Health inspection·October 21, 2021

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete the Comprehensive Minimum Data Set (MDS, an assessment tool used to direct care) within 14-calendar days of admission for two of five sampled residents (Resident 1 and 56). This failure had the potential to delay the development of a comprehensive care plan necessary to provide the appropriate individualized care and services for each resident related to the care areas identified on their Comprehensive MDS. Findings: 1. Review of Resident 1's Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's admission Comprehensive MDS assessment indicated it was due on 4/26/21 and completed on 5/6/21 (10 days late). 2. Review of Resident 56's Face Sheet indicated Resident 56 was admitted to the facility on [DATE]. Review of Resident 56's admission Comprehensive MDS assessment indicated it was due on 5/31/21 and completed on 6/13/21 (13 days late). During an interview with the Regional MDS Coordinator (RMC), on 10/21/21, at 10:30 a.m., the RMC stated Resident 1 and 56's Comprehensive MDS were not completed on time and verified Resident 1's Comprehensive MDS was due on 4/26/21 and completed late on 5/6/21. Furthermore, Resident 56's Comprehensive MDS was due on 5/31/21 and completed late on 6/13/21. During a review of the policy and procedure (P&P) titled, Resident Assessment Instrument, revised 11/2012, the P&P indicated, The Resident Assessment Instrument will be completed timely and accurately, per Federal Guidelines, and will serve as a foundation for the comprehensive care planning process. Page 1 of 20 055276 055276 10/21/2021 Mission Valley Post Acute 2400 Parkside Drive Fremont, CA 94536

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for three of five (Resident 56, 57, and 58) sampled residents, the facility failed to complete Quarterly Minimum Data Set (MDS, an assessment tool used to direct care) Assessments in the regulatory specified manner. Residents Affected - Few This failure had the potential for Residents 56, 57, and 58 to not receive care and services based on their current health status. Findings: 1. Review of Resident 56's the Face Sheet indicated Resident 56 was admitted to the facility on [DATE]. Review of Resident 56's Quarterly MDS assessment indicated it was due on 8/31/21 and completed on 10/14/21 (44 days late). 2. Review of Resident 57's the Face Sheet indicated Resident 57 was admitted to the facility on [DATE]. Review of Resident 57's Quarterly MDS assessment indicated it was due on 9/9/21 and completed on 10/14/21/ (35 days late). 3. Review of Resident 58's Face Sheet indicated Resident 58 was admitted to the facility on [DATE]. Review of Resident 58's MDS Quarterly MDS Assessment indicated it was due on 9/14/21 and completed on 10/16/21 (32 days late). During an interview and concurrent record review of Residents 56, 57, and 58's last MDS Assessments on 10/21/21 at 10:30 a.m., the Regional MDS Coordinator (RMC) stated the Quarterly MDS assessments were completed late for Residents 56, 57, and 58. 055276 Page 2 of 20 055276 10/21/2021 Mission Valley Post Acute 2400 Parkside Drive Fremont, CA 94536

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure one of two sampled residents (Resident 11) was accurately assessed using the Minimum Data Set (MDS - an assessment tool), when Resident 11's MDS was inaccurately assessed as not being a hospice patient. Residents Affected - Few This deficient practice had the potential for Resident 11 to not receive hospice care due to incorrect data entered and receive planned care not consistent with the resident's condition. Findings: During a review of Resident 11's MDS, dated [DATE], which indicated Resident 11 had a BIMS (Brief Interview for Mental Status) score of 02, indicating Resident 11 is severely, cognitively impaired. In addition, it reflected Resident 11 was not receiving hospice care. The medical diagnoses for Resident 11 included heart failure, kidney failure, and Alzheimer's Disease. During a review of Resident 11's physician orders dated 5/3/21 indicated Resident 11 was placed on pallative (relieving pain and optimizing quality of life) care. During an interview with the Assistant Director of Nursing (ADON) on 10/20/21 at 3 p.m., ADON stated Resident 11 was coded incorrectly on the MDS. ADON stated it was marked she was on dialysis and she has never been on dialysis. She is on hospice, which was not marked. Review of the policy, Resident Assessment Instrument (RAI/MDS) last revision 11/2012, indicated the RAI will be completed timely and accurately. 055276 Page 3 of 20 055276 10/21/2021 Mission Valley Post Acute 2400 Parkside Drive Fremont, CA 94536

