Health inspection·May 5, 2022

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure one resident (Resident 274) of two sampled residents (Resident 47 and 274) was free from physical abuse when; Resident 47 grabbed Resident 274 on the back of the neck during an altercation in the lobby area. This deficient practice resulted in repeated episodes of resident to resident altercation and had the potential to cause emotional distress, pain, and injury. Findings: During an interview on 5/3/22 at 10:00 a.m., Resident 274 stated Resident 47 bumped into his wheelchair at the lobby area and grabbed him on the back of his neck. Resident 274 stated he was traumatized. During an interview on 5/3/22 at 10:09 a.m., Resident 47 stated Resident 274 was his roommate. Resident 47 stated he grabbed Resident 274 on the back of his neck because Resident 274 had called him the N word and snored. Resident 47 stated he was upset, and when he bumped into Resident 274 in the lobby, he grabbed his neck and staff separated them immediately. Review of Resident 274's admission Minimum Data Set (MDS- an assessment and care screening tool used to guide care), dated 4/17/22, indicated Resident 274's Basic Interview of mental status (BIMS) score was 15 (meaning cognitively intact). Resident 274 had no behavioral symptoms. Review of Resident 47's admission MDS dated [DATE], indicated Resident 47's BIMS score was 14 (cognitively intact ). Resident 47 diagnoses included anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with ones's daily activities). During an interview on 5/3/22 at 10:20 a.m., the Social Services Director (SSD) confirmed that on 4/30/22, Resident 47 bumped into Resident 274's wheelchair in the lobby area, turned around and grabbed Resident 274 on the back of his neck. Review of the change in condition narrative notes dated 4/30/22 reflected Resident 47 bumped into Resident 274's wheelchair turned around and grabbed Resident 274 on the back of the neck. Review of nursing progress notes dated 4/19/22, indicated Resident 47 had arguments before with Resident 274 in the hallway. Resident 47 tried to gain access to Resident 274, and the on duty nurse Page 1 of 8 055099 055099 05/05/2022 Creekside Healthcare Center 1900 Church Lane San Pablo, CA 94806

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few gave verbal instructions to stop but Resident 47 did not stop. Resident 47 continuously yelled at Resident 274, and the on duty nurse separated both residents and informed the supervisor to change their room. During an interview on 5/4/22 at 12:54 p.m., the Registered Nurse (RN 1) stated she was the on duty charge nurse on 4/19/22 when Resident 47 argued and yelled at Resident 274 in the hallways. RN 1 stated Resident 47 argued aggressively with pointed finger towards Resident 274 and did not stop. when instructed to stop. RN stated she separated both residents and informed her supervisor to consider a room change for Resident 47. During an interview on 5/4/22 at 9:06 a.m., the Licensed Vocational Nurse (LVN 1) stated Resident 47 complained about loud noises at night. LVN 1 stated no formal report was made because it was difficult to understand who Resident 47 was referring too because of the way he talked. Review of the behavior care plan, dated 4/13/22 indicated, Resident 47's behavior included being physically abusive to others and making sexual advances towards staff members. Further review indicated Resident 47's care plans were not revised with new interventions to address the altercation on 4/19/22 resident-to-resident arguments, yelling and Resident 47's complaints of noise at night. During an interview on 5/4/22 at 12:26 p.m., the Director of Nursing (DON) stated she was not aware of the incident on 4/19/22 about Resident 47 and Resident 274 arguments and yelling. DON further stated Resident 47 and 274's care plans were not revised with new interventions regarding the incident on 4/19/22. The facility's policy and procedure, titled, Abuse & Neglect Prohibition, revised May 2013 indicated, Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain or mental anguish. 055099 Page 2 of 8 055099 05/05/2022 Creekside Healthcare Center 1900 Church Lane San Pablo, CA 94806

