's shower record that indicated Resident 15 had a shower at 13:13 (1:13 P.M.) on 7/31/24. The DSD stated the Resident 15's left hand splint should have been removed sooner and should only be on within the time frame per Physician's order within the four-to-six-hour time frame. The DSD stated hand hygiene should have been provided to include Resident 15's fingernails on both hands to be trimmed and cut as long as Resident 15 did not have diabetes (a disease when your body is unable to control blood sugar levels). The DSD reviewed Resident 15's clinical record and indicated Resident 15 did not have a diagnosis of diabetes and therefore stated RNA's and Certified Nursing Assistants (CNAs) should be providing nail care for Resident 15 during ADL care. The DSD stated it did not look like Resident 15 was provided with sufficient nail care for both her hands because it, Should not be long and dirty.

On 8/2/24 at 9:31 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated that Resident 15 did not look like she was getting appropriate nail care for both hands with fingernails that looked long, yellow, thick with noticeable old nail polish on the fingertips and dirty fingernails with dirt under the nail beds. The DON also stated Resident 15's hand splint should not have been left on overnight and the Physician's orders should have been followed to prevent risks for skin breakdown and infection from splint use. The DON stated her expectations for Resident 15's hand hygiene is to inspect the skin for skin breakdown, nails were trimmed to prevent infection from accidental nail injury, and fingernail beds clean.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 27 555290 Department of Health & Human Services Printed: 09/17/2025 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 555290 B. Wing 08/02/2024

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

Stanford Court Skilled Nursing & Rehab Center 8778 Cuyamaca Street Santee, CA 92071

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 0684 Per the facility's policy and procedure titled ADL CARE PROVIDED FOR DEPENDENT RESIDENTS revised March 2018 indicated, Policy Statement: A resident who is unable to carry out activities of daily living Level of Harm - Minimal harm or receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene, receive potential for actual harm this assistance from the facility .

Residents Affected - Few Per the facility's undated policy and procedure titled SPLINT APPLICATION indicated, The splint will be applied on the a.m. shift and removed on the p.m. shift .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 27 555290 Department of Health & Human Services Printed: 09/17/2025 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 555290 B. Wing 08/02/2024

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

Stanford Court Skilled Nursing & Rehab Center 8778 Cuyamaca Street Santee, CA 92071

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 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46235

Residents Affected - Few Based on observation, interview, and record review the facility failed to appropriately care for one of three residents' drainage tube reviewed for staff competency (Resident 177).

This deficient practice had the potential for unresolved infection.

Findings:

Resident 177 was admitted to the facility on [DATE REDACTED] with diagnoses including peritoneal abscess (collection of pus in the body below the abdomen between the hip bones) and sepsis (the body's extreme and life-threatening response to an infection) according to the facility's Admission Record.

During an observation and interview on 7/30/24, at 8:42 A.M. with Resident 177, Resident 177 was sitting on

a wheelchair and showed a tube with an accordion bulb connected to a drainage bag. Resident 177 stated

the drain was due to an abscess and the staff did not properly took care of it. Resident 177 stated it has been two days that the accordion bulb was not squeezed (squeezed - to apply suction to drain the fluid). The accordion bulb was observed with small amount of brown fluid, and the accordion bulb was not squeezed.

On 7/31/24, at 12:27 P.M. Resident 177 was sitting up in the wheelchair. The drainage tube was observed hanging on Resident 177's left side with accordion bulb which was not squeezed.

During a review of physician's orders (POS) for Resident 177, the POS with start date of 7/24/24 indicated, . IR Drain insertion site Site: Left buttocks monitor for drainage, pain and s/sx (signs and symptoms) of infection until healed .

During an interview on 8/1/24, at 10:32 A.M. with licensed nurse (LN) 14, LN 14 stated Resident 177 had a drain on the left buttock due to diverticulitis (small and inflamed pouches that forms in the wall of the large intestine), and the treatment nurse provided care of the drainage tube.

