Health inspection·April 23, 2021

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to respond to residents' call lights in a timely manner for three of 23 sampled residents (Residents 49, 62, and 70), when: Residents Affected - Few 1. Resident 62 waited 25 minutes in the bathroom to get transfer assistance from wheelchair to toilet to urinate. 2. Resident 70 waited ten minutes for her to be turned and repositioned in bed, and 3. Resident 49 waited ten minutes to get a drink. This failure resulted in the delayed response to residents' needs and could potentially cause resident emotional distress. Findings: 1. During an observation on 04/20/21 at 3:25 p.m., Resident 62 was in the bathroom and her call light was on. She stated she needed help to transfer from the wheelchair to toilet to urinate. The certified nursing assistant (CNA) came in the bathroom at 3:50 pm. Resident 62 waited for 25 minutes to get help. 2. During an observation on 04/20/21 at 3:40 p.m., Resident 70's call light was on and was answered at 3:50 p.m. Resident 70 waited 10 minutes for her call light to be answered. During an interview with Resident 70 on 4/20/21 at 3:42 p.m., Resident 70 stated she pressed her call light because she wanted to be turned and repositioned. The CNA responded and turned off the call light and she stated she would be back. The CNA did not return for a long while. Resident 70 also stated this happened all the time, on all shifts when they had to wait longer times for them to get help. During an interview with licensed vocational nurse O (LVN O) on 04/23/21 at 11:15 a.m., she stated residents should not have to wait longer than five minutes at the most to get their call light answered. 3. During an observation on 04/23/21 at 4:10 p.m., Resident 49's call light was on. CNA came in the room at 4:20 p.m. Resident 49 waited ten minutes for her call light to be answered. During an interview with Resident 49 on 04/23/21 at 4:15 p.m., she stated she was thirsty and wanted to ask for something to drink. She claimed she waited for more than five minutes. Page 1 of 31 055797 055797 04/23/2021 Gilroy Healthcare Center 8170 Murray Avenue Gilroy, CA 95020

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with Resident 49's roommate on 04/23/21 at 4:16 p.m., the roommate stated the nursing staff do not come reasonably on time on all shifts. The roommate also stated the facility needed to hire more CNAs to help them. During review of the facility's policy, Call light, Use of dated 2006 indicated, 2. Answer ALL call lights promptly whether or not you are assigned to the resident . 055797 Page 2 of 31 055797 04/23/2021 Gilroy Healthcare Center 8170 Murray Avenue Gilroy, CA 95020

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to implement their abuse policy for three of three sampled residents (Residents 16,18, and 56) when, 1. Residents 16, 18, and 56 were not protected from physical and verbal abuse by certified nursing assistant M (CNA M) and, 2. Residents' 18 and 56 allegations of abuse were not reported. These failures put the residents at risk for further abuse. Residents Affected - Few Findings: 1. Resident 16 had diagnoses including dementia (memory loss) and altered mental status. Resident 16 was non-verbal and had severe cognitive impairment. During the initial tour on 4/19/21 at 12:53 p.m., Resident 94 (co-resident) stated, Resident 16's hands were slapped by CNA M. During an observation on 4/19/21 at 12:53 p.m., Resident 16's right hand was discolored (dark brown) while no discoloration on his left hand was noted. Review of Resident 16's interdisciplinary team (IDT) notes dated 4/14/21 indicated that Resident 94 (co-resident) had reported that CNA M had slapped Resident 16's hand on several occasions when Resident 16 was not cooperating with care. 2. During an interview with Resident 56 on 4/23/21 at 9:44 a.m., Resident 56 stated CNA M had cursed at him twice, which made him feel so bad. Resident 56 also stated, he did not feel safe with CNA M and was afraid that CNA M would be more aggressive. During a concurrent observation and interview with Resident 18 on 4/23/21 at 9:54 a.m., Resident 18 stated CNA M had pulled both of her arms and had yelled at her to shut up. Resident 18's left arm and up to half of the forearm was dark purple in color. During an interview with Resident 59 (co-resident) on 4/23/21 at 9:54 a.m., Resident 59 stated she witnessed CNA M yell and hurt Resident 18 by pulling on her arms. During an interview on 4/23/21 at 10:56 a.m. with the administrator (ADM), he affirmed that he had spoken with Resident 56 regarding his allegations. During an interview on 4/23/21 at 11:39 a.m. with the ADM, he stated he reported the allegation concerning Resident 16 to the state agency but did not report the allegations concerning Residents 18 and 56. During an interview with the DSD on 4/23/21 at 11:57 a.m., she stated Resident 56 told her that CNA M was frequently frustrated when Resident 56 asked for help. The Director of Staff Development (DSD) stated CNA M called Resident 56 dirty and disgusting. The DSD also stated Resident 18 had told her that CNA M was always in a hurry and would get upset when Resident 18 needed to be repositioned. Resident 18 also told the DSD that CNA M was always rough when helping Resident 18 with toileting and would grab Resident 18's wrists tightly. A review of the Grievance/Complaint Resolution Report that was filled out for Resident 18 dated 055797 Page 3 of 31 055797 04/23/2021 Gilroy Healthcare Center 8170 Murray Avenue Gilroy, CA 95020

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 4/14/21 indicated CNA M became upset when help was requested. CNA M was rough when assisting with activities of daily living (ADL) and would cause discomfort to Resident 18's arms. The form also indicated Resident 18 did not feel comfortable telling CNA M of discomfort during care in the past. Review of the Grievance/Complaint Resolution Report that was filled out for Resident 56 dated 4/14/21 indicated CNA M was frequently frustrated while providing care and would call Resident 56 names. Review of the Verification of Incident Investigation/Administrative Summary for Resident 16 dated 4/22/21 indicated Resident 94 (co-resident) had witnessed CNA M slap the hands of Resident 16 multiple times over the past few weeks. Residents 18 and 56 had expressed that CNA M had been rude. A review of the facility's Abuse Prevention, Intervention, Investigation, & Crime Reporting policy revised 11/2016, indicated the resident has the right to be free from abuse. The facility is responsible for assuring resident safety by prohibiting verbal, mental, sexual, or physical abuse . In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility will: Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment . are reported immediately; but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury; or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury; to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State Law. 055797 Page 4 of 31 055797 04/23/2021 Gilroy Healthcare Center 8170 Murray Avenue Gilroy, CA 95020

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on interview and record review, the facility failed to ensure the State Long Term Care Ombudsman (Ombudsman, an advocate for residents in the nursing homes) was notified in writing in a timely manner for 16 out of 16 discharged residents (Residents 133, 130, 135, 128, 175, 136, 176,138, 65, 132, 125, 127, 126 and 131). This failure had the potential of not providing the resident and/or their responsible party (RP, a person who is accountable in making decision in behalf of the resident) with an access to an advocate who could inform them of their rights. Findings: Review of the facility's discharges/transfer out form for March 2021 indicated the following: Resident 133 was discharged home on 3/20/21. Resident 130 was discharged home on 3/11/21. Resident 135 was discharged home on 3/24/21. Resident 128 was discharged home on 3/11/21. Resident 175 was discharged home on 3/4/21. Resident 136 was discharged home on 3/27/21. Resident 176 was discharged home on 3/6/21. Resident 65 was discharged home on 3/2/21. Resident 132 was discharged home on 3/19/21. Resident 125 was discharged home on 3/6/21. Resident 127 was discharged home on 3/7/21. Resident 126 was discharged home on 3/6/21. Resident 131 was discharged home on 3/18/21 and Resident 138 was discharged to a shelter on 3/30/21. Review of the facility's facsimile cover sheet dated 4/10/2021 indicated March Discharges was sent to the ombudsman. During a concurrent interview and record review on 4/23/2021 at 2:52 p.m., with the Regional Discharge Planner (RDP); the RDP confirmed the above record and she stated they were notifying the ombudsman for all the facility's discharges at the end of the month. The RDP further stated, they were not aware they needed to notify the ombudsman prior to residents' discharge. 055797 Page 5 of 31 055797 04/23/2021 Gilroy Healthcare Center 8170 Murray Avenue Gilroy, CA 95020