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide care that met the professional standards of care for one resident out of 20 sampled (Resident 170) when she was cleaned after being incontinent of feces with Chlorox bleach wipes. Residents Affected - Few This deficient practice had the potential to cause pain and chemical burns to Resident 170. Findings: During a review of Resident 170's Minimum Data Set (MDS, an assessment tool used to guide care), dated 10/11/21, indicated she was admitted to the facility on [DATE]. Resident 170 had a BIMS (Brief Interview for Mental Status) score of 13/15, indicating Resident 170 is cognitively intact. The medical diagnoses for Resident 170 included cancer, hip fracture, and pelvic fracture. During an interview with Resident 170 on 10/19/21 at 10:38 a.m., Resident 170 stated the staff from therapy cleaned her after she had a bowel movement and used Chlorox wipes on her bottom. Resident 170 stated she did not know their names and has not seen them since and she thought it was a Sunday that it happened. During an interview with the Occupational Therapy Assistant (OTA) on 10/20/21 at 3:09 p.m., OTA stated Resident 170 had a bowel movement and needed to be cleaned before therapy. OTA stated she grabbed the Chlorox wipes without realizing what it was and cleaned Resident 170. OTA stated she flushed Resident 170's skin with warm water immediately upon realizing what she had done. OTA further stated Resident 170 did not complain of pain or discomfort and reported this to the nurse immediately. OTA stated she should have read the label more carefully. During an interview with the Licensed Vocational Nurse (LVN) 7 on 10/20/21 at 1:40 p.m., LVN 7 stated OTA told her she had cleaned Resident 170 using disinfectant wipes. LVN 7 stated she assessed Resident 170 and did not see any evidence of redness or chemical burn. Resident 170 did not complain of pain or burning. LVN 7 reported the incident to the Administrator right away. During a review of the OT Daily Treatment Note dated 10/16/21 at 12:20 p.m., the note reflected Resident 170 was cleaned with disinfectant wipes by OTA. 055276 Page 4 of 20 055276 10/21/2021 Mission Valley Post Acute 2400 Parkside Drive Fremont, CA 94536

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care for two (Resident 55 and 65) of four residents that required oxygen therapy when Resident 55 and 65 were given oxygen without doctor's orders. Residents Affected - Few These deficient practices had the potential to result in Resident's 55 and 65's inadequate monitoring of Resident 55 and 65's safe use of oxygen and response to oxygen therapy. Findings: A review of the document titled, admission Record, dated 10/21/21 indicated Resident 55 was admitted to the facility on [DATE] with a diagnosis of acute respiratory failure (occurs when fluid builds up in the air sacs in your lungs. When that happens, your lungs can't release oxygen into your blood). A review of Resident 55's Minimum Data Set (MDS- an assessment tool) dated 8/11/21 indicated Resident 55 required the use of oxygen. During an observation on 10/19/21 at 11:20 a.m. Resident 55 was using oxygen at 3 liters per minute through a nasal canula (tube with prongs inserted into the nostrils) and confirmed by Licensed Vocational Nurse 3 (LVN 3). During a concurrent record review and interview on 10/19/21 at 11:40 a.m. of Resident 55's doctor's orders with LVN 6, there were no orders for oxygen use. LVN 3 confirmed there were no doctor's orders for the use of oxygen for Resident 55. LVN 3 further stated Resident 55 has always been on oxygen at the facility and will get an order from the doctor for the use of oxygen. LVN 3 stated there has to be a doctor's orders to give oxygen and monitoring of Resident 55's oxygen use to check on how the resident tolerates the supplemental oxygen. A review of the document titled, admission Record, dated 10/20/21 indicated Resident 65 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD- a group of diseases that cause airflow blockage and breathing-related problems). A review of Resident 65's MDS dated [DATE] indicated Resident 65 required the use of oxygen. During an observation on 10/19/21 at 11:25 a.m. Resident 65 was using oxygen at 3.5 liters per minute through a nasal canula as confirmed by LVN 3. During a concurrent record review and interview on 10/19/21 at 11:45 a.m. of Resident 65's doctor's orders with LVN 6, there were no orders for oxygen use. LVN 3 confirmed there were no doctor's orders for the use of oxygen for Resident 65. LVN 3 further stated Resident 65 has always been on oxygen at the facility and will get an order from the doctor for the use of oxygen. LVN 3 stated it is important to have a doctor's orders for Resident 65's oxygen use because she has COPD. He further added there can be complications that can occur with oxygen use for resident's with COPD. 055276 Page 5 of 20 055276 10/21/2021 Mission Valley Post Acute 2400 Parkside Drive Fremont, CA 94536

