Health inspection·March 27, 2025

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and record review, the facility failed to verify gastrointestinal tube (GT digestive tract and related organs) placement for one of five residents (Resident 10) prior to medication administration. This failure had the potential for medications not to be safely and effectively delivered into the stomach and may lead to serious complications such as aspiration pneumonia. Findings: During a review of Resident 10's admission Record, printed 3/26/25, the record indicated Resident 10 was admitted in 2020 with diagnoses including hemiplegia (muscle weakness on one side of the body) and dysphagia (difficulty swallowing foods or liquids) leading to GT placement. During an observation on 3/25/25, at 12:53 p.m., Licensed Vocational Nurse (LVN) 1 prepared (crushed) two medications separately for Resident 10. LVN 1 placed each medication (med) in a med cup and diluted each with 30 ml (milliliter) of water. LVN 1 did not check if the GT was in the right position in the stomach. LVN 1 then attached a syringe to the feeding tube of Resident 10, started with water flush of 30 ml water, poured each med into the syringe using gravity flow, and poured 15 ml in between the meds. During a review of Resident 10's order summary report with order date 1/18/25, the order summary report indicated, Check GT placement before administering feeding/medication . During an interview on 3/26/25, at 12:34 p.m., with LVN 1, LVN 1 confirmed she did not check GT placement for Resident 10 before administration of the medications on 3/25/25. LVN 1 stated the only time she checked the GT placement was at 8 a.m. before water flush for Resident 10 via the GT and that was what she had always done. During an interview on 3/26/25, at 12:39 p.m., with LVN 1, LVN 1 stated GT placement must be verified before administering meds to ensure the GT is in place and not dislodged, which could result in complications that would lead to sending the resident to the hospital. During an interview on 3/27/25, at 7:50 a.m., with the Director of Nursing (DON), DON stated the GT placement should be verified before administration of medication or feeding to ensure the GT is in place. During a review of the facility's policy and procedure (P&P) titled, Administering Medications Page 1 of 7 056392 056392 03/27/2025 Pleasanton Nursing and Rehabilitation Center 300 Neal Street Pleasanton, CA 94566

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few through an Enteral Tube, revised November 2018, the P&P indicated, The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral (related to intestines) tube .Verify placement of feeding tube: If you suspect improper tube positioning, do not administer feeding or medication . During a review of the National Institutes of Health National Library of Medicine titled, Enteral Tube Management, dated 2021, indicated, According to the American Association of Critical-Care Nursing recommends that the positions of a feeding tube should be checked and documented every four hours and prior to the administration of enteral feedings and medications . https://www.ncbi.nlm.nih.gov/books/NBK593216/ 056392 Page 2 of 7 056392 03/27/2025 Pleasanton Nursing and Rehabilitation Center 300 Neal Street Pleasanton, CA 94566

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food was stored and prepared in a clean environment, within standards for safety when: Residents Affected - Some 1) Ice Machine floor drain was not maintained clean; 2) Food items stored in the refrigerator had expired with past use by dates; 3) Food items in the refrigerator did not have use by and expiration dates; 4) Food items in the pantry not labelled and stored properly; 5) Kitchenware (including pans, cutting boards, cooking utensils, ergo silverware, strainers, blender, food processor) were in poor condition; 6) The two-part sink, on the left side of sink, was being used for washing potatoes and the right side of the sink with a large cleaning bucket filled with rags, water and cleaning solution; 7) Drawers used to store cooking utensils were not maintained clean; 8) Industrial Can-Opener, Blender, Food Processer not maintained clean; 9) Stove and Oven with built up residue, large amounts of food particles and grease, accumulated underneath and on sides of stove; 10) A kitchen oven mitt was found on the top surface of the stove; 056392 Page 3 of 7 056392 03/27/2025 Pleasanton Nursing and Rehabilitation Center 300 Neal Street Pleasanton, CA 94566