During an interview on 8/1/24, at 1:34 P.M. with the treatment nurse (TN), the TN stated she changed Resident 177's drainage tube site dressing, then squeezed the accordion bulb for fluid to drain. The TN further stated the accordion bulb must be squeezed to create suction and drain fluid.

On 8/1/24, at 1:41 P.M. an interview was conducted with LN 11. LN 11 stated she covered for the TN when TN was off. LN 11 stated she flushed Resident 177's drainage tube and covered the site with a dressing. LN 11 stated the drain worked by gravity and the accordion bulb did not have to be squeezed. LN 11 further stated the accordion bulb was squeezed only upon emptying of the drainage bag.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 27 555290 Department of Health & Human Services Printed: 09/17/2025 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 555290 B. Wing 08/02/2024

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

Stanford Court Skilled Nursing & Rehab Center 8778 Cuyamaca Street Santee, CA 92071

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 0726 During a concurrent record review and interview on 8/1/24, at 1:48 P.M. with LN 16. LN 16 read the progress notes from the hospital dated 7/22/14 for Resident 177. The progress notes indicated, . drainage of deep Level of Harm - Minimal harm or pelvic abscess .catheter placed to accordion bag drainage . LN 16 stated Resident 177's drainage tube with potential for actual harm accordion bulb should be squeezed at all times to create negative pressure on the tube and drain the abscess from the site. LN 16 further stated if the accordion was not squeezed, the fluid remained inside the Residents Affected - Few resident's site of infection which defeated the purpose of Resident 177's use of an antibiotic to clear the infection.

During a concurrent record review on 8/1/24, at 1:41 P.M. with LN 16, LN 16 stated the hospital record for Resident 177 titled, After Visit Summary, dated 7/23/24, the record indicated, .Caring for a Closed Suction Drainage Tube. A drainage tube removes fluid from around the incision. This helps prevent infection and promotes healing. The collection bulb at the end of the tube is squeezed and plugged to create suction .

An interview was conducted on 8/2/24, at 12:59 P.M. with the Director of Nurses (DON). The DON stated Resident 177's accordion bulb should be squeezed to create pressure to remove fluids. The DON stated Resident 177's accordion bulb has not been squeezed when she had checked on Resident 177. The DON further stated she expected staff to ensure Resident 177's accordion bulb was squeezed to remove fluid from

the abscess.

During a review of the facility's policy and procedure (P&P) titled, Percutaneous (Pigtail) Drain, Care of, dated, October 2021, the P&P indicated, .The pigtail drain operates on the principle of negative pressure. Compression must be maintained on the bulb/accordion for suction to be preserved .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 27 555290 Department of Health & Human Services Printed: 09/17/2025 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 555290 B. Wing 08/02/2024

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

Stanford Court Skilled Nursing & Rehab Center 8778 Cuyamaca Street Santee, CA 92071

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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. 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 store medications in a secured location for two of three residents (Resident 47 and Resident 30) reviewed for medication storage when:

1. A discontinued order for triamcinolone ointment (a prescribed skin cream to treat skin associated irritation such as rash) was kept uncapped and unsecured on Resident 47's nightstand table.

Cross Reference

F-F684

Findings:

Review of Resident 15's clinical record indicated Resident 15 was readmitted on [DATE REDACTED] with diagnoses which included a history of hemiplegia (one sided muscle weakness) and hemiparesis (inability to move one side of the body) following cerebral infarction affecting left dominant side (a brain attack known as a stroke that stops blood flow to the brain causing left sided weakness and movement to the body) per the facility's Admission Record.

A record review of Resident 15's minimum data set (MDS: a nursing assessment tool) dated 7/18/24 indicated a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's mental status

during the prior seven-day period) score of 15 points out of 15 possible points which indicated Resident 15 had no cognitive (pertaining to memory, judgement, and reasoning ability) deficits.

A record review of Resident 15's MDS dated [DATE REDACTED], indicated that Resident 15's functional abilities status with personal hygiene (the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands) was dependent.

