Health inspection·November 25, 2024

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 Based on interview and record review, the facility failed to ensure treatment orders for respiratory [breathing] therapy (RT, treatment that helps individuals optimize their respiratory function, breathe more easily, and live more comfortably) was carried out as ordered for six out of six residents (Residents 3, 5, 6, 7, 8, and 9). The failure had the potential for the residents not attaining their highest practicable physical well-being, such as not being able to attend activities or carry out the activities of daily living (ADLs; such as eating, toileting, dressing, personal hygiene, etc.) due to reduced respiratory functions. Residents Affected - Some Findings: 1a. A review of Resident 5's clinical record indicated she was admitted to the facility with diagnoses including history of COVD-19. Her Minimum Data Set (MDS, a care area assessment and screening tool), dated 11/5/24, indicated she had a BIMS score of 15 (Brief Interview for Mental Status, a test given by medical professionals that helps determine a patient's cognitive understanding that can be scored from 1 to 15), which indicated she had intact cognitive response. A review of Resident 5's RT care plan, dated 5/16/24, indicated, Resident has history of COVID-19 with present of intermittent cough, resident will benefit from daily respiratory service and Resident has and [sic] alteration in respiratory system secondary to SOB [shortness of breath] that contributes to ADL limitations. Resident has high risk for potential development of respiratory distress. A review of Resident 5's clinical record indicated a physician's order, dated 11/15/24, for chest physiotherapy to bilateral anterior [front] and posterior [back] lung segments. 5 minutes per segment. Chest physiotherapy may include chest percussion and/or huffing/coughing five times a day or as tolerated with pre-and post-oxygen saturation check. On 11/20/24, a review of Resident 5's 11/2024 Respiratory Administration Record (RAR, an official document where staff document the RT) indicated the staff did not carry out the RT 5 times per day. It showed the staff only administered respiratory care: - 11/16/24: only 2 times - 11/17/24: only 2 times - 11/19/24: only 3 times During an interview with Resident 5 on 11/20/24 at 2:30 p.m., she stated she had been receiving respiratory treatment 3 times a day. She stated the RT helps her with breathing better and improving Page 1 of 8 055798 055798 11/25/2024 Vasona Creek Healthcare Center 16412 Los Gatos Boulevard Los Gatos, CA 95032

F 0684 her lung functions. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review with the Director of Staff Development (DSD) on 11/20/24 at 3:37 p.m., he reviewed Resident 5's RAR and verified, as per the RAR documentation, the resident only received 2 times of RT on 11/16 and 11/17, and 3 times on 11/19/24. Residents Affected - Some On 11/25/24, further review of Resident 5's 11/2024 RAR indicated she only received RT two times on 11/20, 11/22, and 11/24/24. During another interview with Resident 5 on 11/25/24 at 10:53 a.m., she stated she only received RT 3 times per day. When asked whether she had ever received RT 5 times per day, she stated, No. During a concurrent interview and record review with the Director of Nursing (DON) on 11/25/24 at 2:05 p.m., the DON reviewed Resident 5's 11/2024 RAR and confirmed Resident 5 did not receive RT treatment 5 times a day, as ordered, on 11/16, 11/17, 11/19, 11/20, 11/22, and 11/24/24. 1b. A review of Resident 6's clinical record indicated she was admitted to the facility with diagnoses including respiratory disorders in diseases classified elsewhere. Her 8/14/24 MDS indicated she had a BIMS score of 15, indicating she had intact cognition. Resident 6 had no care plan for RT. A review of her physician's orders indicated an order, dated 11/16/24 for Chest physiotherapy to bilateral anterior and posterior lung segments, 5 minutes per segment. Chest physiotherapy may include chest percussion and/or huffing/coughing five times per day. A review of Resident 6's 11/2024 RAR indicated her RT treatment was scheduled 5 times daily at 7 a.m., 10 a.m., 1 p.m., 4 p.m., and 7 p.m., but she only received 1 to 3 times per day on the following days: - 11/16/24: 2 times instead of 5 - 11/17/24: 3 times - 11/18/24: 2 times - 11/19/24: 3 times - 11/20/24: 1 time - 11/21/24: 3 times During an interview with Resident 6 on 11/25/24 at 12:42 p.m., she stated RT treatment helped her breathe better; and she only received a RT treatment 2 times per day, once in the morning and once in the afternoon. She clarified that sometimes the staff ran late and administered the afternoon session at 3 p.m., but never after 3 p.m. During a concurrent interview and record review with the DON on 11/25/24 at 2:07 p.m., the DON reviewed Resident 6's 11/2024 RAR and confirmed Resident 6 did not receive RT treatment 5 times a day, as ordered, on 11/16, 11/17, 11/18, 11/19, 11/20, and 11/21/24. 055798 Page 2 of 8 055798 11/25/2024 Vasona Creek Healthcare Center 16412 Los Gatos Boulevard Los Gatos, CA 95032