F 0812 11) Level of Harm - Minimal harm or potential for actual harm Tile on the right side of the dishwashing area not sealed and was separated against the wall; 12) Residents Affected - Some The center of the floor, in the dishwashing area, was dirty with black slimy greasy material underneath the rubber mats. These failures had the potential to result in contamination of food leading to food borne illness, for 133 Residents who resided in the facility. Findings: During an observation on 3/24/25, at 9:25 a.m., with Certified Dietician (CD1), the white ice machine drain was dirty, covered in black film and debris. During a review of the facility's policy and procedure (P&P) titled, Cleaning Instructions; Ice Machine and Equipment, dated 2017, the P&P indicated the ice machine and equipment will be cleaned and sanitized on a regular bases. During an observation on 3/24/25, at 9:30 a.m., with CD1, located in the walk-in refrigerator and available for use were the following food items stored beyond the facility identified use-by dates: -Twenty-five fruit cups of melon, pineapple, cantaloupe, and watermelon with an expired use-by date of 3/22/25. - Opened package of turkey bacon and chicken salad with use-by date of 1/9/25. - One box of (25) cream cheese packages with use-by date of 2/8/25. In addition, the main refrigerator had the following items without labeling of use-by/expiration dates: -Five dinner rolls -Peanut butter and Jelly sandwich -Cups of drinks (cranberry juice, thickened apple juice, and milk.) -Three quarts of Tuna salad with no prepared or use-by date. -One quart of Tuna salad with no prepared or use-by date. -One quart of peaches CD1 confirmed the food items were stored beyond the use-by date. CD1 stated staff should discard items by the use-by date daily and that all food items needed to have a prepared by date and a use-by date. 056392 Page 4 of 7 056392 03/27/2025 Pleasanton Nursing and Rehabilitation Center 300 Neal Street Pleasanton, CA 94566

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 3/24/25, at 9:40 a.m., with CD1, the walk-in fridge had one box of basil and one box of rosemary with no received date and no use-by date. During a concurrent observation and interview on 3/24/25, at 9:50 a.m., with CD1, the pantry had 34 loaves of sliced bread with no received date, expiration date, or use-by date. On the wire rack shelf was an open 1.5 quart jar of Real Mayonnaise, ¾ full. CD1 stated these items should have a clearly identified label of received and use-by date and did not think the mayonnaise needed to be refrigerated after opening. According to the United States Department of Agriculture (USDA), for food safety, the USDA recommends refrigerating mayonnaise after opening to slow down the growth of bacteria and recommends discarding opened mayonnaise that has been at room temperature for more than eight hours. During a concurrent observation and interview on 3/24/25, at 10:00 a.m., in the main pantry, with CD1, the bottom level shelf contained a large cardboard box with an opened plastic bag, unsealed, with 25 pounds (lbs) of white powder. CD1 stated it was thickener used for pureed food and stated the box in the packaging should not be open and exposed, and should be in a container with a used-by and opened date. During a review of the kitchen policy and procedure (P&P) manual, dated 2023, the P&P indicated, 1) All foods should be covered, labeled and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their use-by dates or discarded. 2) All food items should be stored upon delivery, and careful rotation procedures should be followed. 3) Food should be dated as it is placed on the shelves, and date marking should be visible and 4) Plastic containers with tight fitting covers or sealable plastic bags must be used for storing lots of bulk foods or opened packages. During a concurrent observation and interview on 3/24/25, at 10:15 a.m., with CD1 and [NAME] 1, [NAME] 1 soaked approximately 60 potatoes on the left side of a two-compartment sink in a pool of cloudy water. [NAME] 1 stated a potato was placed in the drain to soak the potatoes. On the right side of the two-compartment sink [NAME] 1 stated there was a blue bucket of cleaning solvent with dish rags used for wiping down surfaces. CD1 stated there should not be cleaning solvent next to the food prep area as it could result in cross-contamination of solvent onto food. During observation on 3/24/25, at 10:45 a.m., the two-compartment sink had a build-up of food and debris on the corners of the sink and sink drain. During an observation on 3/24/25, at 10:25 a.m., with CD1, there were 12 large resting trays with dirty greasy film, and 14 flat sheet roasting trays and one large roasting pan, which were all considered clean, with metal flakes and grease build-up. There was one large and one medium size sauté pan, with protective coating coming off, and all the pans observed were in poor condition with dents and grease build up. The food strainer had an orange build up on the rim and a 3 inch gap on the strainer. The large green cutting board was being used with an accumulation of scrapes and black marks. During an observation on 3/24/25, at 10:30 a.m., with CD1, a large industrial can opener base was filled with food and oil with food particles on the rotary blade. During a review of the facility's P&P titled, Cleaning Instructions, dated 2017, the P&P indicated, 056392 Page 5 of 7 056392 03/27/2025 Pleasanton Nursing and Rehabilitation Center 300 Neal Street Pleasanton, CA 94566