F 0657 Level of Harm - Minimal harm or potential for actual harm Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on interviews and record review, the facility failed to revised one of two sampled residents (Resident 47) care plans with new interventions to address Resident 47's aggressive arguments and complaint. Residents Affected - Few This deficient practice did not ensure interventions were developed and implemented to avoid repeat altercations. Findings: Review of the nursing progress notes dated 4/19/22, indicated Resident 47 had arguments with Resident 274 in the hallway and tried to gain access to Resident 274. The on duty nurse documented Resident 47 continued to yell at Resident 274 and would not stop which required the on duty nurse to separate the residents. A room change was considered at that time following the altercation. During an interview on 5/4/22 at 12:54 p.m., the Registered Nurse (RN 1) stated she was the on duty charge nurse on 4/19/22 when Resident 47 argued and yelled at Resident 274 in the hallways. RN 1 stated she verbally notified her supervisor. During an interview on 5/4/22 at 9:06 a.m., the Licensed Vocational Nurse (LVN 1) stated Resident 47 had complained about loud noise at night. LVN 1 stated no formal report was made because it was difficult to understand who Resident 47 was referring too because of the way he talked. Review of the behavior care plan, dated 4/13/22 indicated Resident 47's behavioral manifesting included physically abusive to others and making sexual advances towards staff members. Further review indicated Resident 47's care plans was not revised with new interventions about the 4/19/22 resident-to-resident arguments, yelling, and complaints of noise at night. Review of change in condition narrative notes dated 4/30/22 indicated Resident 47 bumped into Resident 274's wheelchair turned around and grabbed Resident 274 on the back of the neck. During an interview on 5/4/22 at 12:26 p.m., the Director of Nursing (DON) stated she was not aware of the 4/19/22 incident between Resident 47 and Resident 274 . DON stated Resident 47 and Resident 274's care plan, were not updated with new interventions. The facility's policy and procedure titled, Comprehensive Plan of Care, revised date 11/15/2001, indicated, the comprehensive plan of care must: Be periodically reviewed and revised by the interdisciplinary team as changes in the resident's care and treatment occur. 055099 Page 3 of 8 055099 05/05/2022 Creekside Healthcare Center 1900 Church Lane San Pablo, CA 94806

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure safe medication storage when the eye drops and ear drops were stored next to each other in green and white boxes and there was an expired 1000 ml (milliliter) bag of 10% Dextrose (sugar water solution given intravenously or into the vein) in the medication storage room. These failures had the potential for medication errors to occur (for example, administering ear medication into the eye which could cause blindness) or or the resident to receive expired intravenous (IV) fluids. Findings: 1. During an observation on [DATE] at 11:15 a.m., there were eye drops and ear drops kept next to each other on a shelf. Both were in green and white boxes. During an interview with the Registered Nurse (RN) 2 on [DATE] at 11:15 a.m., RN 2 stated they should not be stored next to each other because it would be easy to grab the wrong one. 2. During an observation of the Medication Storage Room on [DATE] at 11:15 a.m., there was a bag of 10% Dextrose in a drawer with a pharmacy label indicating a room temperature expiration date of [DATE]. The prescription filled date was [DATE]. During an interview with Registered Nurse 2 (RN) on [DATE] at 11:15 a.m., RN 2 stated the 10% Dextrose was to hang when a Resident was not getting his TPN (total parenteral nutrition, a special formula given through a vein). RN 2 stated the expiration date from the manufacturer was 06/22. During a telephone interview with the Pharmacist (Ph) on [DATE] at 11:49 a.m., Ph stated once the bag of fluids is removed from the moisture bag (a protective overwrap), it expires in 30 days. Ph stated this bag was opened on [DATE], so the expiration date is [DATE]. During a review of the Drug & Biological Storage policy, dated 03/00, the policy indicated that no discontinued, outdated or deteriorated drugs or biologicals may be retained for use. 055099 Page 4 of 8 055099 05/05/2022 Creekside Healthcare Center 1900 Church Lane San Pablo, CA 94806

F 0803 Level of Harm - Minimal harm or potential for actual harm 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. Based on observation, interviews, and record review, the facility failed to follow a current seasonal menu and meal plan when the facility used the Fall/Winter 2021 menu to prepare the residents' meals. Residents Affected - Some This deficient practice did not ensure seasonal foods which offer variety, palatability, and nutritional value were made available to residents. Findings: During an interview on 5/2/22 at 11:11a.m., the Certified Dietary Manager (DS) provided a copy of the menu titled, Fall/Winter 2021. DS stated the facility currently uses the Fall/Winter 2021 menu to prepare the residents' meal. During an interview on 5/2/22 at 12:42 p.m., the Registered Dietician (RD) stated the spring menu cycle began in April 2022. RD stated the facility had contacted the menu provider in order to initiate the new menu cycle. During an interview on 5/3/22 at 10:06 a.m., the Administrator (Admin) stated the facility had been in contact with the menu provider for updated seasonal menus and continued to wait. During the tray line observation on 5/3/22 at 11:33 a.m., the facility used the Fall/Winter 2021 menu for food preparation and served the following for lunch: Fish, carrot and rice pillar, gravy, tomato soup, chicken and rice soup, baked chickens , mashed potato, beef parties, broccoli, puree fish, or chicken ravioli as an alternative. The facility's policy and procedure titled, Menu revised 7/1/2017, indicated the menus incorporate regional tastes, seasonal changes, and dietary modification. 055099 Page 5 of 8 055099 05/05/2022 Creekside Healthcare Center 1900 Church Lane San Pablo, CA 94806