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide care for three (Resident 44, 45 and 118) of three residents that required dialysis (artificial kidney machine that rids your blood of unwanted toxins, waste products and excess fluids by filtering your blood). Staff did not do a complete assessment before Resident 45 and Resident 118's dialysis treatment or complete the dialysis communication record for Resident 45 and 118 before they went to their dialysis treatments. Residents Affected - Few This deficient practice resulted in an inaccurate assessment of Resident 45 and 118's dialysis access site and functionality and failure to communicate potential changes in the resident's physical condition prior to receiving dialysis care. Findings: A review of the document titled, admission Record, dated 10/20/21 indicated Resident 44 was admitted to the facility and had a diagnosis of End Stage Renal (kidney) Disease or ESRD, a longstanding disease of the kidneys leading to renal failure. A review of Resident 44's Minimum Data Set (MDS- an assessment tool) dated 10/3/21 indicated Resident 44 is on dialysis. A review of Resident 45's Order Summary Report dated 10/21/21 indicated Resident 44 has dialysis treatments on Tuesdays, Thursdays, and Saturdays. A review of the document titled, admission Record dated 10/20/21 indicated Resident 45 was admitted to the facility with a diagnosis of ESRD. A review of Resident 45's MDS dated [DATE] indicated Resident 45 is on dialysis. A review of Resident 45's Order Summary Report dated 10/21/21 indicated Resident 45 has dialysis treatment on Mondays, Wednesdays and Fridays. A review of the document titled, admission Record, dated 10/20/21 indicated Resident 118 was admitted to the facility with a diagnosis of ESRD. A review of Resident 45's MDS dated [DATE] indicated Resident 45 is on dialysis. A review of Resident 118's Order Summary Report dated 10/20/21 indicated Resident 118 has dialysis treatment on Tuesdays, Thursdays, and Saturdays. During a concurrent record review and interview on 10/20/21 at 10:40 a.m. of Resident 45's Dialysis Communication Record treatment on 10/14/21, with the Assistant Director of Nursing (ADON), the staff indicated a bruit (an audible vascular sound associated with turbulent blood flow) and thrill (a vibratory sensation felt on the skin) were present on Resident 45's access site. ADON stated the nursing staff's assessment of Resident 45's access site was not correct because there is no bruit or thrill present on a permacath (a flexible tube that is inserted in a vein). During a concurrent record review and interview on 10/20/21 at 10:40 a.m., of Resident 118's 055276 Page 6 of 20 055276 10/21/2021 Mission Valley Post Acute 2400 Parkside Drive Fremont, CA 94536

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Dialysis Communication Record dated 10/9/21, 10/21/21, 10/14/21, 10/16/21, and 10/21/21 with ADON, the staff indicated a bruit and thrill were present on Resident 118's access site. ADON stated the nursing staff's assessment of Resident 118's access site was not correct because there is no bruit or thrill present on a permacath. During a concurrent record review and interview with ADON on 10/21/21 at 10:45 a.m., of Resident 45's Dialysis Communication Record, there was one dialysis treatment record dated 10/14/21. ADON stated Resident 45 has attended all dialysis treatment appointments. ADON further stated there should be dialysis communication records for every treatment Resident 45 received, including Resident 45's condition before dialysis treatment and for the dialysis center to communicate Resident 45's condition during her dialysis treatment to the facility upon return. During a concurrent record review and interview with ADON on 10/21/21 at 10:55 a.m., of Resident 44's Dialysis Communication Record, there were three records for Resident 44's dialysis treatment dated 10/6/21, 10/9, 21 and 10/16 which ADON confirmed. ADON further stated Resident 45 has been in the facility since 9/29/21 and attended all dialysis treatments. She stated there should be a dialysis communication in the binder for every treatment Resident 44 attended and the communication information from the dialysis center after dialysis treatment. During an interview on 10/28/21 at 9:45 a.m. with the Facility Administrator (FA), FA stated Resident 118 has a permacath. He further stated a bruit or thrill will not be present for a resident with a permacath. During an interview on 10/28/21 at 10:30 a.m. with the Clinic Manager (CM), CM stated Resident 45 has a permacath, and a bruit or thrill will not be present for a resident with a permacath. 055276 Page 7 of 20 055276 10/21/2021 Mission Valley Post Acute 2400 Parkside Drive Fremont, CA 94536