F 0812 The can opener will be cleaned after each use. Level of Harm - Minimal harm or potential for actual harm During an observation on 3/24/25, at 10:40 a.m., with CD1, the roasting oven was dirty on the outside with grease and food build up as well as on the metal grates inside the oven. Residents Affected - Some During an observation on 3/24/25, at 10:45 a.m., with CD1, the stove top grill had thick food and grease buildup on all 8 of the metal grills and underneath the stove, and on the sides of the stove was a thick accumulation of both sticky substance and food debris stuck throughout the rim of the stove. During an observation on 3/24/25, at 12:30 p.m., the blender and food processor had an accumulation of debris and food particles stuck to the equipment. The food processor had a 2 x 3 inch broken piece on the side of the machine that had built up accumulation of dried debris. During a review of the facility's P&P titled, Cleaning Instructions, dated 2017, the P&P indicated, Food preparation appliances, small appliances such as mixers and food processors will be cleaned and sanitized after each use. During an observation on 3/24/25, at 10:40 a.m., with CD1, the serving and cooking spoons and utensils were in poor condition. The plastic handles on the cooking utensils had been melted and the metal scoops were indented. There was one ergonomic spoon and one knife in the clean bucket that was visibly dirty with food remaining on the utensil. According to the 2022 Federal Food Code, multiuse food-contact surfaces are to be smooth and food-contact equipment and utensil surfaces are to be clean to sight and touch. During an observation on 3/25/25, at 11:50 a.m., the drawers next to the two-compartment sink had accumulated large particles of food on the borders and on the side of the drawer. There were two shredding contraptions that had food particles on the grading slicers. The second drawer to the left was also dirty and stored one dirty spatula and one masher in poor repair, with plastic melted on the handle of the masher and brown substance inside the holes, not able to come off with a cloth. During a review of the facility's P&P titled, Cleaning Instructions: Cabinets and Drawers, dated 2017, the P&P indicated, Cabinets and drawers will be free of food particles and dirt. They should be cleaned at least twice a month and as needed when spills occur. According to the 2022 Federal Food Code, food-contact equipment and utensil surfaces are to be clean to sight and touch, and nonfood-contact surfaces of equipment are to be free of an accumulation of dust, dirt, food residue, and other debris. During an observation on 3/26/25, at 10:35 a.m., there was a large gray/black oven mitt on the stove top. During a review of the facility's P&P titled, Safety in Food Preparation, dated 2017, the P&P indicated, Towels or mitts will not be placed on stove top, and grease should be considered a fire hazard. Do not allow grease to build up on equipment. During a concurrent observation and interview on 3/26/25, at 10:25 a.m., with [NAME] 2 and CD1, [NAME] 2 was using the extra-large roasting pan to prepare the meat on top of the stove. [NAME] 2 056392 Page 6 of 7 056392 03/27/2025 Pleasanton Nursing and Rehabilitation Center 300 Neal Street Pleasanton, CA 94566

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated the pan was old, but it was what he had to cook large portions. The stove are had copious amounts of food and grease debris on the sides of the stove and large amounts of food particles and grease underneath the metal grates. [NAME] 2 stated that was not good. During a review of the facility's P&P titled, Cleaning Instructions Ovens, dated 2017, the P&P indicated, Ovens will be cleaned as needed and according to the cleaning schedules (at least once every two weeks). Spills and food particles will be removed after each use. During an observation on 3/24/25, at 10:30 a.m., with CD1, the dishwashing area had a large dirty grease trap, and the white drain below the industrial washer contained a black slimy build up and food particles. There were food peelings in the drain. The tile on the floor to the right of the cleaning area had a large open gap separating the tile from the wall for an approximate five foot (ft) length. During a concurrent observation and interview on 3/24/25, at 10:40 a.m., with Director of Maintenance (DM) and CD1, in the dishwashing area, the floor underneath the mats had an accumulation of dark and slimy sludge and the grease trap underneath the sink was dirty with accumulation of grease around the perimeter on the floor. Both DM and CD1 stated having an unclean kitchen could lead to illness and attract animals. According to the 2022 Federal Food Code, floors and floor coverings are to be constructed so they are smooth and easily cleanable. In addition, when cleaning methods other than water flushing are used for cleaning floors, the floor and wall junctures are to be covered and closed to no larger than 1 mm (millimeter). If water flush cleaning methods are used, wall junctures are to be covered and sealed. According to the Annex, pooling liquid wastes could attract pests such as insects and rodents or contribute to problems with certain pathogens. According to the 2022 Federal Food Code, if used, grease traps are to be easily accessible for cleaning. According to the Annex, failure to properly maintain and clean a grease trap can result in the harborage of vermin and/or failure of the sewage system. In addition, pooling of floor drains could attract pests such as insects and rodents or contribute to problems with certain pathogens such as Listeria monocytogenes (a type of bacteria that can cause infection). 056392 Page 7 of 7