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1c. A review of Resident 3's clinical record indicated she was admitted to the facility with diagnoses including bronchiectasis (a chronic lung disease that causes the airways to widen and thicken, making it difficult to move air in and out of the lungs). Her MDS 11/8/24 MDS indicated she had a BIMS code of 99 indicating the resident could not complete the mental status assessment. A review of Resident 3's care plan for RT, dated 11/19/24, indicated, Resident has an alteration in respiratory system secondary to .BRONCHIECTASIS . that contributes to ADL/functional limitations. Resident has high risk for potential development of cardio-pulmonary [related to heart and lung] symptoms and/or respiratory distress. A review of Resident 3's physician's orders, dated 11/19/24, for Chest physiotherapy to bilateral anterior and posterior lung segments. 5 minutes per segment. Chest physiotherapy may include chest percussion and/or huffing/coughing five times a day. A review of Resident 3's 11/2024 RAR indicated she did not receive 5 times RT treatment on the following days: - 11/19/24: only 2 times - 11/20/24: only 3 times - 11/22/24: zero times received - 11/23/24: only 3 times - 11/24/24: only 3 times During a concurrent interview and record review with the DON on 11/25/24 at 2:07 p.m., the DON reviewed Resident 3's 11/2024 RAR and confirmed Resident 3 did not receive RT treatment 5 times a day, as ordered, on 11/19, 11/20, 11/22, 11/23, and 11/24/24. 1d. A review of Resident 7's clinical record indicated he was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (COPD, an ongoing lung condition caused by damage to the lungs) and asthma. A review of his 9/18/24 MDS indicated he had a BIMS score of 15, indicating he had intact cognition. A review of his care plan for RT, dated 5/6/24, indicated, Resident has an alteration in respiratory system secondary to . CHRONIC OBSTRUCTIVE PULMONARY DISEASE . ASTHMA that contributes to ADL/functional limitations. Resident has high risk for potential development of cardio-pulmonary systems and/or respiratory distress. On 11/2/24, Resident 7 received a physician's order for chest physiotherapy to bilateral anterior and posterior lung segments. 5 minutes per segment. Chest physiotherapy may include chest percussion and/or huffing/coughing five times a day or as tolerated with pre-and post-oxygen saturation check. On 11/25/24, a review of Resident 7's 11/2024 RAR indicated he did not received 5 times treatment on the following days: - 11/8/24: only 4 times 055798 Page 3 of 8 055798 11/25/2024 Vasona Creek Healthcare Center 16412 Los Gatos Boulevard Los Gatos, CA 95032