On 7/31/24 at 10:39 A.M., an observation and interview was conducted with Resident 15, in Resident 15's room. Resident 15 was seen lying in bed resting with a left-hand contracture without a hand splint. Resident 15's fingernails on both hands were long, thick, yellowish brown with brown dirt-like debris (accumulation of waste and/or dead skin) underneath her nailbeds with old chipped brownish red nail polish on the tip of the fingernails. Resident 15 stated that the staff puts on her hand splint only when they thought of doing so. Resident 15 stated she did not remember the last time they put on the hand splint or provided nail care.

On 8/1/24 at 8:53 A.M., an observation and interview was conducted with Resident 15, in Resident 15's room. Resident 15 was observed with a hand splint to her left contracted hand. Resident 15's fingernails on both hands were long, thick, yellowish brown with brown dirt-like debris underneath her nailbeds and old chipped brownish red nail polish on the tip of the fingernails. Resident 15 stated the nursing staff did not provide nail care for her.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 27 555290 Department of Health & Human Services Printed: 09/17/2025 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 555290 B. Wing 08/02/2024

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

Stanford Court Skilled Nursing & Rehab Center 8778 Cuyamaca Street Santee, CA 92071

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 0677 On 8/1/24 at 2:02 P.M., an interview and record review was conducted with the restorative nursing assistant (RNA: nursing staff providing rehabilitation [rehab] exercises for range of motion [ROM] as per Physician's Level of Harm - Minimal harm or order) 1. RNA 1 stated Resident 15's hand splints orders were for passive range of motion (PROM: exercises potential for actual harm to help improve movement with assistance from staff to physically move the joints) and active range of motion (AROM: exercises to help movement without assistance). RNA 1 stated that Resident 15's orders Residents Affected - Few included the palm guard (hand splints) to apply for four to six hours as tolerated. RNA 1 stated that it was charted that the splint was applied at 10:15 A.M., on 7/31/24 and hand hygiene for Resident 15's hands should have been done. RNA 1 stated, Her [Resident 15] fingernails are dirty, and I would not leave her like that. I would clean and clipped them for sure.

On 8/1/24 at 2:25 P.M., an observation and interview was conducted with RNA 1 and Resident 15, in Resident 15's room. Resident 15 stated her left hand splint was not removed since they applied the splint

after her shower from 7/31/24. Resident 15 stated, Hurting a bit when RNA 1 moved her hand to remove the splints due to the stretching. Resident 15's left hand was mildly reddened on the inside palm. Resident 15's fingernails on both hands remained long, thick, yellowish brown with brown dirt-like debris underneath her nailbeds with old chipped brownish red nail polish on the tip of the fingernails. RNA 1 stated Resident 15's left hand splint should have been removed yesterday according to the Physician's order.

On 8/1/24 at 2:57 P.M., an interview and record review was conducted with the Director of Staff Development (DSD). The DSD stated it did not look like Resident 15 was provided with sufficient nail care for both her hands because it, Should not be long and dirty.

On 8/2/24 at 9:31 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated that Resident 15 did not look like she was getting appropriate nail care for both hands. The DON stated Resident 15 should receive quality nail care to include trimmed and clean nails.

The facility policy and procedure titled FINGERNAILS/TOENAILS, CARE OF revised, February 2018 indicated, .The purpose of this procedure are to clean the nail bed, to keep nails trimmed and to prevent infections .General Guidelines 1. Nail care includes daily cleaning and regular trimming .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 27 555290 Department of Health & Human Services Printed: 09/17/2025 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 555290 B. Wing 08/02/2024

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

Stanford Court Skilled Nursing & Rehab Center 8778 Cuyamaca Street Santee, CA 92071

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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48263 potential for actual harm Based on observations, interviews, and record reviews, the facility did not ensure that a resident received Residents Affected - Few needed care and services in accordance with professional standards of practice for one out of four residents reviewed requiring dependent (helper does all the effort. Resident does none of the effort to complete the activity) assistance.

This failure had the potential to compromise Resident 15's health status.

Cross Reference

F-F813

Findings:

Review of Resident 58's Admission Record indicated Resident 58 was admitted to the facility on [DATE REDACTED] with diagnoses that included Malignant Neoplasm of Endometrium (cancer of uterus).