F 0756 Level of Harm - Minimal harm or potential for actual harm Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interview and record review, the facility failed to ensure the pharmacist's medication regimen review (MRR) was promptly acted upon for two (Residents 63 and 66) of 20 sampled residents. Residents Affected - Few This failure had the potential for a delay in treatment and risk for serious side effects for Residents 63 and 66. Findings: Review of the admission Record indicated Resident 63 was admitted to the facility with multiple diagnoses that included seizures (a disorder in which nerve cell activity in the brain is disturbed, casing seizures). Review of the facility's Consultant Pharmacist (CP) Medication Regimen Review (MRR) dated 8/1/2021 and 9/1/2021, indicated Resident 63 was currently on Carbidopa-Levodopa tablet 10-100 mg (milligram) for seizures. The recommendation indicated please clarify diagnosis for Carbidopa/Levodopa use- this is not used for seizures but Parkinson's Disease. Review of the admission Record indicated Resident 66 was admitted to the facility with multiple diagnoses that included major depressive disorder and dementia (memory disorder) in other disease classified elsewhere with behavioral disturbance. Review of the facility's Consultant Pharmacist (CP) Medication Regimen Review (MRR) dated 9/26/2021, indicated Resident 66 was currently on Paxil 10 mg and Trazadone 100 mg for depression, Zyprexa 2.5 mg every morning and 5 mg every night for psychosis, and Ativan 0.5 mg BID for anxiety. The recommendation indicated, Per regulations, a GDR (gradual dose reduction) should be attempted in two separate quarters within the first year (with at least one month between attempts) and annually unless clinically contraindicated. She continues with some behaviors of yelling/cursing, making statements of sadness, and screaming/yelling. She is redirectable at times and non-pharmacological interventions attempted. Trazadone was recently increased and no side effects noted at this time. Is a GDR of Zypreza, Ativan, or Paxil indicated at this time? During an interview on 10/20/2021 at 11:40 a.m., with the Assistant Director of Nursing (ADON) ADON stated Resident 63 and 66's MRR were not done. In a telephone interview with CP on 10/20/2021 at 11:45 a.m., CP stated the facility has 72-hours to complete the MRR after the date the facility receives the recommendations. CP further stated she emailed her recommendations to the Director of Nursing/ Administrator the next day after her visit. Review of the policy and procedure titled, Medication Regimen Review (Monthly Report) dated 6/2021 indicated, The findings are phoned, faxed, or e-mailed to the director of nursing or designee and documented and stored with the other consultant pharmacist recommendations within 72-hours. The prescriber and / or medical director is notified if needed. Recommendations are acted upon and documented by the facility staff and or the prescriber. 055276 Page 8 of 20 055276 10/21/2021 Mission Valley Post Acute 2400 Parkside Drive Fremont, CA 94536

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on observation, interview, and record review, the facility failed to ensure one (Resident 66) of 20 sampled residents was free from unnecessary psychotropic (drugs that affect the brain activities associated with mental processes behavior) medications when Resident 66 received: 1. Zyprexa ( used to treat certain mental/mood conditions (such us schizophrenia, bipolar disorder) without a gradual dose reduction (GDR, a tapering of a dose to determine if symptoms, conditions, or risk can be managed by a lower dose or if the dose medication can be discontinued) attempt or resident -specific clinical rationale for continuing the medication since 7/30/2020. 2. Ativan (used to treat anxiety) without a GDR attempt or resident -specific clinical rationale for continuing the medication since 6/25/2020. 3 Paxil (used to treat depression) without a GDR attempt or resident -specific clinical rationale for continuing the medication since 6/8/2020. Review of the admission Record indicated Resident 66 was admitted to the facility with multiple diagnoses that included major depressive disorder, dementia in other disease classified elsewhere with behavioral disturbance and unspecified psychosis not due to a substance or known physiological disturbance. Review of Physician order dated 7/30/2020 indicated the resident had been on Zyprexa 2.5 mg (milligram) in the morning and 5 mg at each bedtime for screaming/yelling, making disruptive sounds since 7/30/2020. Further review indicated resident had been on Ativan 0.5 mg twice a day since 6/25/2020 and had been on Paxil 10 mg daily since 6/8/2020. There was no documented evidence to show the facility attempted a GDR or had a resident-specific clinical rationale for continuing the medications. During an interview on 10/20/2021 at 11:40 a.m., with the Assistant Director of Nursing (ADON), ADON confirmed there was no evidence of any GDR attempts or a clinical rationale for Zyprexa, Paxil and Ativan. Review of policy and procedure titled, Psychotropic Medication Management dated 10/24/17 indicated, The Director of Nursing or designee, will be responsible for reviewing new psychoactive medication orders for clinical compliance with federal regulations as identified through the change-in-condition process, 24 hour reporting process, and review of new incoming orders. Referrals will be made to the IDT (interdisciplinary team) as indicated. Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. If antipsychotic medications are used, an AIMES (abnormal involuntary movement scale) assessment will be completed upon admission, at the onset of a new order, and every 6 months while receiving anti psychotic therapy. 055276 Page 9 of 20 055276 10/21/2021 Mission Valley Post Acute 2400 Parkside Drive Fremont, CA 94536