F 0623 Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy, Admission, Transfer, Discharge and bed-holds dated 12/2016, indicated a discharge notice will be completed and provided to the resident at the time of discharge or as soon as practicable, a copy of the notice will be sent to the ombudsman. Residents Affected - Some 055797 Page 6 of 31 055797 04/23/2021 Gilroy Healthcare Center 8170 Murray Avenue Gilroy, CA 95020

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 interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS, an assessment tool) for two of 23 sampled residents (Residents 27 and 230) when the MDS did not reflect the current status of the residents. This failure had the potential to affect inappropriate care planning and intervention. Residents Affected - Few Findings: 1. Review of Resident 27's situation background assessment and recommendation (SBAR, a form of communication tool for healthcare providers) dated 1/7/31 indicated the resident had a fall. The SBAR did not indicate Resident 27 sustained a major injury. During a concurrent interview and record review on 4/23/21 at 08:26 a.m., with the minimum data set coordinator (MDSC), the MDSC reviewed Resident 27's SBAR dated 1/7/21 and the MDS Quarterly review dated 1/27/21 and confirmed Resident 27 did not sustain a major injury during a fall on 1/7/21. The MDSC acknowledged she coded Resident 27's fall with major injury and confirmed the MDS was coded incorrectly. Review of the Centers for Medicare and Medicaid Services (CMS, a federal agency) Resident Assessment Instrument (RAI, a standardized assessment tool for resident) RAI 3.0 Version 1.17.1 Manual Section J, indicated to code none if the resident had no injurious fall . 2. During an initial tour on 4/1921at 10:05 a.m., in Station 1's yellow zone (residents on observation for any signs and symptoms of COVID), Resident 230 was in his room lying on his bed while both wheelchair and walker were at his bedside. During an observation on 4/1921at 12:54 a.m. in resident's room, he was sitting on his wheelchair eating his lunch without staff assistance. During an observation and concurrent interview with Resident 230 on 4/2121at 1:13 p.m., he was seen walking back to his bed from the bathroom using his walker. Resident 230 stated he was independent with almost everything. He can ambulate with walker or use the wheelchair independently. Resident 230 also stated he did not need assistance with bathing, toileting and self-grooming. During an interview with certified nursing assistant Q (CNA Q) on 4/2221at 9:19 a.m., she stated Resident 230 can ambulate safely using his walker going to the bathroom and in the hallway. He was independent with bathing and toileting. Resident 230 can also do his activities of daily living (ADL) with minimal assistance. Review of Resident 230's clinical record indicated he had the diagnoses of muscle weakness, edema, contusion of right thigh and hepatic failure. Review of Resident 230's MDS dated [DATE], indicated he had a brief interview for mental status (BIMS) score of 13 (a score of 13 to 15 indicates the resident is cognitively intact). Review of Resident 230's MDS dated [DATE], indicated Resident 230's bathing was total dependence and no use of mobility device was needed, i.e., walker and wheelchair. 055797 Page 7 of 31 055797 04/23/2021 Gilroy Healthcare Center 8170 Murray Avenue Gilroy, CA 95020

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview and record review with the MDSC on 4/2321at 4:01 p.m., she confirmed the discrepancies of the assessment. She stated she did not do the actual assessment but will see to it to correct the inaccuracy. The MDSC acknowledged the importance of reliable assessment in resident's care. Review of the 10/2019 Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI manual, MDS coding instructions) indicated clinical competence, observational, interviewing and critical thinking skills, and assessment expertise from all disciplines are required to develop individualized care plans. 055797 Page 8 of 31 055797 04/23/2021 Gilroy Healthcare Center 8170 Murray Avenue Gilroy, CA 95020

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure services were provided to meet the professional standard of practice for three of 23 sampled residents when: Residents Affected - Few 1. Resident 12's input and output was not measured and documented appropriately; 2. Resident 70 and Resident 117's physician orders for the use of oxygen was not followed. These failures had the potential to affect the residents' health condition and care. Findings: 1. Review of Resident 12's clinical record indicated, he had diagnoses of unspecified calorie malnutrition (an imbalances of a person's intake of nutrients) and urinary infection (UTI, an infections in any part of the urinary system). During an observation on 4/20/21 at 9:30 a.m., Resident 12 had a urinary catheter (a sterile flexible tube that collects urine in the bladder that is connected to a urine bag). Review of Resident 12's medication administration record (MAR) for March 2021 indicated, monitor intake and output every shift for signs and symptoms of dehydration (loss of too much fluid in the body)/fluid volume over load (too much fluid in the blood) and total intake and output for the day. Further review of Resident 12's MAR for March 2021 did not indicate the resident's output in volume on the following dates and shifts: Day shift: 3/2; 3/5, 3/11 to 3/13. 3/18, 3/20, 3/25, 3/26, 3/27, 3/28 Evening shift: 3/1, 3/2, 3/5 to 3/9, 3/11 to 3/14, 3/17, 3/18, 3/24, 3/25, 3/26 Night shift: 3/8 Additional review of Resident 12's MAR for March 2021 did not indicate the resident's 24 hour total output on 3/1, 3/2, 3/5 to 3/9, 3/11 to 3/21 and 3/24 to 3/26. Review of Resident 12's April 2021 MAR indicated, monitor intake and output every shift for signs and symptoms of dehydration volume over load and total intake and output for the day. Further review of the April 2021 MAR did not indicate Resident 12's output in volume on the following dates and shift: Day shift: 4/1, 4/4, 4/9, 4/18, 4/20 Evening shift: 4/1, 4/4, 4/12, 4/13, 4/19 Resident 12's April 2021 MAR did not indicate the resident's 24 hour total output on April 1, 4. 12, 13 and 19. 055797 Page 9 of 31 055797 04/23/2021 Gilroy Healthcare Center 8170 Murray Avenue Gilroy, CA 95020

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review with the assistant director of nursing (ADON), she reviewed the MAR and confirmed the above record. The ADON further stated the volume of Resident 12's output should have been recorded. Review of the facility's policy Intake and Output (I/O) dated August 2014 indicated intake and output should be monitored and accurately documented in order to assess and manage fluid needs. 2a. Review of Resident 70's clinical record indicated she had diagnoses including chronic obstructive pulmonary disease, idiopathic fibrosis, acute and chronic respiratory failure with hypoxia. Review of Resident 70's physician order dated 1/26/21 indicated oxygen at two liters per minute (lpm, measurement of the velocity at which air flows into the sample probe) via nasal cannula (flexible tubing that is inserted into the nostrils and attached to an oxygen source) continuous. During a concurrent observation and interview on 4/20/21 at 10:42 a.m., Resident 70 was lying in bed with an oxygen concentrator (a device that delivers oxygen) set at 2.5 lpm via nasal cannula, LN F confirmed the observation. 2b. During an observation and concurrent interview with licensed nurse B (LN B) on 4/20/2021 at 9:30 a.m., Resident 117 was lying in bed with an oxygen concentrator (device that delivers oxygen) set at 4 liters per minute (LPM, a measurement of the velocity at which air flows into the sample probe) by means of nasal cannula (flexible tubing that is inserted into the nostrils and attached to an oxygen source). LN B confirmed the observation and stated she knew Resident 117 was not supposed to be on 4 LPM. She also stated she would normally check the oxygen setting twice during her shift but did not check the setting earlier. Review of Resident 117's April 2021 physician's order with LN B indicated an oxygen order of 2 LPM via nasal cannula continuous every shift. She acknowledged the physician's order was not followed. Review of Resident 117's clinical record indicated he had diagnoses of dependence on supplemental oxygen and type 2 diabetes. Review of Resident 117's latest minimum data set (MDS, an assessment tool), indicated he had a brief interview for mental status (BIMS) score of 9 (a score of 8 to 12 indicates resident's cognition was moderately intact). During an interview with the assistant director of nursing (ADON) on 4/22/2021 at 2:15 p.m., she stated the charge nurse should check the oxygen setting during their rounds to prevent breathing problems. A review of the facility's undated policy, Oxygen Administration, indicated to check physician's order for liter flow and method of administration. 055797 Page 10 of 31 055797 04/23/2021 Gilroy Healthcare Center 8170 Murray Avenue Gilroy, CA 95020

