Health inspection·December 21, 2022

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to ensure a medication error rate below five percent for two of nine sampled residents (Resident 23 and 32) when: Residents Affected - Few 1. Resident 32 was administered sennosides (medication to induce bowel movement) 8.6 milligram (mg, a unit of weight measurement) instead of docusate (medication to induce bowel movement) 200 mg as prescribed by physician's order; and 2. Resident 23 did not receive vitamin d3 (a vitamin needed for various body function) 25 mcg (microgram, a unit of measurement) as prescribed. This failure resulted in two medication errors out of 30 opportunities during observation of medication administration which resulted in the facility having a medication error rate of 6.67% and resulted in residents not receiving the correct medication or receiving the medication as prescribed. Findings: 1. During a concurrent medication pass observation and interview on 12/19/22, at 9:40 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 administered to Resident 32, two tablets of sennosides 8.6 mg. LVN 1 stated the two tablets of sennosides 8.6 mg was for Resident 32's order for docusate 200 mg. Docusate 200 mg was not given to Resident 32. A record review of Resident 32's physician's orders, dated 12/19/22, indicated Resident 32 did not have an order for sennosides 8.6 mg. The physician's order indicated Resident 32 had an order for docusate 200 mg, twice a day. During an interview and record review on 12/19/22, at 12:10 p.m., with LVN 1, Resident 32's Medication Administration Record (MAR) was reviewed. LVN 1 identified a bottle of sennosides 8.6 mg which two tablets were removed for Resident 32's order for docusate 200 mg. When asked to verify on the MAR if Resident 32 had an order for sennosides 8.6 mg, LVN 1 stated Resident 32 did not have an order for sennosides 8.6 mg. During an interview on 12/20/22, at 11:52 a.m., with the Director of Nursing (DON), the DON stated nursing staff should check medications against physician's order and MAR before administration. 2. A review of Resident 23's admission record dated 12/20/22 indicated Resident 23 had a diagnosis of vitamin d3 deficiency. During a medication pass observation and interview on 12/20/22, at 9:15 a.m., with LVN 2, LVN 2 Page 1 of 5 056170 056170 12/21/2022 Excell Health Care Center 3025 High Street Oakland, CA 94619

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few administered three medications to Resident 23. LVN 2 stated the medications in the cup were two Tylenol (a pain reliever) 325 mg tablets, two sennosides 8.6 mg tablets, and two vitamin B12 (vitamin needed for blood production) tablets. LVN 2 stated a total of six pills were in the medication cup. A review of Resident 23's physician's orders, dated 12/21/22, indicated Resident 23 had another order for vitamin d3 25 mcg, once a day. During an interview and record review on 12/20/22, at 12:22 p.m., with LVN 2, Resident 23's MAR was reviewed. Resident 23's MAR indicated LVN 2 administered vitamin d3 25 mcg at 9:21 a.m. The MAR further indicated at 9:21 a.m., Resident 23 received two tablets of Tylenol 325 mg, two tablets of sennosides 8.6 mg and two tablets of vitamin B12. LVN 2 stated she gave Resident 23 all his morning medications at the same time and did not administer other medications before or after the 9:15 a.m. medication pass observation. LVN 2 recalled again six pills were in the medication cup. Reviewing Resident 23's MAR, LVN 2 stated Resident 23 should have received seven pills and could not recall giving vitamin d3. During an interview on 12/20/22, at 11:52 a.m., with the DON, the DON stated nursing staff should administer medications according to the MAR and document the administration after giving the medication. A review of facility policy and procedure (P&P) titled, Medication Administration, dated 9/2/22, indicated staff review MAR to identify medication to be administered and compare medication source with MAR to verify .medication name, form, dose, route and time. 056170 Page 2 of 5 056170 12/21/2022 Excell Health Care Center 3025 High Street Oakland, CA 94619