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility had a score of 11.43% medication error rate when four medication errors of 35 opportunities were observed during medication pass observation as follows: Residents Affected - Some 1. Eliquis tablet 5 mg (milligram) also known as Apixaban- used to prevent serious blood clots due to irregular heartbeat) was not administered as prescribed by the physician. 2. Metformin HCL (hydrochloride) 500 mg (oral diabetes medicine that helps control blood sugar levels ) was given on an empty stomach. 3. Reglan 10 mg (metoclopramide-use to treat nausea,vomiting) was not administered as prescribed by the physician. 4. Peridex solution (Chlorhexidine gluconate, used as an oral rinse to treat the symptoms of gingivitis-gum disease) 5 ml.(milliliters) was not administered as prescribed by the physician. These failures had the potential of ineffective medication treatment for Residents 45, 318 and 118. Findings: 1. Review of the admission Record indicated Resident 45 was admitted to the facility with multiple diagnoses that included Long standing persistent Atrial Fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). During the morning medication pass observation and concurrent interview on 10/19/2021 at 9:10 a.m.,with Licensed Vocational Nurse (LVN 2), LVN 2 gave all 9 a.m. medications by mouth, except Eliquis. LVN 2 stated resident 45 will not receive her morning dose of Eliquis because it is not available. Review of the physician orders dated 9/11/2021 indicated Eliquis tablet 5 mg give one tablet by mouth two times daily for longstanding persistent Atrial Fibrillation. Review of the Medication Administration Record (MAR) dated October 2021 indicated Eliquis was to be given at 9 a.m. 5 p.m. 2. Review of the admission Record indicated Resident 318 was admitted to the facility with multiple diagnoses that included Type 2 diabetes mellitus ( the body either doesn't produce enough insulin, or resists insulin). During the morning medication pass observation on 10/20/2021 at 6:32 a.m., Resident 318 was in his wheelchair in his room. LVN 4 gave Resident 318 his Metformin. Review of the Physician order dated 10/13/2021 indicated Metformin HCL tablet 500 mg give 0.5 tablet by mouth one time daily take with meals. Review of the MAR dated 10/14/2021 indicated Metformin 500 mg give 0.5 mg take with meal at 6:30 a.m. 055276 Page 10 of 20 055276 10/21/2021 Mission Valley Post Acute 2400 Parkside Drive Fremont, CA 94536

F 0759 Level of Harm - Minimal harm or potential for actual harm During an interview on 10/20/2021 at 7:10 a.m., with Resident 318. He stated he usually eats breakfast around 7:30 a.m. to 7:45 a.m. In a telephone interview on 10/20/2021 at 11:45 with the Consultant Pharmacist (CP), CP stated Metformin is best given with meals especially for a new order and has on the medication card to take it with meals. Residents Affected - Some 3. Review of the admission Record indicated Resident 118 was admitted to the facility with multiple diagnoses that included severe sepsis (sepsis associated with organ dysfunction) with septic shock and gastro-esophageal reflux disease (GERD, a condition in which acidic acid gastric fluid flows backward into the esophagus, resulting in heartburn). During the morning medication pass observation and concurrent interview on 10/20/2021 at 8:55 a.m., with Registered Nurse (RN 1). RN 1 gave the 9 a.m. medications by mouth, except metoclopramide HCl 10 mg give 0.5 mg and Peridex solution 5 ml. RN 1 stated, The metoclopramide and Peridex are not available. Review of the physician orders dated 10/19/2021 indicated metoclopramide HCl tablet give 0.5 tablet by mouth two times a day related to GERD and Peridex solution dissolve 5 ml buccally (inside the cheek) every 12 hours for pneumonia prevention. Review of the MAR dated October 2021 indicated that Reglan was to be given at 9 a.m. and 5 p.m., and Peridex to be given at 9 a.m. and 9 p.m. During an interview on 10/20/2021 at 1:15 p.m. with RN 2, RN 2 stated it is everyone's responsibility to order medications, especially when the orders are three times or two times a day. During an interview and concurrent record review on 10/20/2021 at 2:15 p.m., with the Assistant Director of Nursing (ADON), ADON stated there was no documentation to show the physician was notified. Review of facility's policy and procedure titled, Medication Administration -General Guidelines, dated April 2008 indicated Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnosis or conditions, the nurse calls the provider pharmacy for clarification prior to to administration of the medication or if necessary contacts the prescriber for clarification. This interaction with the pharmacy and/or prescriber and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate. 055276 Page 11 of 20 055276 10/21/2021 Mission Valley Post Acute 2400 Parkside Drive Fremont, CA 94536