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to provide routine and accurate administerstration of medications for one of 23 sampled residents (Resident 10), and accurate accountability of controlled substance (CS, drugs with high potential for abuse or addiction) medications for three of four random record reviews (Residents 80, 112, and 229), when: 1. Resident 10, who had recent eye surgery, did not routinely receive two of her eye medications as ordered on 4/19 and 4/20/21. This had the potential for delay in treatment for the resident; 2. The nursing staff did not document medication administration and did not give routine medications to Resident 10 in a timely manner for two days in April 2021; and, 3. CS medications were signed out from the Controlled Drug Record (CDR, an inventory sheet) but not documented on the Medication Administration Record (MAR) to indicate they were given to Residents 80, 112, and 229. This failure had the potential for CS drug abuse or diversion. Findings: 1. On 4/19/21, a review of Resident 10's clinical record indicated she was admitted to the facility with diagnoses including unspecified glaucoma (condition of increased pressure within the eyeball, causing gradual loss of sight), diabetes, and high blood pressure (BP). Review of the quarterly Minimum Data Set (a care area assessment and screening tool), dated 4/12/21, indicated Resident 1 had a Brief Interview for Mental Status score of 14 (BIMS score, a test given by medical professionals that helps determine a patient's cognitive understanding, scored from 1 to 15), indicating she had intact cognition. A review of Resident 10's clinical record indicated she had a recent eye surgery called vitrectomy (type of eye surgery used to treat problems of the eye's retina and vitreous, gel-like fluid that fills the eye), on 3/29/21. Her medication orders included: a. Trusopt (treats increased eye pressure caused by glaucoma) Solution 2%, instill 1 drop in the right eye two times a day for Glaucoma, dated 1/6/21. It was scheduled to be administered daily at 9 a.m. and 5 p.m. b. Prednisolone (for swelling and inflammation) suspension 1%, instilled 1 drop in right eye four times a day for post vitrectomy while awake, dated 4/14/21. The facility scheduled to give it daily at 9 a.m., 1 p.m., 5 p.m., and 9 p.m. c. Brimonidine (for reduction of pressure in the eye) solution 0.2%, instill 1 dose in the right eye two times daily for glaucoma, dated 1/6/21. The facility scheduled to give it daily at 9 a.m. and 5 p.m. During a medication pass observation on 4/19/21 at 4:20 p.m., licensed nurse (LN) A was observed giving 7 medications, including brimonidine and prednisolone eye medications, to Resident 10. There was no administration of Trusopt eye solution during this medication pass. During an interview on 4/19/21 at 5:10 p.m., with LN A, she said the Trusopt eye medication was 055797 Page 11 of 31 055797 04/23/2021 Gilroy Healthcare Center 8170 Murray Avenue Gilroy, CA 95020

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some also due at 5 p.m. but she did not give it because it ran out and was not available to give. She said she documented in the resident's medical record: Medication not available. Nurse has ordered from pharmacy. Will follow up with pharmacy. A review of Resident 10's April 2021 MAR, under the 4/19/21 at 5 p.m. entry, it showed MN and LN A's initials. The chart codes on the MAR indicated MN to mean medication not available. During an interview the next morning, on 4/20/21 at 9:05 a.m., with LN F, she said she could not locate the Trusopt for Resident 10 in the medication cart. She also could not find the prednisolone eyedrop, both of which were due for administration that morning. During a follow-up interview on 4/20/21 at 11:29 a.m., LN F said she called the pharmacy which informed her the Trusopt and prednisolone eyedrops would be delivered later that afternoon. LN F said she did not give the Trusopt and Prednisolone to Resident 10 that morning. This was verified on the MAR entry on 4/20/21 at 9 a.m. During an interview on 4/20/21 at 2:35 p.m., with Resident 10, she said she was informed by the facility about two missing eyedrops. She said she was not happy but she was okay with it as she was not experiencing any pain in her right eye at the moment. 2. On 4/19/21, a review of Resident 10's April 2021 MAR indicated her routine medications were not given during the morning medication pass at 9 a.m. on 4/14 and 4/15/21. The MAR entries were left blank on these days. The medications included aspirin, furosemide (for high BP), metoprolol (for high BP), amlodipine (for high BP), clonidine (for high BP), Humulin 70/30 (insulin for diabetes), Trusopt eyedrop, brimonidine eyedrop, gabapentin (for pain), hydralazine (for high BP), isosorbide dinitrate (for chest pain), acetazolamide (for glaucoma), Cipro eye solution (antibiotic to treat infections), and prednisolone eye solution. On 4/22/21, a review of Resident 10's nursing progress notes, documented on 4/14/21 at 8:17 a.m., indicated the resident out of facility at this time @ follow up Vitrectomy appt with [Dr's name] at Retinal Diagnostic Center and Resident back from follow-up Vitrectomy appointment with [Dr's name] with new orders . on 4/14/21 at 9:30 a.m. During an interview on 04/23/21 at 8:25 a.m., with the assistant director of nursing (ADON), she said she reviewed Resident 10's clinical record and confirmed the resident was in the facility on 4/14 and 4/15/21, except she was out for an appointment from 8:17 a.m. to 9:30 a.m. on 4/14/21. The ADON said she could any find any documentation why the medications were not administered. She said medication administration should have been documented on the MAR as given to the resident. The ADON said LN G was the resident's morning nurse on those days. During an interview on 4/23/21 at 8:50 a.m., with Resident 10, she said she believed she got her medications on the daily basis, with the exception of missing her eyedrops on certain days. She said there were days her medications were not given timely such as insulin given after meals instead of before meals, but she believed she received her medications every day. During an interview on 4/23/21 at 1:20 p.m., with LN G, she said she remembered giving Resident 10 her medications on 4/14 and 4/15/21, but they were given late on both days, due to the resident coming back from the appointment, and due to her other responsibility as a treatment nurse. She said she forgot to chart on the MAR, and said she should have been documented to indicate the medications 055797 Page 12 of 31 055797 04/23/2021 Gilroy Healthcare Center 8170 Murray Avenue Gilroy, CA 95020

F 0755 were administered. Level of Harm - Minimal harm or potential for actual harm A review of the facility's 12/2012 Medication Administration Operating Standard Guideline indicated: Routine . medications will be administered as ordered within the timeframes indicated per facility practice . Medications must be given within one hour of the time stated on the MAR. Residents Affected - Some 3. On 4/19/21, four random Controlled Drug Records (CDR, an inventory sheet) for four residents were requested for review. a. Resident 112 had a physician's order for Norco (a potent narcotic for pain) 5/325 milligrams (mg) 1 tablet every 4 hours as needed for pain, dated 3/25/21. On 4/20/21, a review of the CDR for Resident 112's Norco indicated the nursing staff signed out 4 tablets on: 4/6/21 at 8:30 a.m. and 12:30 p.m.; and on 4/7/21 at 8:20 a.m. and 12:20 p.m. However, none was documented on the MAR to indicate they were given to the resident. This was confirmed with the ADON during a concurrent interview and review of Resident 112's clinical record on 4/20/21 at 11:47 a.m. She reviewed the CDR, MAR, and nursing progress notes but could not find any documentation the Norco was given at the date and time in question. She said any time the nursing staff signed out a CS medication from the CDR, they needed to document on the MAR to indicate the medication was given to the resident. The ADON verified 4 Norco tablets for Resident 112 were not accounted for. b. Similarly, Resident 229 had a physician's order for Norco 5/325 mg 1 tablet every 4 hours as needed for pain, dated 3/28/21. On 4/20/21, a review of the CDR for Resident 229's Norco indicated the nursing staff signed out 6 tablets, as follows, but they were not documented on the MAR as given to the resident: - 4/4/21 at 6:53 p.m. - 4/6/21 no time documented - 4/7/21 at 3 p.m. - 4/8/21 at 3 p.m. and 7 p.m. - 4/12/21 at 9:56 p.m. During a concurrent interview and review of Resident 229's clinical record on 4/20/21 at 11:52 a.m., with ADON, she said she could not find any documentation they were given. She acknowledged 6 Norco tablets for Resident 229 were unaccounted for. c. Resident 80 had a physician's order for Norco 10/325 mg 1 tablet by mouth every 6 hours as needed for pain, dated 4/5/21. On 4/20/21, a review of the CDR for Resident 80's Norco indicated one tablet was signed out on 4/9/21 at 10:28 a.m. but it was not documented on the MAR to indicate it was given to the resident. 055797 Page 13 of 31 055797 04/23/2021 Gilroy Healthcare Center 8170 Murray Avenue Gilroy, CA 95020