On 7/30/24 at 9:20 A.M., an observation of Resident 58's room was conducted. Resident 58's door had signage which indicated Resident 58 was on neutropenic precautions.

On 7/30/24 at 9:25 A.M., an interview with Resident 58's roommate (Resident 59) was conducted. Resident 59's bedside table had a basket of raw fruits which consisted of apples and oranges. Resident 59 stated her daughter brought in the basket of fruits few weeks ago and left them on her bedside table. Resident 59 stated a supervisor from the facility took them out yesterday after the State saw the basket of raw fruits. Resident 59 stated she did not realize the raw fruits were not allowed in the room.

On 8/2/24 at 9:30 A.M., an interview with Certified Nursing Assistant (CNA) 23 was conducted. CNA 23 stated Resident 58 was on neutropenic precautions to protect her from outside germs brought in by staff and visitors since Resident 58 was prone to infection. CNA 23 stated staff must gown up before entering Resident 58 's room and do hand hygiene. CNA 23 stated flowers were allowed in Resident 58's room, same with fruits and vegetables if they have been washed. CNA 23 stated visitors must gown up too but often they did not.

On 8/2/24 at 9:57 A.M., an interview with licensed nurse (LN) 21 was conducted. LN 21 stated staff needed to wear mask, gown and gloves when entering Resident 58's room. LN 21 stated the facility does laboratory work to monitor Resident 58's white blood cell to ensure Resident 58 was protected from infection.

On 8/2/24 at 10:02 A.M., an interview with LN 22 was conducted. LN 22 stated Resident 58 was on neutropenic isolation due a low white blood cell count. LN 22 stated staff needed to gown up and wear mask prior to entering Resident 58's room. LN 22 stated that was done to protect Resident 58 from infection. LN 22 stated there should be no fresh or raw fruits, vegetables, or flowers in Resident 58's room. LN 22 stated Resident 58's visitors were advised to gown up and are not allowed to bring fruits, vegetables, and flowers of any kind.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 27 555290 Department of Health & Human Services Printed: 09/17/2025 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 555290 B. Wing 08/02/2024

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

Stanford Court Skilled Nursing & Rehab Center 8778 Cuyamaca Street Santee, CA 92071

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 On 8/2/24 at 10:30 A.M., an interview with the Infection Preventionist Nurse (IPN) was conducted. IPN stated IPN stated Resident 58 was bedbound but goes outside of her room at times with a mask to protect herself Level of Harm - Minimal harm or from infection from all sources. potential for actual harm

On 8/2/24 at 2:00 P.M., an interview with the Director of Nursing (DON) was conducted. DON stated she was Residents Affected - Few made aware of the fruits found in Resident 58's room on 7/30/24. The DON stated she took the fruits off of Resident 59's bedside table. DON stated the staff should be following the neutropenic protocol to protect Resident 58 from contamination and infection. DON stated it was important for staff to know what kind of precautions Residents 58's required, and what personal protective equipment (PPE-protection from injury and infection) to use when inside Resident 58's room.

A record review of Resident 58's Admission orders dated 9/23/2023 indicated .Neutropenic precautions related to malignant neoplasm of endometrium, indicated no outside food, plants, and flowers .

A review of the facility's Neutropenic Precautions policy and procedure dated April 2018 .precautions continued .#4 plants and flowers shall be removed from the resident room . dietary concerns .#2 raw and partially cooked meat, vegetables and fruits are prohibited .miscellaneous .#3 family members and visitors may be required to wash their hands, put gown on and wear mask .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 27 555290

F-F880

2. Resident 47 had three unlabeled food items with a brownish yellow banana, placed on top of a cluttered emesis basin, plastic wrapped chocolate pastries on top of a plastic container and a sandwich in an open plastic container unsecured without a lid at the bedside.

This failure had the potential to attract pests (insects and rodents that carry harmful bacteria or viruses that could be passed on to humans), spoilage (the process in which food or other substances stop being good enough to eat or use) of food and risks of foodborne illnesses from food consumption.