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure one (Resident 45) of 20 sampled residents was free of significant medication errors when Eliquis tablet 5 mg (Apixaban- used to prevent serious blood clots due to an irregular heartbeat) was not administered as prescribed by the physician. Residents Affected - Few This failure had the potential for an increased risk of stroke (not enough blood flow and oxygen to the brain due to a clot) when the medication was not provided. Findings: Review of the admission Record indicated Resident 45 was admitted to the facility with multiple diagnoses that included Long standing persistent Atrial Fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). During the morning medication pass observation and concurrent interview on 10/19/2021 at 9:15 a.m.,with Licensed Vocational Nurse (LVN 2), LVN 2 gave all 9 medications by mouth, except the Eliquis. LVN 2 stated, Resident 45 will not receive her morning dose of Eliquis because it is not available. Review of Physician order dated 9/11/2021 indicated Eliquis tablet 5 mg give one tablet by mouth two times daily for Longstanding persistent Atrial Fibrillation. Further review indicated Eliquis is supposed to be given at 9 a.m. and 5 p.m. In a follow up interview and record review on 10/20/2021 at 8:15 a.m., with Registered Nurse (RN) 2, RN 2 confirmed Eliquis 5 mg was not administered yesterday at 9 a.m. Review of facility's policy and procedure titled, Medication Administration -General Guidelines, dated April 2008 indicated Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnosis or conditions, the nurse calls the provider pharmacy for clarification prior to to administration of the medication or if necessary contacts the prescriber for clarification. This interaction with the pharmacy and/or prescriber and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate. 055276 Page 12 of 20 055276 10/21/2021 Mission Valley Post Acute 2400 Parkside Drive Fremont, CA 94536

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. Based on observation, interview and record review, the facility failed to ensure safe medication storage when: 1. In the Medication Room, there were multiple unlabeled, discontinued intravenous (administered into the vein) solution in a medium size plastic bin. 2. Station 3-Medication Cart 3 was dirty with small pieces of aluminum paper and multiple loose tablets in the bottom of the cart. 3. Station 2-Medication Cart 2 was dirty with small pieces of aluminum paper and multiple loose tablets in the bottom of the cart. Discontinued medication was still stored in Medication Cart 2 and had multiple opened eyedrops, an unlabeled bottle of nitroglycerine (used for heart/chest pain), and bisacodyl suppositories (laxative) were stored together in a small plastic bin. These failures had the potential for medication tampering, receiving expired medications that could lose their efficacy or the wrong medication. Findings: 1. During a concurrent observation and interview on 10/18/2021 at 5:40 p.m., with the Assistant Director of Nursing (ADON), the medication room had a medium size bin with 10 bags of unlabeled discontinued intravenous medications. ADON stated, It is my responsibility to check the medication room daily and discard the discontinued medications. 2. During an inspection of Medication Cart 3 and concurrent interview with Licensed Vocational Nurse (LVN) 5, on 10/20/2021 at 11:40 a.m., LVN 5 confirmed Medication Cart 3's second and third drawers contained 13 loose tablets and small pieces of aluminum papers. 3. During an inspection of Medication Cart 2 and concurrent interview with LVN 6 on 10/20/2021 at 1:10 p.m., LVN 6 confirmed Medication Cart 2's second and third drawers contained 24 loose tablets and small pieces of aluminum papers, and a half bottle of discontinued liquid Amoxicillin antibiotic while the first drawer had a small bin with multiple eyedrops unlabeled, an opened bottle of nitroglycerine, and 12 pieces of bisacodyl suppository stored together. LVN 6 stated discontinued medications should be place in the medication room for disposal and suppository, eyedrops and tablets should not store in one container. During a review of the facility's policy and procedure (P&P) titled,Medication Storage, dated 4/2008 which indicated, C: Orally administered medications are kept separate from externally used medications, such as suppositories, liquids, and lotions. During a review of the facility's (P&P) titled, Disposal of Medications and Medication-related Supplies, dated 10/17 indicated, A: if a medication expires, or a prescriber discontinues a medication, the discontinued drug container shall be marked or otherwise identified and shall be stored in a separate location designated solely for this purpose. The date the medication was discontinued shall be indicated on the medication container. B: internal and External medications shall be stored 055276 Page 13 of 20 055276 10/21/2021 Mission Valley Post Acute 2400 Parkside Drive Fremont, CA 94536