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some This was confirmed with ADON during a concurrent interview and review of Resident 80's clinical record on 4/20/21 at 12:17 p.m. She verified one dose of Resident 80's Norco 10/325 mg was not accounted for. A review of the facility's Safeguarding Controlled Substances Operating Standard, dated 1/2009, indicated: Each facility will engage in safe and secure practices related to . reconciling . controlled substances and Following removal and administration, the nurses is to document on the residents MAR the date, time, and reasons (if PRN [as needed]) a controlled substance had been given. 055797 Page 14 of 31 055797 04/23/2021 Gilroy Healthcare Center 8170 Murray Avenue Gilroy, CA 95020

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observation, interview, and record review, the facility's consultant pharmacist (CP) failed to identify and make recommendations to the facility regarding drug storage concerns and irregularities related to the residents' drug regimen for four of 23 sampled residents (Residents 32, 47, 80, and 117). The failures resulted in inadequately monitored medications, which could lead to unsafe and ineffective medications for residents, and unnecessary medications for the residents, which had the potential to place them at risk for harm or adverse consequences. Findings: 1. During an inspection of the Medication Room in Station 3/4 conducted with the assistant director of nursing (ADON) on 4/19/21 at 10:50 a.m., an opened Novolin NPH (long acting insulin to treat high blood sugar) vial for Resident 28 was identified. Its label indicated it was opened on 12/1/20, and to discard after 1/1/21. An inspection of Medication Cart #4 on 4/19/21 at 3:36 p.m. with licensed nurse (LN) D and LN E identified 3 of 3 Xalatan (latanoprost, to treat high pressure inside the eye due to glaucoma) eye solution for 3 residents (Residents 31, 123, and 124) were opened without the open date. The manufacturer's label for the Xalatan solution indicated: Opened bottle may be stored at room temperature .for 6 weeks. The pharmacy label indicated they were dispensed on 9/25/20 (almost 7 months ago) for Resident 31; on 2/17/21 (2 months prior) for Resident 123; and on 4/2/21 for Resident 124. During a telephone interview on 4/23/21 beginning at 3:54 p.m., with CP, she said part of her duties during the monthly visit at the facility included inspection of the medications in the medication rooms and medication carts. When relayed about an insulin vial expiring in 1/2021 and multiple Xalatan eyedrops which may have been opened months ago without the open date, CP said she must have missed them during her monthly medication inspection at the facility. 2. During an inspection of the Medication Room in Station 1/2 with the ADON on 4/19/21 beginning at 11:19 a.m., the medication refrigerator (Ref #1) was identified. Ref #1 was observed to contain: 5 vials of multi-dose influenza vaccine, 5 vials of Pneumovax 23 (vaccine used to help prevent infections caused by certain types of germs or bacteria called pneumococcus); and 10 syringes of Prevnar 13 (vaccine helps protect against the 13 types of pneumococcal bacteria that most commonly cause serious infections). A review of the temperature logs for Ref #1 with ADON during the inspection indicated the nursing staff had been monitoring the temperature once daily for at least since August 2020 until the inspection day (9 months). She said the facility received the flu vaccine around October 2020. During an interview on 4/22/21 at 9:30 a.m., with the director of nursing (DON), she said if the medication refrigerator contained vaccines, it should be monitored twice daily. A review of the facility's policy and procedures (P&P) titled Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, revised 10/28/19, indicated: Facility Staff should monitor the temperature of vaccines twice a day. During a telephone interview on 4/23/21 beginning at 3:54 p.m., with CP, she said the nursing staff 055797 Page 15 of 31 055797 04/23/2021 Gilroy Healthcare Center 8170 Murray Avenue Gilroy, CA 95020

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some should monitor temperature in medication refrigerators once daily. When relayed about the facility P&P requiring twice daily monitoring for medication refrigerators, CP said she did not identify once daily monitoring as an irregularity in her monthly report to the facility, and added, We will fix that. 3. A review of the facility's 11/2017 Psychotropic Medication Management P&P indicated, When psychoactive medications [drugs affecting the mind] are prescribed, the clinical record should reflect the diagnosis and specific condition, or target behavior being treated. On 4/23/21, a review of Resident 47's clinical record indicated she had a physician's order, dated 1/19/21, for divalproex sodium (Depakote, a medication that can treat certain seizure disorders and mental/mood conditions) 125 milligrams (mg) two times daily for Alzheimer's dementia. The order did not indicate the target behavior(s) or mood problems for the staff to monitor. During a concurrent interview and record review on 4/23/21 at 2:05 p.m., with the DON and ADON, the DON confirmed there were no specific target behaviors for staff to monitor and to assess the effectiveness related to the use of Depakote. On 4/23/21, a review of Resident 47's clinical record reflected no CP's recommendation related to the resident's Depakote. During a telephone interview on 4/23/21 at 4:30 p.m., with CP, when asked if she made a recommendation related to the lack of target behavior(s) for Resident 47's Depakote, CP said, No, I didn't do it. I thought the way we did is okay. 4. Similarly, on 4/22/21, a review of Resident 80's clinical record indicated a physician's order, dated 3/2/21, for Prozac (fluoxetine, an antidepressant) 20 mg 1 cap daily for depression. There was no specific depression symptoms such as tearfulness, social isolation, insomnia, withdrawn, refusing care, etc. In other words, there was a diagnosis of depression, but there was no specific condition or target behaviors/symptoms for the staff to monitor. During a concurrent interview and record review on 4/23/21 at 2:13 p.m., with DON and ADON, they both confirmed there were no specific depression symptoms, specific to Resident 80, for staff to monitor. On 4/23/21, a review of Resident 80's clinical record reflected no CP's recommendation for the resident's Prozac. During a telephone interview on 4/23/21 at 4:35 p.m., with CP, when asked if she made a recommendation related to the lack of target symptoms for the use of Resident 80's Prozac, CP said, No, I thought our system works. 5. On 4/22/21, a review of Resident 117's clinical record reflected he had a physician order, dated 1/28/21, for duloxetine (an antidepressant) 60 mg 1 capsule by mouth one time a day for depression. The order did not indicate what specific depression symptoms for staff to monitor. During an interview on 4/23/21 at 11:20 a.m. with LN B, she said she could not locate any specific behaviors except depression for the use of duloxetine. Also, she could not find documented evidence the staff was monitoring for its side effects. 055797 Page 16 of 31 055797 04/23/2021 Gilroy Healthcare Center 8170 Murray Avenue Gilroy, CA 95020