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 observations, interviews, and record review, the facility failed to ensure medications were stored and labeled appropriately when: 1. two insulin (a medication to maintain blood sugar in diabetics) pens (an insulin dispensing device with replaceable needles) and a vial of insulin were found without an open or expiration date in a drawer in Medication Cart (Med Cart) 3; 2. six loose pills were found in two drawers in Med Cart 3; 3. two expired glucagon (a medication to raise blood sugar) auto-injectors (a device that automatically injects medication) were found in a drawer in Med Cart 3, 4. a bottle of fluticasone propionate solution 50 mcg/act (nasal spray used to relieve nasal symptoms, such as stuffy nose, itching and sneezing) was stored on Resident 30's nightstand. These failures had the potential for administration of expired medications to residents and administration of medications to the wrong resident. Findings: 1.During a concurrent inspection of Med Cart 3 and interview on 12/20/22, at 10:08 a.m., with Licensed Vocational Nurse (LVN) 2, two insulin pens and one vial of insulin were found in a drawer in Med Cart 3. LVN 2 stated the two insulin pens and vial of insulin did not have an open or expiration date written on the appropriate label. LVN 2 stated whoever opened the pens and vial should have labeled them appropriately. LVN 2 stated she did not know when the open dates for the two insulin pens or insulin vials were. During a review of manufacturer's storage recommendation for insulin pens and vial, dated 11/2019, the recommendations indicated opened insulin pens and vials be discarded after 28 days. 2.During an observation and interview on 12/20/22, at 10:08 a.m., with LVN 2, Med Cart 3 was inspected. Six loose pills were found in two of Med Cart 3's drawer. LVN removed the six pills and stated those pills should not be found loose in the drawers. 3.During an observation and interview on 12/20/22, at 10:10 a.m., with LVN 2, two expired glucagon auto-injectors were found in a drawer in Med Cart 3. LVN 2 stated the expiration date of the two glucagon auto-injectors was 8/22. During an interview on 12/20/22, at 10:20 a.m., with the Director of Nursing (DON), the DON stated expired medications needed to be removed from medication carts as they are found. During a review of facility policy and procedure (P&P) titled, Medication Storage, dated 9/2/22, the P&P indicated medication carts are routinely inspected by the consulting pharmacist for .medications with worn, illegible, or missing labels. The P&P further indicated medications be stored according to the manufacturer's recommendations .to ensure proper sanitation, temperature, light, 056170 Page 3 of 5 056170 12/21/2022 Excell Health Care Center 3025 High Street Oakland, CA 94619

F 0761 ventilation, moisture control, segregation, and security. Level of Harm - Minimal harm or potential for actual harm 4. During a concurrent observation of Resident 30's room and interview with LVN 3, on 12/19/22 at 9:40 a.m., there was a bottle of fluticasone propionate suspension 50 mcg/act (nasal spray used to relieve nasal symptoms, such as stuffy nose, itching and sneezing) placed on Resident 30's nightstand. LVN 3 acknowledged the bottle of fluticasone propionate suspension 50 mcg/act at Resident 30's nightstand. LVN 3 stated Resident 30 has no current orders for this medication. LVN 3 stated this medication should not be at Resident 30's nightstand for the resident's safety. Residents Affected - Some During an interview on 12/21/21 at 1:40 p.m. with DON, DON stated Resident 30 has no orders to self-medicate. DON stated there is no assessment done for Resident 30's self medication. DON further stated medication should never be left at bedside for the safety of the residents. A review of the facility P&P titled, Medication Storage in the Facility, dated April 2008, indicated, Bedside medication storage is permitted for residents who are able to self-administer medications, upon the written order of the prescriber and when it is deems appropriate in the judgment of the facility's interdisciplinary resident assessment team. The P&P Section A indicated, A written order for the bedside storage of medication is present in the resident's medical record and Section F further indicated, All nurses and aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage and to give unauthorized medications to the charge nurse for return to the family or responsible party. Families or responsible parties are reminded of this procedure and related policy when necessary. 056170 Page 4 of 5 056170 12/21/2022 Excell Health Care Center 3025 High Street Oakland, CA 94619

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store and serve food in a sanitary manner when food items stored in the snack refrigerator were unlabeled and food items served during lunch did not have their temperatures checked before being served. These deficient practices had the potential to cause food borne illness that can affect all residents. The facility census was 99 and 95 residents were served food from the kitchen. Findings: During a concurrent observation and interview on 12/19/22 at 9:10 a.m. of the kitchen with Dietary Manager (DM) 1, three food items stored in the snack refrigerator were not labeled. DM 1 confirmed the three food items stored in the snack refrigerator were not labeled. DM 1 stated food items stored in the snack refrigerator should all have a label to identify what food items are stored in the container. During an observation and interview on 12/20/22 at 12:30 a.m. with [NAME] 1 during lunch service, two servings of rice, one serving of carrots and one serving of hot dog were served. [NAME] 1 stated the two servings of rice, one serving of carrots and one serving of hot dog were all prepared earlier in the kitchen. During a concurrent record review and interview on 12/20/22 at 12:45 p.m. of the 12/20/22 lunch temperature log, the temperatures of the rice, carrots and hot dog were not recorded. DM 1 acknowledged the temperatures of the rice, carrots and hot dog's temperatures were not recorded. DM 1 further stated the rice, carrots and hot dog were served to residents for lunch. A review of the facility document titled, Labeling and Dating of Foods, undated, indicated Policy: All food items in the storeroom, refrigerator, and freezer need to be labeled and dated . All prepared foods need to be covered, labeled and dated . Leftovers will be covered, labeled and dated. A review of the facility document titled, Record of Food Temperatures, undated, indicated Policy: It is the policy of this facility to record food temperatures daily to ensure food that is at the proper serving temperature(s) before trays are assembled . 1. Food temperatures will be checked on all items prepared in the dietary department . 6. Measure and record the temperatures for each food product and mil at all meals. Record temperatures on temperature log. 056170 Page 5 of 5