F 0761 separately. Level of Harm - Minimal harm or potential for actual harm C: Discontinued medications are destroyed in accordance with Medication Destruction policy. Residents Affected - Few 055276 Page 14 of 20 055276 10/21/2021 Mission Valley Post Acute 2400 Parkside Drive Fremont, CA 94536

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the nutritive value, flavor, and appearance of the food prior to serving. Residents Affected - Some This failure had the potential to decrease the nutrition status of the residents in promoting recovery from illness or injury. Findings: Observations made in the kitchen on 10/18/21 at 11:50 a.m., showed the bread dressing and pork loin lacked color. The pork loin appeared dry and brussel sprouts looked mushy. During an interview with Resident 61 on 10/18/21 at 1 p.m., Resident 61 stated he could not eat most of his lunch because the chicken was tough and dry and the brussel sprouts were mushy. Resident 61 stated they would not serve food like this at their home, so why would they serve this to us? Surveyor informed Resident 61 it was not chicken but pork loin. Resident 61 stated he could not tell from the taste. During an observation of Resident 61's tray after eating on 10/18/21 at 1 p.m., indicated Resident 61 did not eat the pork loin or the brussel sprouts. During an interview with Resident 170 on 10/19/21 at 10:11 a.m., Resident 170 stated the food is awful. During an interview with Resident 15 on 10/19/21 at 10:56 a.m., Resident 15 stated the food is not good. Resident 15 stated she can not eat it most of the time. A test tray was prepared on 10/19/21 at 12 p.m., which contained chicken thigh, baked potato, green beans, apple crisp, and milk. Observations of the test tray by the survey team showed the chicken was dry and tough to cut. The green beans was over cooked, mushy and had no flavor. During an interview with the Dietary Manager Assistant (DMA) on 10/20/21 at 8:30 a.m., DMA stated we are aware there are issues with the food. We are trying to work through them. During a review of the facility policy, Food: Quality and Palatability (last revision 9/2017) indicated foods are prepared in a manner that meets the resident's needs and the cook uses proper cooking techniques to ensure color and flavor. 055276 Page 15 of 20 055276 10/21/2021 Mission Valley Post Acute 2400 Parkside Drive Fremont, CA 94536

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to prepare, store, and serve food under sanitary conditions when they were using unpasteurized eggs and proper hand washing was not done. These failures had the potential to expose residents who received nutritional services from the kitchen to food borne illness. Findings: 1. During an observation of the kitchen on 10/18/21 at 11:18 a.m.,the eggs stored in refrigerator #3 were not pasteurized. During an interview with the [NAME] on 10/18/21 at 11:50 a.m., [NAME] stated if a resident asked for eggs over easy she would cook them. [NAME] stated she does get that request. During an interview with Dietary Manager (DM) and Dietary Manager Assistant (DMA) on 10/18/21 at 11:20 a.m., stated they were not aware the eggs were not pasteurized. 2. During an observation in the kitchen on 10/18/21 at 12:10 p.m., [NAME] was plating lunches while wearing gloves. [NAME] touched dinner rolls with gloved hand after touching other items. During an interview with [NAME] on 10/18/21 at 1 p.m., [NAME] stated she should have removed her gloves, washed her hands, and put on clean gloves before touching the dinner rolls. Review of the policy, Food: Preparation (last revision 9/2017) indicated, all staff will practice proper hand washing techniques and glove use. It further indicated that only pasteurized egg products will be used for soft cooked egg items. 055276 Page 16 of 20 055276 10/21/2021 Mission Valley Post Acute 2400 Parkside Drive Fremont, CA 94536

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the accuracy of the electronic medical record for one of 20 sampled residents (Resident 2), when Resident 2's medical record had information scanned into it belonging to Resident 171. This deficient practice did not ensure the medical record contained records specifically for Resident 2. For Resident 171, the resident's confidential record was not protected and the Preadmission Screening and Resident Review (PASRR), a screening tool to ensure individuals with mental illness are not inappropriately placed and receive specialized services if indicated) was not readily available to the healthcare team. Findings: During a review of Resident 2's Minimum Data Set (MDS - an assessment tool used to guide care) dated 10/14/21 indicated Resident 2 had a readmission date of 10/6/21. The Brief Interview for Mental Status (BIMS) reflected Resident 2 scored 11/15 which meant moderately, cognitively impaired. Resident 2's diagnoses included end stage kidney disease, dialysis (artificial kidney machine to filter the blood of waste products), diabetes (blood sugar disorder), and stroke (not enough oxygen to the brain caused by a clot or bleeding). During a review of Resident 171's MDS dated [DATE], Resident 171 had an admission date of 10/6/21. On the Brief Interview for Mental Status (BIMS), Resident 171 scored 15/15, or cognitively intact. Resident 171's diagnoses include respiratory failure, frequent falls, atrial fibrillation (irregular heart beat), and encephalopathy (disease that alters brain function). During a review of Resident 2's PASRR, Resident 171's PASRR was in Resident 2's electronic medical record. During an interview with the Regional Clinical Consultant (RCC) on 10/21/21 at 10:06 a.m., RCC stated the PASRR was in the wrong chart. 055276 Page 17 of 20 055276 10/21/2021 Mission Valley Post Acute 2400 Parkside Drive Fremont, CA 94536

