Inspection·August 28, 2019

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 meet professional standards of practice for one of eight sampled residents (Resident 3), when LVN B crushed two medications at the same time in one pill pocket, which had the potential to result to altered drug formulary and cause medication adverse effects. Residents Affected - Few Findings: During an observation on 08/26/19 at 05:03 p.m., LVN B at the same time, crushed one tablet of Metformin 500 mg and one tablet of Aspirin 81 mg in one pill pocket. LVN B then mixed both medications with Activia yogurt and offered it to Resident 3. During an interview with LVN C on 08/27/19 at 4:15 p.m., LVN C stated if you need to crush two or more medications, each should be crushed and taken seperately. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056443 If continuation sheet Page 2 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE George L Mee Memorial Hospital D/P Snf 300 Canal Street King City, CA 93930 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide restorative nursing program (RNP, nursing program to assist or promote the resident's ability to attain the maximum function potential) for two of eight sampled residents (Residents 1 and 13). This failure could result in further decline in residents' functional mobility. Findings: 1. During an interview with the facility's ombudsman (public /residents' advocate who addresses complaints or violation of rights) on 8/22/19 at 9:32 a.m., she stated Resident 1 was not receiving rehabilitation (restoring someone to health through training or therapy) service. During the resident council meeting on 8/26/19 at 3:00 p.m., Resident 1, through a Spanish speaking interpreter, stated he was not receiving RNP services consistently as staff was pulled to the floor instead of doing RNP. He stated he felt like instead of moving forward, he was going backwards, in reference to his progress in the RNP. Review of Resident 1's clinical record indicated he was admitted to skilled nursing services on 6/10/19 with diagnoses to include paraplegia (paralysis of the legs and lower body typically caused by spinal injury or disease). Review of Resident 1's physician order, dated 6/10/19, indicated he had an order for RNP for active range of motion (ROM, full movement potential of a joint, usually its range of flexion and extension) with core stability exercises (training the muscles in the pelvis, lower back, hips and abdomen to work in harmony which lead to better stability and balance) daily three to four days a week. Review of Resident 1's RNP activity document from 6/1/19 through 8/14/19, (excluding leave of absence and medical appointments) indicated he only had a total of 16 RNP activities. During an interview with the unit manager (UM) on 8/28/19 at 2 p.m., she stated there were currently 12 residents in the RNP. She also confirmed there was a shortage of CNAs (certified nursing assistants) in recent weeks due to leave of absence and voluntary termination which affected the provision of RNP services to residents. 2. During an observation and interview with Resident 13 on 8/26/19 at 2:48 p.m., she was in a wheelchair and feeling sleepy. She stated she was in the wheelchair too long. She did not mention any staff doing exercises with her. During an interview and record review with LVN A on 8/27/19 at 9:02 a.m., she stated Resident 13 had significant change in condition due to a decline in ADLS. LVN A stated Resident 13 was currently on the RNP. During an interview with CNA D on 8/28/19 at 11:09 a.m., CNA D stated there were no restorative nursing assistants (RNAs) available to do her exercises. Review of Resident 13's clinical record indicated she was admitted on [DATE] with diagnoses to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056443 If continuation sheet Page 3 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE George L Mee Memorial Hospital D/P Snf 300 Canal Street King City, CA 93930 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few include depression (feeling of sadness, misery) and anxiety (feeling of worry ,concern, nervousness). She was dependent on staff for care and had limited ROM to both upper and lower extremities. Review of Resident 13's care plan dated 6/7/19, indicated RNA services as one of the interventions for impaired physical mobility. It indicated active ROM and therapeutic exercises to include upper and lower extremities strengthening exercises 4-5 times per week for 90 days. Review of Resident 13's RNA activity document from 6/10/19 to 8/14/19, indicated Resident 13 received RNA only twice. There was no documentation that Resident 13 refused RNA. During an interview with restorative nursing assistant E (RNA E) on 6/28/19 at 1:41 p.m., RNA E stated she worked part-time and she would often be pulled to the floor to work as a certified nursing assistant (CNA). RNA E also stated the RNA document would indicate no RNA or left blank indicating RNA was not done. She further stated if the resident refused, it should be documented as refused. During an interview with the UM on 8/28/19 at 2:00 p.m., she stated if the resident refused RNA, the staff should document as refused and should notify the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056443 If continuation sheet Page 4 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE George L Mee Memorial Hospital D/P Snf 300 Canal Street King City, CA 93930 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to store external use drugs separately from drugs for internal use, when rectal medications were found on the same shelf with eye, ear and oral medications, which had the potential to cause medication error. Findings: During medication storage inspection on 8/27/19 at 4:00 p.m., two bottles of Fleet mineral oil enema (liquid lubricant laxative administered through the anus) 4.5 fl oz (133 ml) were found beside on same shelf with oral medications (one Bismatrol and two Milk of Magnesia), two ear medications [one Murine Ear Wax 0.5 fl oz (15 ml) removal drops and one Rugby Earwax Treatment drops 0.5 fl oz (15 ml) and three eye drops (one opened Refresh Lacrilube eye ointment and two (3.5 g) artificial tears ointment were found in the medicine cabinet with no labels. During an interview with LVN B on 8/27/19 at 4:01 p.m., LVN B stated the above items should be stored in another shelf area or must be labeled properly on the shelf, so as not to mislead the licensed nurses. She acknowledged there was a potential for medication error. The facility's policy and procedure, Storage of Medication, copyright dated year 2007, indicated 4. Internally administered medications are stored separately from medications used externally such as lotions, creams, ointments, and suppositories .6. Eye medications are stored separately from ear medications and inhalers, etc FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056443 If continuation sheet Page 5 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE George L Mee Memorial Hospital D/P Snf 300 Canal Street King City, CA 93930 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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 ensure food was stored and served under sanitary conditions when: (1) two small cans of diet soda were dented; (2) one bottle of used soy sauce was undated; (3) large tray of baked muffins was uncovered; (4) three pasteurized eggs with cracked small opening on top mixed with other pasteurized eggs; (5) a gallon sized plastic bag with boiled eggs undated; (6) two boxes of dry cereal opened without an open dates; (7) lid covers of large storage bins for dry goods had dust particles on it; (8) particles of ice formed on side of the freezer door and at the bottom of the freezer; (9) used dirty spoon and fork in the condiments counter with the clean utensils holder next to it; and (10) frozen slices of ham wrapped in plastic undated. These failures could cause food borne illnesses to residents in the facility. Findings: During the initial kitchen tour with the dietary supervisor (DS) on 8/26/19 at 8:10 a.m., she confirmed the findings above. She discarded all the undated items. During a concurrent interview with the DS, she stated their policy was to label opened food items with the date it was opened. She also stated dented cans should be removed. The DS stated the kitchen counters should be kept clean. During a follow-up visit to the kitchen's walk-in freezer on 8/27/19 at 10:30 a.m. with the interim dietary manager (IDM), frozen slices of ham wrapped in plastic had no date on it. During a concurrent interview with the IDM, he stated all food items in the freezer should have a date label on them. Review of the facility's revised policy, Receiving and Storage, approved 8/13, indicated .Food in the refrigerator will be covered, labeled, and dated .Food in the freezers will be tightly wrapped, labeled and dated to prevent freezer burn . Sanitation procedures will be adhered to following daily and weekly. cleaning, FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056443 If continuation sheet Page 6 of 6