Findings:

1. Review of Resident 59's clinical record indicated Resident 59 was readmitted on [DATE REDACTED] with diagnoses which included a history of hemiplegia (one sided muscle weakness) and hemiparesis (inability to move one side of the body) following cerebral infarction affecting left non-dominant side (a brain attack known as a stroke that stops blood flow to the brain causing left sided weakness and movement to the body).

A record review of Resident 59's minimum data set (MDS: a nursing assessment tool) dated 6/3/24, indicated a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's mental status

during the prior seven-day period) score of 15 points out of 15 possible points which indicated Resident 47 had no cognitive (pertaining to memory, judgement, and reasoning ability) deficits.

On 7/30/24 at 9:26 A.M., an observation and interview was conducted with Resident 59. Resident 59 had a mesh bag that contained oranges and apples in a clear plastic bag beside fresh flowers on the nightstand to her right. Resident 59 stated she liked fruits and that her daughter had brought over the oranges and apples about a week ago and had been placed there for easy access for when she craved them.

On 8/1/24 at 9:34 A.M., an observation and interview was conducted with Resident 59. Resident 59 stated that the facility had removed her oranges and apples because, They have State here [the facility] and was told by the nursing staff to keep the oranges and apples in the closet. Resident 59 stated that the nursing staff had placed her oranges and apples in her closet so that it was not left out in the open.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 27 555290 Department of Health & Human Services Printed: 09/17/2025 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 555290 B. Wing 08/02/2024

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

Stanford Court Skilled Nursing & Rehab Center 8778 Cuyamaca Street Santee, CA 92071

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 On 8/1/24 at 1:34 PM an observation, interview and record review was conducted with licensed nurse (LN) 1. LN 1 stated that she was Resident 59's nurse for the past two days. LN 1 stated that all food items brought Level of Harm - Minimal harm or by outside visitors and family to residents should be stored, labeled with resident's name, date and time, and potential for actual harm discarded within 24 hours. LN 1 stated the outside food from visitors were stored in the east wing refrigerator for all residents. An observation was conducted with LN 1 at the east wing refrigerator for personal food Residents Affected - Few storage. Resident 59's oranges and apples were not stored in the residential refrigerator. LN 1 stated that

they would have to disclose this policy for outside food to all residents and family. LN 1 stated that Resident 59's oranges and apples should not have been placed at Resident 59's bedside because the fruits needed to be refrigerated and should have been discarded since it had been over a week and not stored properly to prevent spoilage and consumption to prevent food borne illnesses. A record review was conducted with LN 1 regarding neutropenic (a decrease in white blood cells that help fight off infection) precautions (unwashed fruits and fresh flowers may contain harmful bacteria [tiny organisms found everywhere] and fungi [mold] that is harmful for people with neutropenia) for Resident 59's room. LN 1 stated Resident 59 was not on neutropenic precautions, but her roommate was on neutropenic precautions as to why the sign posted outside of Resident 59's room prior to entry. LN 1 stated that fruits and fresh flowers that were kept in Resident 59's room could potentially compromise Resident 59's roommates health because the room should not have fresh flowers or fruits due to the roommate's poor immune system to fight off infection.

On 8/01/24 at 2:57 P.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated Resident 59's fruits should have been stored in the personal items' refrigerator for residents' [all facility residents] located in the east wing and properly labeled to prevent foodborne illness from consuming spoiled food. The DSD stated it should not be stored in the closet as this could attract pests and it should had been discarded since it was not properly stored in Resident 59's room for over two days.

On 8/2/24 at 9:20 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated her expectations were for visitors to be informed regarding the facility's policies and procedures for bringing outside food and for the nursing staff to properly store the food items at the right temperature to prevent spoilage and to prevent foodborne illnesses from consuming spoiled foods. The DON stated that Resident 59's roommate was on neutropenic precautions and having fresh fruits and flowers should not be allowed in

the room to prevent infection from harmful bacteria and mold that can grow on fruits and plants.

Per the facility's policy and procedure titled FOOD BROUGHT by FAMILY/VISITORS dated, March 2022 indicated, . Policy and Interpretation and Implementation .4. Safe food handling practices are explained to

the family/visitors in a language and format that they understand .5. Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that it is clearly distinguishable from facility-prepared food .