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow infection control practices when; Residents Affected - Some 1. The staff did not wash hands between residents during medication pass for Resident 54 and Resident 7. 2. The staff did not change gloves between residents when obtaining blood pressures (BP) or sanitize the BP cuff for Residents 63 and 22. 3. In the medication room specimen refrigerator, there was a urine specimen dated 10/15/2021 and unlabeled [NAME] - [NAME] (JP- drain is a closed- suction medical device for collecting body fluids from surgical sites) with 30 ml (milliliter) of brown color liquid. These failures increased the potential for cross contamination. Findings: 1. During the medication pass observation on 10/18/2021 at 4:10 p.m., with Licensed Vocational Nurse (LVN ) 1, LVN 1 gave medications to Resident 54 and Resident 7 without performing hand hygiene between resident medication administration. 2. Further medication observation on 10/18/2021 at 4:26 p.m., LVN 1 was obtaining the BP of Resident 63 and Resident 22. LVN 1 did not change gloves or sanitize the BP cuff between Resident 63 and Resident 22. During an interview on 10/18/2021 at 4:50 p.m., LVN 1 stated she should have washed her hands between residents during medication pass, changed her gloves and sanitized the BP cuff between residents for infection control purposes. During a review of the facility's policy and procedure (P&P) titled, Hand Hygiene dated 1/10/2019 which indicated, Employees are required to wash theirs hands thoroughly: Before beginning work day, Between patients, Between procedures on the same patient After touching objects that may be soiled and after removing gloves,After removing gloves, Anytime hands become soiled, before meals and after restroom use. Equipment Cleaning and Disinfecting: Shared patient care equipment will be cleaned and disinfect according to current infection prevention guidelines. 3. During an inspection of the medication room and concurrent interview on 10/18/2021 at 5:15 p.m.,with the Director of Nursing (DON), the medication room specimen refrigerator had a urine specimen dated 10/15/2021 and an unlabeled JP drainage bag with 30 ml of brown colored liquid. DON stated the urine specimen belonged to a resident that was discharged and the JP drain should not be stored in 055276 Page 18 of 20 055276 10/21/2021 Mission Valley Post Acute 2400 Parkside Drive Fremont, CA 94536

F 0880 the refrigerator. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/20/2021 at 3:05 p.m., with Director of Staff Development (DSD), DSD stated they (staff) don't store JP drain fluids in the refrigerator. Nurses are supposed to measure and check the character of the fluid, document the assessment in the residents record, then discard the fluid. DSD further stated the night shift nurses are responsible to check and document the temperature of the room and refrigerator when recording the refrigerator log temperature. Residents Affected - Some 055276 Page 19 of 20 055276 10/21/2021 Mission Valley Post Acute 2400 Parkside Drive Fremont, CA 94536

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide 22 of 22 residents in the following multiple resident rooms (27, 28, 29, 30, 31, 32, 34) with at least 80 square feet per resident. This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff and for the lack of sufficient space for residents to have personal belongings at the bedside. After observation and interview, there was adequate space for residents and staff to move about without obstruction. Recommend granting waiver. Findings: Accompanied by the Maintenance Director (MD), on 10/20/21, at 1:40 p.m., the following multiple resident rooms were measured in feet (ft) and inches (in) which were less than 80 square ft: room [ROOM NUMBER]: 11 ft. 3.5 in x 19 ft 2 in room [ROOM NUMBER]: 11 ft 1 in x 19 ft 2 in room [ROOM NUMBER]: 11 ft 1 in x 19 ft 2 in room [ROOM NUMBER] 11 ft 3.5 in x 19 ft 2 in room [ROOM NUMBER] 11 ft 3.4 in x 19 ft 1 in room [ROOM NUMBER] 11 ft 2 in x 19 ft 2 in room [ROOM NUMBER] 14 ft 10 in x 20 ft 4 in During an interview with the Administrator (Admin), on 10/18/21, at 10:42 a.m., Admin stated there were no personal space issues from the residents residing in those rooms. 055276 Page 20 of 20