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent interview and record review on 4/23/21 at 2:28 p.m., with the ADON, she confirmed there were no specific behaviors prescribed for the use of Prozac and nursing had not been monitoring for its side effects. On 4/23/21, a review of Resident 117's clinical record reflected no CP's recommendation for the resident's duloxetine. During a telephone interview on 4/23/21 at 4:40 p.m., with the CP, she said she did not make recommendations related to the lack of specific target symptoms and side effect monitoring for Resident 117's duloxetine. She said she thought the system works. 6. On 4/21/21, a review of Resident 32's clinical record indicated the resident had been receiving Seroquel (an antipsychotic), in various doses, since 12/2019 (more than 1 year ago). Her current physician order, dated 3/25/21, indicated Seroquel 12.5 mg by mouth in the evening for agitation. A review of Resident 32's clinical record indicated there was no evidence the facility conducted the Abnormal Involuntary Movement Scale (AIMS, a rating scale designed to measure involuntary movements, known side effects of long-term treatment of antipsychotic medications) assessment for Resident 32 since 12/2019. During the concurrent interview and review of Resident 32's clinical record on 4/23/21 at 2:43 p.m., with the ADON, she verified there had been no AIMS assessment done since 12/2019. She said it should have been done every 6 months for residents on antipsychotic medications. A review of the facility's 11/2017 Psychotropic Medication Management policy and procedures indicated: If antipsychotic medications are used, an AIMS assessment will be completed upon admission, at the onset of a new order, every six months, and if medication dose is increased. On 4/23/21, a review of Resident 32's clinical record indicated no CP's recommendations for AIMS assessment. During a telephone interview on 4/23/21 at 4:45 p.m., with the CP, she said she did not make recommendation for AIMS assessment related to Resident 32's Seroquel use because she thought it would be overwhelming for the nurses to do too many tests. On 4/23/21, the facility provided an undated document titled Scheduled 1-A Required Consultant Services. It indicated: 1. Consultant shall provide consultation regarding all material aspects of providing pharmaceutical services to Facility . 3. Consultant shall assist Facility in determining that residents' medication therapy is necessary and appropriate . 5. Consultant shall identify any irregularities as defined in the State Operations Manual . 9. Consultant shall assist Facility in determining that medications are labeled in accordance with federal and state labeling requirements and accepted standards of practice. 055797 Page 17 of 31 055797 04/23/2021 Gilroy Healthcare Center 8170 Murray Avenue Gilroy, CA 95020

F 0756 10. Consultant shall assist Facility in reviewing the safe . storage of medications . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 055797 Page 18 of 31 055797 04/23/2021 Gilroy Healthcare Center 8170 Murray Avenue Gilroy, CA 95020

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure one of 23 sampled residents (Resident 117) was free from unnecessary medications when the nursing staff did not monitor for signs and symptoms of adverse effects related to the use of blood thinning medications. Resident 117 was receiving Lovenox (generic name enoxaparin, an anti-coagulant, or blood thinning medication) and Plavix (anti-platelet agent to prevent heart attacks or strokes). This had the potential for side effects of these medications (such as bleeding, excessive bruising, etc.) to go undetected or recognized for timely intervention. Residents Affected - Few Findings: On 4/23/21, a review of Resident 117's clinical record indicated he was an elderly resident admitted to the facility with diagnoses including the presence of a pacemaker (a medical device that sends electrical pulses to help your heart beat at a normal rate and rhythm) and deep vein thrombosis (DVT, a blood clot forms in a vein located deep inside your body). A review of the clinical record indicated two physician's orders, as follows: a. Lovenox 100 milligrams (mg) twice daily for DVT, dated 4/12/21; and b. Plavix 75 mg 1 tablet daily, dated 3/28/21. To date, the Prescribing Information for Lovenox indicates to monitor signs and symptoms of bleeding such as bruising that is not normal, nosebleeds, red/black tarry stools, bleeding from the gums, etc. According to Lexi-comp, a nationally recognized drug information resource, the combined use Lovenox and Plavix results in a drug-drug interaction (interaction between a drug and another substance that prevents the drug from performing as expected) risk-rating Level D (moderate severity, which means to avoid or consider therapy modification). It indicated, Antiplatelet agents and enoxaparin both increase the risk of bleeding . If concomitant administration is unavoidable, monitor closely for signs and symptoms of bleeding. A concurrent interview and record review of Resident 117's clinical record was conducted with licensed nurse B (LN B) on 04/23/21 at 11:20 a.m. LN B said the resident developed DVT on the left arm after it became swollen, and was prescribed Lovenox for DVT. LN B reviewed the resident's 4/2021 MAR and said there was no documented evidence the staff monitored for signs and symptoms of adverse effects of Lovenox and Plavix. This was confirmed with the assistant director of nursing (ADON) during a concurrent interview and review of Resident 117's clinical record on 4/23/21 at 2:28 p.m. She said there should be side effect monitoring the Lovenox and Plavix on the medication administration record. A review of the facility's Anticoagulant Therapy Procedure, dated September 2010, indicated Monitor for signs and symptoms of adverse drug effects, including, but not limited to, abnormal or prolonged bleeding, excessive bruising, petechiae [tiny round brown-purple spots due to bleeding under the skin], melena (blood in stool), hematuria [blood in urine], coffee ground emesis [vomit], bleeding from eyes, nose, or gums, etc. 055797 Page 19 of 31 055797 04/23/2021 Gilroy Healthcare Center 8170 Murray Avenue Gilroy, CA 95020

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 six of 23 sampled residents (Residents 9, 32, 47, 70, 80, and 117) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) when: 1. Resident 9 received five doses of as-needed lorazepam (a controlled medication to treat agitation and anxiety) when the nursing staff documented no behaviors observed, and there was no documented evidence the resident exhibited behaviors before receiving the lorazepam doses; 2. Resident 32 received Seroquel (an antipsychotic medications) with inadequate monitoring when there was no Abnormal Involuntary Movement Scale (AIMS; a rating scale designed to measure involuntary movements known as tardive dyskinesia, a disorder that sometimes develops as a side effect of long-term treatment with antipsychotic medications) assessment conducted since the start of Seroquel; 3. Resident 47 received divalproex sodium (Depakoke; a medication that can treat certain seizure disorders and mental/mood conditions) without appropriate monitoring for use. There was no specific target behavior(s) being monitored, and no care plan developed; 4. Resident 80 received Prozac (an antidepressant) without adequate monitoring for use. There was no specific depression symptom(s) being monitored for the use of Prozac; 5. Resident 117 received duloxetine (an antidepressant) without specific target symptom(s) and side effect monitoring; and 6. Resident 70 received valproic acid (a medication that can treat certain seizure disorders and mental/mood conditions) without target or specific behavior(s) being monitored. The failures resulted in lack of adequate monitoring and unnecessary medications for the residents, which had the potential for increased risks associated with the use of psychotropic medications that include but are not limited to sedation, respiratory depression, falls, constipation, anxiety, agitation, and memory loss. Findings: 1. On 4/21/21, a review of Resident 9's clinical record indicated she was an elderly resident admitted to the facility with diagnoses including Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), anxiety disorder, and unspecified dementia (a condition characterized by memory loss). During a concurrent observation and interview on 4/21/21 at 3:24 p.m., with Resident 9, she was in her bed, conversant, and in pleasant manner. No behaviors were observed. During an interview on 4/21/21 at 4:05 p.m., with licensed nurse (LN) M, she said Resident 9 had occasional behaviors of verbally aggressive and spitting at staff. A review of Resident 9's medical record indicated a physician's order for lorazepam 0.5 mg, half 055797 Page 20 of 31 055797 04/23/2021 Gilroy Healthcare Center 8170 Murray Avenue Gilroy, CA 95020