F 0684 - 11/11/24: only 2 times Level of Harm - Minimal harm or potential for actual harm - 11/12/24: only 3 times - 11/16/24: only 3 times Residents Affected - Some - 11/17/24: only 2 times - 11/22/24: only 2 times - 11/23/24: only 2 times - 11/24/24: only 3 times During an interview with Resident 7 on 11/25/24 at 10:50 a.m., when asked how often he received RT treatment, he stated, Two to three times a day. He stated the RT treatment helped him breathe better. During a concurrent interview and record review with the DON on 11/25/24 at 2:07 p.m., the DON reviewed Resident 7's 11/2024 RAR and confirmed Resident 7 did not receive RT treatment 5 times a day, as ordered, on the above dates. 1e. A review of Resident 8's clinical record indicated he was admitted to the facility with diagnoses including respiratory disorders in diseases classified elsewhere. A review of his RT care plan, dated 10/7/24, indicated the resident had alteration in respiratory system due to respiratory disorders in diseases classified elsewhere and atelectasis [the collapse of a lung or part of a lung, also known as a lobe] that contributes to ADL limitations. Resident has high risk for potential development of respiratory distress. On 11/15/24, Resident 8 received a physician's order for chest physiotherapy to bilateral anterior and posterior lung segments. 5 minutes per segment. Chest physiotherapy may include chest percussion and/or huffing/coughing five times a day or as tolerated with pre-and post-oxygen saturation check. A review of Resident 8's 11/2024 RAR indicated the resident only received 3 times RT treatment on 11/17/24 and 11/23/24. During a concurrent interview and record review with the DON on 11/25/24 at 2:07 p.m., the DON reviewed Resident 8's 11/2024 RAR and confirmed Resident 8 did not receive RT treatment 5 times a day, as ordered, on 11/17/24 and 11/23/24. 1f. Resident 9 was admitted to the facility with diagnoses including OTHER SPECIFIED SYSTEMS AND SIGNS INVOLVING THE CIRCULATORY [system that delivers nutrients and oxygen to all cells in the body] AND RESPIRATORY SYSTEMS A review of his RT care plan, dated 8/26/24, indicated, Resident has an alteration in respiratory system secondary to OTHER SPECIFIED SYSTEMS AND SIGNS INVOLVING THE CIRCULATORY AND RESPIRATORY SYSTEM that contributes to ADL/functional limitations . 055798 Page 4 of 8 055798 11/25/2024 Vasona Creek Healthcare Center 16412 Los Gatos Boulevard Los Gatos, CA 95032

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 9's physicians orders indicated an order, dated 11/15/24, for chest physiotherapy to bilateral anterior and posterior lung segments. 5 minutes per segment. Chest physiotherapy may include chest percussion and/or huffing/coughing five times a day or as tolerated with pre-and post-oxygen saturation check. A review of Resident 9's 11/2024 RAR indicated he did not receive RT treatment 5 times a day on the following days: - 11/15/24: 4 times only - 11/16/24: 3 times only - 11/17/24: 3 times only - 11/22/24: 3 times only - 11/23/24: 3 times only During a concurrent interview and record review with the DON on 11/25/24 at 2:07 p.m., the DON reviewed Resident 9's 11/2024 RAR and confirmed Resident 9 did not receive RT treatment 5 times a day, as ordered, on 11/15, 11/16, 11/17, 11/22, and 11/23/24. 2. During an interview with the respiratory therapist on 11/25/24 at 11:21 a.m., she explained that many elderly residents need RT due to their many medical conditions that cause reduced respiratory functions. She explained the chest physiotherapy is the procedure that helps breaking the mucous and makes them cough it out, thereby improving their breathing. She stated some nursing staff have received training and been assigned RT duty as part of their responsibilities. When asked whether the residents have received 5 times daily treatment, she stated, It's trick to get five times a day. I can guarantee 3 times a day treatment for those residents assigned to her. As far as documentation on the RAR, she stated, If therapy is completed, they should document after. During a review with the DSD on 11/25/24 at 12:15 p.m., he stated he and four other nursing staff have received training and been assigned resident RT treatment as part of their responsibilities. For documentation on the RAR, he stated the nurses do not have the computer (like the medication nurses) to document after each treatment administered, but the expectation is that they document at the end of their shift. During an interview with the DON on 11/25/24 at 2:40 p.m., the DON stated she did not know the residents not receiving their respiratory treatment as ordered. She also stated the expectation is that the staff carry out the physician's orders, whether it's medication, dietary, physical therapy, or RT, as ordered. As for documentation, the DON stated, They are supposed to document after each service is being done. The facility was requested to provide the policy and procedures related to carrying out the physician's orders on 11/20, 11/21, and 11/25/24. On 11/25/24 at 2:48 p.m., the DON stated she could not find any policies addressing the implementation of the physician's orders besides that for medication orders. A review of the California Title 22 regulations, section 72314(a)(2), indicated, Medications and 055798 Page 5 of 8 055798 11/25/2024 Vasona Creek Healthcare Center 16412 Los Gatos Boulevard Los Gatos, CA 95032