2. Review of Resident 47's clinical record indicated Resident 47 was readmitted on [DATE REDACTED] with diagnoses which included a history of hemiplegia (one sided muscle weakness) and hemiparesis (inability to move one side of the body) following cerebral infarction affecting left non-dominant side (a brain attack known as a stroke that stops blood flow to the brain causing left sided weakness and movement to the body).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 27 555290 Department of Health & Human Services Printed: 09/17/2025 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 555290 B. Wing 08/02/2024

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

Stanford Court Skilled Nursing & Rehab Center 8778 Cuyamaca Street Santee, CA 92071

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 A record review of Resident 47's MDS dated [DATE REDACTED], indicated a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's mental status during the prior seven-day period) score of 15 points out Level of Harm - Minimal harm or of 15 possible points which indicated Resident 47 had no cognitive (pertaining to memory, judgement, and potential for actual harm reasoning ability) deficits.

Residents Affected - Few On 7/30/24 at 9:19 A.M., an observation and interview was conducted with Resident 47, in Resident 47's room. Food items were observed at Resident 47's bedside which included unlabeled and undated food items such as a sandwich wrapped in a plastic wrap in a container without a lid, chocolate pastries stored outside of a plastic container wrapped in plastic and a brownish yellow banana on top of a cluttered emesis basin with resident belongings was observed placed on Resident 47's left nightstand. Resident 47 stated that he did not like the food at the facility and that his wife brought all the food items from home.

On 8/01/24 at 1:34 P.M., an interview was conducted with LN 1, at the west wing nursing station. LN 1 stated that they store outside food items brought by visitors and family to a resident needed to be stored in a refrigerator located in the east wing. LN 1 stated it was not appropriate to have Resident 47's food items stored and unlabeled at his bedside. LN 1 stated that Resident 47's food items that were placed on the nightstand which included a sandwich, chocolate pastries, and a banana are all perishable (foods that can spoil easily without proper storage) and should have been labeled, stored in a refrigerator, or discarded. LN 1 stated since the food items were not labeled and not stored properly it was best to discard the food items to prevent any food-borne illnesses.

On 8/1/24 at 2:57 P.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated Resident 47's sandwich and chocolate pastries should be stored in a tight-fitting container with a lid with a label and dated. The DSD stated that Resident 47's food items should be stored appropriately in the residents' fridge located in the East wing nursing station should the food be consumed at a later time. The DSD stated if food items are not labeled then the nursing staff would need to discard it right away to prevent attracting pests that can carry infection and the consumption of spoiled foods that could lead to food-borne illnesses.

On 8/2/24 at 8:57 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated foods should not be on stored at Resident 47's bedside. The DON stated outside food items should be labeled to prevent spoilage and stored properly in tight fitting containers with lids to prevent attracting pests from contaminating food items that are harmful to all the facility residents and to prevent the consumption of spoiled foods to prevent food-borne illnesses.

Per the facility's policy and procedure titled FOOD BROUGHT by FAMILY/VISITORS dated, March 2022 indicated, . Policy and Interpretation and Implementation .4. Safe food handling practices are explained to

the family/visitors in a language and format that they understand .5. Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that it is clearly distinguishable from facility-prepared food a. Non-perishable foods are stored in re-sealable containers with tightly fitting lids b. Perishable foods are stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers are labeled with the resident's name, the item and the use by date .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 27 555290 Department of Health & Human Services Printed: 09/17/2025 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 555290 B. Wing 08/02/2024

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

Stanford Court Skilled Nursing & Rehab Center 8778 Cuyamaca Street Santee, CA 92071

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47466 potential for actual harm Based on observation, interview and record review, the facility failed to ensure a neutropenic (low white Residents Affected - Few blood cell count- part of the body's immune system) precautions room for one reviewed resident (Resident 58), was free of potential infection from raw foods.

This failure had the potential outcome of endangering Resident 58's health condition and possible decline from exposed raw foods.

Cross reference