F 0758 tablet by mouth every 8 hours as needed for anxiety, since 3/24/21. Level of Harm - Minimal harm or potential for actual harm A review of Resident 9's care plan for anxiety, dated 4/14/19, indicated the resident had anxiety manifested by Aggressiveness or Agitated Behavior yelling/screaming/pinching/scratching/spitting. Residents Affected - Some A review of Resident 9's 4/2021 medication administration record (MAR) showed, for the lorazepam administration, the staff was to document date and time of medication administration and a YES or NO on the Beh. O [behavior observed] entry. The MAR showed the nursing staff administered lorazepam doses on the following days and times: 4/4 at 6:08 p.m., 4/5 at 7:23 p.m., 4/7 at 6:49 p.m., 4/16 at 5:45 p.m., and 4/17/21 at 5:10 p.m. However, each of these administrations had a NO on the Beh. O entry. During a concurrent interview and record review on 04/23/21 at 11:46 a.m., with the assistant director of nursing (ADON), she verified the staff documented NO behaviors on the MAR but the lorazepam doses were given. Additionally, she could not find supporting evidence, such as in the nursing progress notes, that indicated the resident exhibited behaviors before receiving the lorazepam doses on the days mentioned above. A review of the facility's 12/2012 Medication Administration Operating Standard Guideline indicated, PRN [pro re nata, meaning as-needed] medications- Given upon request or administered per body language or behavior. Document reason and follow up . 2. On 4/21/21, a review of Resident 32's clinical record indicated she was an elderly resident admitted to the facility with diagnoses including Alzheimer's Disease with late onset and unspecified psychosis (mental disorder characterized by a disconnection from reality). A review of Resident 32's clinical record revealed the resident had been on various doses of Seroquel since 12/2019. Her current physician order, dated 3/25/21, indicated Seroquel 12.5 mg by mouth in the evening for agitation. Lexi-comp, a nationally recognized drug information resource, indicated the side effects for Seroquel included abnormal involuntary muscle movements such as continuous muscle spasm and contractions, tremors, and tardive dyskinesia (or TD: irregular, jerky movements). It indicated to monitor abnormal involuntary movements and TD at baseline and every 6 months for high-risk patients. A review of Resident 32's clinical record indicated there was no evidence the facility conducted the AIMS assessment for Resident 32 since the start of Seroquel in 12/2019 (more than 1 year ago). During the concurrent interview and review of Resident 32's clinical record on 4/23/21 at 2:43 p.m., with ADON, she verified there had been no AIMS assessment done since 12/2019. She said it should have been done every 6 months for residents on antipsychotic medications. She added, I just did one today. A review of the facility's 11/2017 Psychotropic Medication Management policy and procedures indicated: If antipsychotic medications are used, an AIMS assessment will be completed upon admission, at the onset of a new order, every six months, and if medication dose is increased. 3. A review of the facility's 11/2017 Psychotropic Medication Management policy and procedures indicated: When psychoactive medications [drugs affecting the mind] are prescribed, the clinical record 055797 Page 21 of 31 055797 04/23/2021 Gilroy Healthcare Center 8170 Murray Avenue Gilroy, CA 95020

F 0758 should reflect the diagnosis and specific condition, or target behavior being treated. Level of Harm - Minimal harm or potential for actual harm On 4/23/21, a review of Resident 47's clinical record indicated she was an elderly resident admitted to the facility with diagnoses including Alzheimer's Disease and dementia with Lewy body (a type of dementia). Residents Affected - Some A review of a physician's order, dated 1/19/21, indicated: divalproex sodium (Depakote) 125 mg two times daily for Alzheimer's dementia. The order did not indicate specific target behavior(s) or mood problems for the staff to monitor. A concurrent interview and record review with LN M was conducted on 4/23/21 at 10:36 a.m. She reviewed Resident 47's clinical record and said, It's not specifically stated what behavior(s) the Depakote was used for except for the diagnosis of Alzheimer's Dementia. She confirmed there was no care plan developed that addressed the behavior(s), goals, and interventions related to the resident's mood/behavior condition. She said the nursing staff did not have specific target behaviors to monitor related to the use of Depakote. During a concurrent interview and record review on 4/23/21 at 2:05 p.m., with the director of nursing (DON) and ADON, the DON confirmed there were no prescribed target behaviors for staff to monitor and to assess the effectiveness related to the use of Depakote. She said there should have been specific behaviors for its use, and it should be care planned. 4. On 4/22/21, a review of Resident 80's clinical record reflected she was admitted to the facility with diagnoses including anxiety disorder and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 80's clinical record indicated a physician's order, dated 3/2/21, for Prozac (fluoxetine) 20 mg 1 cap daily for depression. There was no specific depression symptoms such as tearfulness, social isolation, insomnia, withdrawn, refusing care, etc. In other words, there was a diagnosis of depression, but there was no specific condition or target behaviors/symptoms for the staff to monitor. During a concurrent interview and record review, on 4/23/21 at 10:47 a.m., with LN M, she said there were no specific target symptoms related to the use of Prozac for staff to monitor. When asked what mood or behaviors the staff had been monitoring, she said there was a generic template that consisted of forty plus different behaviors for staff to monitor, but they were not specific to the resident. During a concurrent interview and record review on 4/23/21 at 2:13 p.m., with DON and ADON, they both confirmed there were no specific depression symptoms, specific to Resident 80, for the staff to monitor. The ADON said the staff just do general monitoring, not specific to the resident's symptoms. 5. On 4/23/21, a review of Resident 117's clinical record reflected he was admitted to the facility with diagnoses including major depressive disorder. A review of Resident 117's physician order, dated 1/28/21, indicated duloxetine 60 mg 1 capsule by mouth one time a day for depression. The order did not indicate what specific depression symptoms for the staff to monitor. 055797 Page 22 of 31 055797 04/23/2021 Gilroy Healthcare Center 8170 Murray Avenue Gilroy, CA 95020

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 4/23/21 at 11:20 a.m. with LN B, she said she could not locate any specific behaviors except depression for the use of duloxetine. Also, she could not find documented evidence the staff was monitoring for its side effects. During a concurrent interview and record review on 4/23/21 at 2:28 p.m., with ADON, she said the order just says depression, and there had been no side effect monitoring for the use of duloxetine. She acknowledged there should have been specific target behaviors and side effect monitoring for the use of duloxetine. A review of the facility's 11/2017 Psychotropic Medication Management policy and procedures indicated: Observed or reported behaviors, effectiveness . and monitoring of medication side effects are to be documented in the EHR [electronic health record]. 6. Review of Resident 70's clinical record indicated, she had diagnoses including psychotic disorder (severe mental disorder) with delusions (fixed, false beliefs that conflict with reality). Review of Resident 70's physician order dated 1/28/21 indicated, valproic acid (a medication that can treat certain seizure disorders and mental/mood conditions) capsule 250 mg two capsules by mouth BID (BID, two times a day) for psychosis with behaviors. The order did not indicate what was Resident 70's specific behavior. During an interview on 4/22/21 at 10:20 a.m. with licensed vocational nurse (LVN) N, she stated there was no certain behavior nurses were monitoring for Resident 70. During a concurrent interview and record review on 4/22/21 at 4:32 p.m., with the DON, she reviewed Resident 70's care plan and confirmed there was no target or specific behavior for the use of Valproic acid. During an interview on 4/22/21 at 4:45 p.m., with the DON, she confirmed there was no specific behavior being monitored for Resident 70. Review of the facility's policy Psychotropic Medication Management dated November 2017 indicated, residents behaviors should be evaluated for psychotropic use. Care plans should be updated to reflect resident's behavior(s) causing functional, emotional, or safety impairment . 055797 Page 23 of 31 055797 04/23/2021 Gilroy Healthcare Center 8170 Murray Avenue Gilroy, CA 95020

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 7.14% error rate when two medication errors out of 28 opportunities were observed during the medication pass. Resident 10 did not receive an eye medication as scheduled; and the nursing staff administered eye medications not in accordance with the facility's medication administration guideline and accepted professional standards of practice. The failure resulted in medications not given as ordered and as per accepted professional standards of practice, which may negatively affect the resident's health. Residents Affected - Few Findings: 1. During a medication pass observation on 04/19/21 at 04:20 p.m., licensed nurse A (LN A) was observed preparing and administering 7 medications, including two eye medications: prednisolone (to treat swelling and inflammation) 1% eye solution and brimonidine (for reduction of pressure in the eye) 0.2% eye solution, to Resident 10. At Resident 10's bedside, on 4/19/21 at 4:31 p.m., LN A administered 1 drop of the prednisolone eye solution to the resident's right eye. She then gave the resident's oral medications which the resident took all at once followed by a drink of water. One minute later from the first eyedrop administration, on 4/19/21 at 4:32 p.m., LN A instilled 1 drop of the brimonidine eye solution into the resident's right eye. Shortly after the medication pass, LN A said she would normally wait about 1 to 2 minutes between different eye medications for residents. She acknowledged she waited about 1 minute between Resident 10's two different eye medications. During an interview on 4/20/21 at 9:20 a.m., with the director of staff development (DSD), she said the nursing staff should wait 5 minutes between giving different eye medications. A review of the facility's Medication Administration Operating Standard Guideline, dated 12/2012, indicated, Wait 3-5 minutes between drops and different eye medications. In the Tips for Administering Eye Drops, the American Academy of Allergy Asthma and Immunology indicated, When administering multiple eye medications, wait 5 to 15 minutes before delivering second medication to same eye in order to prevent dilution. (www.aaaai.org; accessed 4/26/21). 2. On 4/19/21, a review of Resident 10's medical record revealed Resident 10 was to receive 3 different eye medications during the daily 5 p.m. medication pass: prednisolone, brimonidine, and Trusopt (treat high pressure inside the eye) 2% eye solutions. A review Resident 10's physician's order, dated 1/6/21, indicated: Trusopt Solution 2% Instill 1 drop in the right eye two times a day for Glaucoma indefinite. It was scheduled to be administered daily at 9 a.m. and 5 p.m. There was no administration of Trusopt eye solution during the medication pass observation with LN A. During an interview on 4/19/21 at 5:10 p.m., with LN A, she said she did not give the Trusopt because it ran out and was not available to give. She said she documented in the resident's medical 055797 Page 24 of 31 055797 04/23/2021 Gilroy Healthcare Center 8170 Murray Avenue Gilroy, CA 95020