F 0684 treatments shall be administered as prescribed. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 055798 Page 6 of 8 055798 11/25/2024 Vasona Creek Healthcare Center 16412 Los Gatos Boulevard Los Gatos, CA 95032

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure appropriate storage of medications in two of four medication rooms when: 1. The medication room that housed the facility's automated dispensing unit (ADU - where medications are stored and electronically tracked) was unlocked when not in use; 2. Two expired medications were identified in the medication refrigerators; and 3. The medication refrigerator temperature in Medication room [ROOM NUMBER] was not consistently monitored twice daily as per the U.S. Centers for Disease Control and Prevention's (CDC) guidelines. The failures had the potential for unauthorized access to dangerous medications; expired medications given to residents; and ineffective medications or loss of drug potency due to unmonitored temperatures. Findings: 1. During a visit to the second floor with Assistant Director of Nursing B (ADON B) on 11/20/24 at 9:30 a.m., an unmarked room was identified unlocked. The ADON B opened the door without using a key. The room housed a large ADU, the facility's main medication supply. A large white bucket was observed in front of the ADU. It contained 5 tablets of clonidine (medication for high blood pressure) 0.1 milligrams. Opposite from the bucket was a large plastic multi-drawer bin/cart that contained multiple intravenous supplies and hydration solutions. The ADON B stated, The door should be locked. A review of the facility's undated policy titled Medication Labeling and Storage indicated, Compartments (nilcuding, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use . 2. During a visit to Station 1 Medication Room with ADON B on 11/20/24 at 9:40 a.m., a bag containing an eye drop solution called latanoprost (medication for glaucoma) 0.005% for Resident 10 was identified inside the medication refrigerator. The yellow sticker outside the bag indicated it was opened on 9/30/24 and expired on 10/28/24. ADON B verified this medication had expired, and stated it should not be in the refrigerator. During a visit to Station 3/4 Medication Room with ADON B on 11/20/24 at 10:01 a.m., an opened multi-dose tuberculin (a protein extract used in a skin test to help diagnose tuberculosis infection) solution vial was identified in the medication refrigerator. The yellow sticker on the vial indicated it was opened on 10/13/24, and expired on 11/13/24. ADON B confirmed the product had expired. A review of the facility's undated policy titled Medication Storage- Refrigerators indicated, Charge nurses or designated employee will be responsible for ensuring medication in refrigerators are not expired. 3. During a visit to Station 1 Medication Room with ADON B on 11/20/24 at 9:40 a.m. , a medication 055798 Page 7 of 8 055798 11/25/2024 Vasona Creek Healthcare Center 16412 Los Gatos Boulevard Los Gatos, CA 95032

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few refrigerator was identified. It was observed to contain a round, household-type thermometer and various refrigerated medications such as insulin vials and pens, eye drops, and 13 boxes of flu vaccine. Each box of flu vaccine contained 10 pre-filled single-dose syringes. A review of the November 2024 temperature log with ADON B indicated the staff did not log it 10 times this month, from 11/1 to 11/20/24: 6 times during the NOC (night) shift and 4 times during the day shift. The ADON confirmed this finding and stated the refrigerator should be monitored twice daily. A review of the facility's undated policy titled Medication Storage- Refrigerators indicated the charge nurses/designate employee will check and record refrigerator temperature daily. During an interview with the Director of Nursing on 11/25/24 at 4:28 p.m., she stated medication refrigerator temperature should be monitored and recorded twice daily. A review of the CDC's Vaccine Storage and Handling Toolkit, dated 3/29/24, indicated the following for monitoring of refrigetors containing vaccine: If your TMD [temperature monitoring device] does not read minimum/maximum temperatures, then check and record the current temperature a minimum of two times per workday. 055798 Page 8 of 8