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to serve palatable food when the facility served chicken rice soup that was too salty. Residents Affected - Some This deficient practice had the potential to cause residents to not enjoy their meal and decline to eat. Findings: Review of the Fall/Winter 2021 menu indicated the lunch menu included, Mediterranean style cod, rice pilaf, carrot, wheat roll, margarine, strawberries with whipped topping, coffee with tea, milk with garnish of choice. During the tray line observation on 5/3/22 at 11:33 a.m., the facility served for lunch- Fish, carrot and rice pillar, gravy, tomato soup, chicken and rice soup, baked chicken, mashed potato, beef patties, broccoli, puree fish, and chicken ravioli as the alternate choice. During a sampled meal tray test on 5/03/22 at 1:21 p.m., accompanied by the Certified Dietary Manager (DS), and test tasted by the Registered Dietician (RD) and the Surveyor, the chicken and rice soup tasted too salty. DS stated the soup was canned soup and the facility will work on it. The facility's policy and procedure, titled Food Service Policy, revised 4/15/2001, indicated; The facility provides and each resident receives food that is: prepared by methods that conserve nutritive value, flavor, and appearance, palatable, attractive, and at the proper temperature, and prepared in a form designed to meet individual needs. 055099 Page 6 of 8 055099 05/05/2022 Creekside Healthcare Center 1900 Church Lane San Pablo, CA 94806

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interviews, and record review, the facility failed to follow proper sanitation and food storage practices as follows: Residents Affected - Some a. Dishwashing racks with brownish discoloration, b. Plate covers had a faded, discolored appearance c. Air vent had a thick layer of black dust. These deficient practices had the potential to result in foodborne illness. Findings: During the initial observation tour of the kitchen on 5/02/22 at 9:47 a.m., accompanied by the Certified Dietary Manager (DS), the dishwashing racks had brownish discoloration, plate covers had a faded discolored appearance, and the air vent had a thick layer of black dust. During an interview on 5/02/22 at 9:47 a.m., DS stated the Maintenance Supervisor (MS) was responsible for the cleaning of the kitchen air vent. DS stated the dishwashing racks and plate covers will be ordered and replaced. During an interview on 5/05/22 at 9:05 a.m., MS stated the air vent in the kitchen was supposed to be cleaned weekly. MS further stated the facility had a contractor that does the cleaning, but unfortunately, was not cleaned during the contractor's visit in April 2022. The facility's policy and procedure titled, Sanitation and Infection Control, dated 2018 indicated, sanitation and infection control measures will be followed to ensure resident/patients and staff receives safe food and water. Employees must follow specific procedures in all areas .to ensure the department operates under sanitary conditions on a daily basis 055099 Page 7 of 8 055099 05/05/2022 Creekside Healthcare Center 1900 Church Lane San Pablo, CA 94806

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, for one (Resident 27) of five random sampled resident charts reviewed for their pneumonia vaccination, the facility failed to offer the pneumococcal vaccine recommended by the Advisory Committee on Immunizations Practices (ACIP-group of medical a public health experts) based on the age group and had no medical contraindication against it. Residents Affected - Few This failure increased the risk and potential for Resident 27 to acquire, transmit or experience complications from pneumococcal disease. Findings: During a concurrent interview and medical record review on 05/04/22 at 8:30 A.M., Resident 27's documented date for pneumonia vaccine indicated it was given at the hospital in 2014. The Infection Preventionist (IP) stated she could not find a recent date of when the pneumonia vaccine was given to Resident 27. IP stated the hospital kept track of the pneumonia vaccine record and would request a copy. IP further stated the IP, the Director of Nursing (DON) and nurse supervisor are responsible to keep the vaccination record current. During an interview on 05/04/22 at 3:00 P.M., DON stated she was unable to find Resident 27's pneumococcal vaccination record after 2014, and contacted the hospital for Resident 27's pneumococcal vaccination record. During a follow-up interview on 05/05/22 at 9:40 A.M., DON stated the hospital did not have a subsequent pneomococcal vaccination record for Resident 27 after 2014. DON further stated the facility will administer the pneumococcal vaccine for Resident 27 based on her age and which vaccine was given in 2014. During an interview on 05/05/22 at 10:45 A.M., IP stated pneumonia vaccine is given every five years for residents less than [AGE] years old and every year for residents greater than [AGE] years old. IP stated Resident 27 should have been offered the pneumonia vaccine in 2019. During a review of the document, Influenza Adult Immunization Guide, dated 2021-2022, it indicated two types of vaccinations against bacterial pneumonia are available. ACIP expects administrations of both Prevnar (PCV13) and Pneumovax (PPSV23) will provide optimal protection against pneumococcal infections. The recommendations for adults aged <65 years are different than for adults aged >65 years so they should be vaccinated based on the ACIP recommendations for their age groups. 055099 Page 8 of 8