F 0759 record: Medication not available. Nurse has ordered from pharmacy. Will follow up with pharmacy. Level of Harm - Minimal harm or potential for actual harm A review of Resident 10's April 2021 medication administration record (MAR), under the 4/19/21 at 5 p.m. entry, it showed MN and LN A's initials. The chart codes on the MAR indicated MN to mean medication not available. Residents Affected - Few 055797 Page 25 of 31 055797 04/23/2021 Gilroy Healthcare Center 8170 Murray Avenue Gilroy, CA 95020

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. Based on observation, interview, and record review, the facility failed to store and label medications in accordance with the manufacturer's instructions and the facility policy and procedures when: 1. One vial of insulin (medication to treat high blood sugar) and one vial of flu vaccine were found in active stock past their discard date; and 4 multi-dose vials (medication, usually in liquid, intended for more than one dose of medication), one oral inhaler, and 3 Xalatan (or lanatoprost, to treat high pressure inside the eye due to glaucoma) eye solution bottles were opened without an open date. Two of the Xalatan eye solutions for 2 residents were being used past the discard date. 2. A Lantus (long-acting insulin) vial was identified without patient-specific label; 3. The nursing staff had been monitoring the temperature in one of two medication refrigerators (Ref #1) once daily, a practice inconsistent with the facility's policy and procedures; and 4. Medication refrigerator temperature was not monitored on a daily basis for Ref #1. The deficient practices had a potential for residents to receive medications with unsafe and reduced potency from being used past their discard date; medication errors due to medications not being labeled; and inadequately monitored medications, which could lead to unsafe and ineffective medications for residents. Findings: 1a. An inspection of the medication room in Station 3/4 was conducted with the assistant director of nursing (ADON) on 4/19/21 at 10:50 a.m. The inspection of the medication refrigerator identified the following: 1) Two opened tuberculin (an agent indicated to aid diagnosis of tuberculosis infection) vials were without the open date. The manufacturer's label on the tuberculin carton box indicated, Discard opened product after 30 days. 2) An opened Novolog (rapid-acting insulin) vial for Resident 124 without the open date. The pharmacy label on the Novolog vial indicated to discard 28 days after opening. 3) An opened Novolin NPH (long acting insulin) vial for Resident 28 indicated the vial was opened on 12/1/20 and to discard after 1/1/21. During the inspection, the ADON verified the above findings. 1b. During an inspection of the medication room in Station 1/2 with the ADON on 4/19/21 beginning at 11:19 a.m., the medication refrigerator (Ref #1) was identified. The inspection revealed the following: 1) A Novolin 70/30 (combination insulin) vial for Resident 10 was without an open date. The pharmacy label indicated it was dispensed on 2/11/21 (2 months prior. The ADON verified the finding, looked 055797 Page 26 of 31 055797 04/23/2021 Gilroy Healthcare Center 8170 Murray Avenue Gilroy, CA 95020

F 0761 up her drug information resource, and said it was good for 42 days after opening. Level of Harm - Minimal harm or potential for actual harm 2) One 5-milliliter flu vaccine that had the open date of 3/5/21. The ADON said it was good for 28 days after opening. The vial should be discarded on 4/3/21. Residents Affected - Some During the inspection, the ADON verified the above findings. 1c. During an inspection of medication cart #4 on 4/19/21 at 3:36 p.m., with licensed nurse (LN) D and LN E, identified: 1) a Breo Ellipta (Inhaler for asthma) for Resident 83 without an open date. The manufacturer label indicated: Discard the inhaler 6 weeks after opening the moisture-protective foil tray. There were two auxiliary labels from the pharmacy indicating to write in the Date Opened and Discard After but none was filled in by the facility staff. 2) Three of three Xalatan eye solution bottles for 3 residents (Residents 31, 123, and 124) were opened without the open date. The manufacturer label on the Xalatan bottle indicated: Opened bottle may be stored at room temperature .for 6 weeks. The pharmacy label indicated they were dispensed on 9/25/20 (almost 7 months ago) for Resident 31; on 2/17/21 (2 months ago) for Resident 123; and on 4/2/21 for Resident 124. LN E verified the findings and acknowledged the Xalatan solution bottles were used past the discard date (6 weeks after opening) for Residents 31 and 123. A review of the facility's Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, revised 10/28/19, indicated: Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications and If a multi-dose vial of an injectable medication has been opened or accessed . the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. 2. During an inspection of Medication Cart #1 on 4/19/21 at 3:15 p.m., with LN C, a Lantus vial was identified without a pharmacy label with the resident's name and other identifiers on it. The carton box containing the Lantus vial indicated it belonged to Resident 113. LN C said the label must have fallen off. LN C acknowledged this could potentially result in an error because the unlabeled Lantus vial could be mistakenly placed in another Lantus carton box that belonged to another resident. A review of the facility's policy and procedures, Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, revised 10/28/19, indicated: Facility should destroy and reorder medications . with . missing labels or cautionary instructions. 3. During an inspection of the medication room in Station 1/2 with the ADON on 4/19/21 beginning at 11:19 a.m., a round analog thermometer was observed inside the medication refrigerator (Ref #1). This thermometer could only read real-time temperature reading, and had no capacity to record minimum (min) or maximum (max) temperature. During the inspection, Ref #1 was observed to contain: 5 vials of multi-dose influenza vaccine, 5 vials of Pneumovax 23 (vaccine used to help prevent infections caused by certain types of germs or bacteria called pneumococcus), and 10 syringes of Prevnar 13 (vaccine helps protect against the 13 types of pneumococcal bacteria that most commonly cause serious infections). 055797 Page 27 of 31 055797 04/23/2021 Gilroy Healthcare Center 8170 Murray Avenue Gilroy, CA 95020

F 0761 Level of Harm - Minimal harm or potential for actual harm A review of the Temperature Log for Ref #1 with the ADON during the inspection indicated the nursing staff had been monitoring the temperature once daily. The instructions on the Temperature Log indicated in part: 2. If using temperature monitoring divide (TMD; digital data logger recommended) that records min/max temps, document min/max once each workday . If using TMD that does not record min/max temps, document current temps twice, at the beginning and end of each workday. Residents Affected - Some During the inspection above, the ADON reviewed the monthly temperature logs for Ref #1 and acknowledged the staff had been logging the temperature only once daily at least since August 2020 until present day (9 months). She said the facility got the flu vaccine in around October 2020. During an interview on 4/22/21 at 9:30 a.m., with the director of nursing (DON), she said if the medication refrigerator contained vaccines, it should be monitored twice daily. A review of the facility's policy and procedures, Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, revised 10/28/19, indicated Facility Staff should monitor the temperature of vaccines twice a day. 4. During an inspection of the medication room in Station 1/2 with the ADON on 4/19/21 beginning at 11:19 a.m., review of the monthly temperature logs, from August 2020 to April 2021, for Ref #1 with the ADON indicated the nursing staff was monitoring the temperature once daily. However, it was not monitored consistently on a daily basis. The following days were not logged: 9/4, 10/7, 10/8, 10/9, 10/27, 12/15, 12/16/2020; and 1/22, 1/27, 1/28, 1/29, 2/14, 2/19, 3/1, and 3/9/2021. The ADON verified the nursing staff was not monitoring the medication refrigerator temperature on a daily basis for Ref #1. 055797 Page 28 of 31 055797 04/23/2021 Gilroy Healthcare Center 8170 Murray Avenue Gilroy, CA 95020

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 2. During a concurrent observation and interview on 4/19/21 at 4:25 p.m., LN H was not wearing his facemask while in the nursing station with another staff. When asked if he needed to wear his facemask, he stated he could not answer the surveyor. Residents Affected - Many During an interview with the director of nursing (DON) on 4/19/21 at 4:43 p.m., she stated staff were expected to wear a face mask while in the facility. According to the Centers for Disease Control and Prevention website https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, Health care provider (HCP) should wear well-fitting source control (e.g facemasks or respirators) at all times while they are in the healthcare facility. 3. During an observation 4/20/21 at 8:54 a.m., LN F wore gloves while preparing medications. LN F went to room (rm) X to talk with a resident without taking off her gloves. At 8:57 a.m., LN F came out from rm X and removed her gloves. During an interview on 4/20/21 at 9:00 a.m., with LN F, she confirmed the above observation and stated she did change her gloves in rm X. LN F further stated she should have removed her gloves prior to entering the resident's room. According to the World Health Organization (WHO) website https://www.who.int/gpsc/5may/Glove_Use_Information_Leaflet.pdf, When wearing gloves, change or remove gloves in the following situations: during patient care if moving from a contaminated body site to another body site including mucous membrane, non-intact skin or a medical device within the same patient or the environment) 4a. During an observation on 4/22/21 at 7:50 a.m., certified nursing assistant (CNA I) was in rm XX, left the room and went to get a chair in rm XXX. CNA I did not perform hand hygiene in between tasks. During an interview on 4/22/21 at 7:51 a.m., with CNA I, he confirmed the above observation and stated he should have performed hand hygiene. b. During an observation on 4/22/21 at 7:54 a.m., CNA J exited rm XXXX and went to rm X. CNA J exited rm X, preceded to the linen cart, and took a white cloth. During an interview on 4/22/21 at 7:55 a.m., with CNA J, she confirmed the above observation and then performed hand hygiene. c. During an observation on 4/22/21 at 7:59 a.m., the LS wheeled Resident 97 to his room. The LS exited the room and returned to the clean laundry cart without performing hand hygiene. During an interview on 4/22/21 at 8:02 a.m., with the LS, she confirmed the above observation. Review of the CDC website https://www.cdc.gov/handhygiene/providers/index.html indicated, Perform hand hygiene after touching a patient or the patient's immediate environment. 5. During an initial tour on 4/19/21 at 10:55 a.m., in Station 1's yellow zone (residents on observation for any signs and symptoms of COVID), the licensed physician (LP) was observed leaving room A 055797 Page 29 of 31 055797 04/23/2021 Gilroy Healthcare Center 8170 Murray Avenue Gilroy, CA 95020

F 0880 and entering rooms B, C, D and E without changing his gown. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/19/21 at 11:20 a.m., the LP acknowledged the above observation and stated he was not aware of the facility policy on the use of personal protective equipment (PPE) in the yellow zone. He stated he knew the importance of following the facility's infection prevention protocol to prevent the spread of infection in the facility. Residents Affected - Many During an interview with the assistant director of nursing (ADON) on 4/22/21 at 2 p.m., she stated everyone must follow the facility's guidelines on the donning and doffing of appropriate PPE. A posted sign by the wall near room B indicated Do change the gown and gloves between patients because some could be and others could be. A review of the facility's 9/16/2020 policy, COVID-19 Mitigation Plan, indicated to remove all PPE before exiting the patient room. 6. During an observation and concurrent interview on 4/22/21 at 8:45 a.m. with certified nursing assistant Q (CNA Q), Resident 117's urinal was hanging in the trash can next to the resident's bed. CNA Q stated the urinal should be cleaned and placed in the bathroom to prevent contamination. During an observation and concurrent interview on 4/23/21 at 1:45 p.m. with certified nursing assistant R (CNA R), Resident 117's urinal containing used gauze was hanging in the trash can. CNA Q acknowledged, the urinal should not be hanged in the trash can. During an interview with the ADON on 4/23/21 at 2:30 p.m., she stated the urinal should be emptied and cleaned immediately after each use and must be stored in a clean area. A review of the facility's undated policy, Administration of Bedpan/Urinal, indicated do not place urinal on floor or bedside stand and clean and store urinal per facility procedure. 7. During observation on 04/23/21 at 2:05 p.m., Resident 109 was self-propeling in a wheelchair in the hallway. Resident 109's urinary catheter tubing (long plastic cylinder that collects urine) from the drainage bag was touching the floor. During interview with LVN N on 04/23/21 at 2:15 p.m., LVN N acknowledged the finding and stated that should not be touching the floor. 8. During the initial tour on 4/19/21 at 11:48 a.m., the oxygen concentrator filter for Resident 89 was dusty. During an observation on 4/19/21 at 11:51 a.m. of the oxygen concentrator filter for Resident 54, the oxygen concentrator filter for Resident 54 was dusty. During an observation on 4/19/21 at 12:03 p.m., of the oxygen concentrator filter for Resident 43, it was observed that the oxygen concentrator filter for Resident 43 was very dusty. During an interview on 4/20/21 at 10:20 a.m. with certified nursing assistant L (CNA L), in Resident 43's room, CNA L stated the oxygen concentrator filter did not look like it had been cleaned. 055797 Page 30 of 31 055797 04/23/2021 Gilroy Healthcare Center 8170 Murray Avenue Gilroy, CA 95020

F 0880 Level of Harm - Minimal harm or potential for actual harm During an interview on 4/20/21 at 10:25 a.m. with licensed vocational nurse K (LVN K), in Residents 54 and 89's room, LVN K stated both oxygen concentrator filters looked dirty. During an interview on 4/20/21 at 10:35 a.m. with central supply staff (CS), CS stated the oxygen concentrator filters for Residents 43, 54, and 89 needed to be changed. Residents Affected - Many Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Glucometer was not disinfected after a resident use; 2. Licensed nurse (LN) H did not wear his facemask while talking to another staff; 3. LN F did not remove gloves prior to entering a resident room; 4. Three staff did not perform hand hygiene in between tasks; 5. Physician did not change gown in between residents in the observation unit; 6. Urinal was observe hanging in a trash can; 7. Resident 109's urinary catheter tubing was touching the floor; 8. Three oxygen filters were dirty. These failures could result in the spread of infection and cross-contamination. Findings: 1. During a medication pass observation on 4/19/21 at 4:28 p.m., licensed nurse A (LN A) was observed giving medications to Resident 10 and obtaining the resident's blood sugar (BS) at the bedside. LN A pricked the resident's finger with the lancet (a cutting device), then collected a small blood sample on a testing strip that was connected to the glucometer. After completing reading the BS, LN A disposed of the testing strip, went back to the medication cart, and placed the glucometer in the medication cart without cleaning and disinfecting it. During an interview on 4/19/21 at 4:41 p.m., with LN A, she said she did not clean and disinfect the glucometer because she wore gloves during the blood sample collection, and it did not touch the resident. She said the glucometer was being used to collect blood samples from multiple residents. Then she added, You are right. I should wipe it down after each resident, and proceeded to wipe the glucometer with the disinfectant wipe. During an interview on 04/19/21 04:46 p.m., with the director of nursing (DON), she said the nurse should wipe down the glucometer after use on each resident. The facility provided the undated Cleaning and Disinfecting Guidelines from the maker of the glucometer. It indicated to clean and disinfect the meter between patient use with the appropriate cleaning and disinfectant wipe. 055797 Page 31 of 31