Health inspection·April 29, 2021

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of five sampled resident rooms had accurate wall clocks. This failure resulted in emotional distress from not knowing what time it was for two (Resident 306 and Resident 307) of four residents in the rooms with inaccurate wall clocks. Findings: During a review of Resident 306's admission Record, the Record showed Resident 306 was his own responsible party. During a review of Resident 306's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 4/28/21, the MDS indicated Resident 306 had a Brief Interview for Mental Status score of 13. (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) the MDS also indicated Resident 306 had adequate vision. During a review of Resident 307's Order Summary Report dated 4/27/21, the Report indicated Resident 307 had been admitted to the facility on [DATE], with the mental capacity to make healthcare decisions. During a review of Resident 307's MDS dated [DATE], the MDS indicated Resident 307 had a BIMS score of 12, an indication of moderate cognitive impairment. A review of the facility census dated 4/25/21 indicated Resident 306 and 307 shared a room. During an interview on 4/26/21, at 11:21 a.m., with Resident 306, in the shared room of Resident 306 and 307, Resident 306 stated he was hungry, but he didn't know if it was lunchtime because there was no clock in his room. During an observation on 4/26/21, at 11:25 a.m., the shared room of Resident 306 and 307 had a clock on the wall, the clock was not keeping time, and had stopped with the hands at 12:01. During an interview with Resident 307, in the shared room of Resident 306 and 307, Resident 307 stated the clock had not worked since he had been admitted into this room, although he had told the nurses multiple times it was broken. Resident 307 stated the lack of a working clock made him feel hopeless. During an interview on 4/26/21, at 12:10 p.m., with Certified Nursing Assistant 1 (CNA) 1, in the Page 1 of 16 056475 056475 04/29/2021 Vista Post Acute 3269 D Street Hayward, CA 94541

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few shared room of Resident 306 and 307, CNA 1 confirmed the wall clock had stopped at 12:01. CNA 1 stated it was the first time he had been in this room, so he had not known the clock was not working. During a concurrent observation and interview on 4/26/21, at 12:25 p.m., with Certified Nursing Assistant 2 (CNA 2) in Resident 309's room, the room had a clock on the wall which indicated the current time was 11:24. CNA 2 confirmed the clock was not showing the correct time. During an interview on 4/27/21, at 9:45 a.m., with Social Services Director (SSD), in SSD office, SSD stated it was important for the clocks in resident rooms to be accurate so that residents would know what time of day it was. During an interview on 4/27/21, at 9:50 a.m., with the Activity Director (AD), in the hallway near nursing station 1, AD stated he checked resident rooms on Tuesdays and Thursdays but had not seen any nonfunctioning clocks. AD stated resident room clocks were important to helping prevent confusion and increasing awareness of routines for residents. During a concurrent interview and record review on 04/27/21, at 12:10 p.m., with the Administrator (ADM), the facility Maintenance Log was reviewed. ADM confirmed the Log showed no documentation of clock maintenance for the clock in the shared room of Resident 306 and 307. ADM stated any employee could enter a work order request in the maintenance log whenever equipment required repairs. During a review of the facility's policy and procedure (P&P) titled, Quality of Life - Dignity, dated February 2020, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem. 056475 Page 2 of 16 056475 04/29/2021 Vista Post Acute 3269 D Street Hayward, CA 94541

F 0584 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview, and record review, the facility failed to provide a homelike environment for two (Resident 39 and Resident 11) of 23 sampled residents when; Residents Affected - Few 1. the facility did not address Resident 39's complaints of noise. 2. the facility did not replace Resident 11's broken television for over three weeks. For Resident 39 this failure resulted in decreased sleep and rest from excessive noise which caused mental and physical stress. For Resident 11, this failure resulted in less enjoyment of life from not being able to watch his favorite television shows on a screen large enough for him to see the shows. Findings: 1. A review of Resident 39's admission Record dated 4/27/21, indicated Resident 39 was admitted to the facility in 2015 with diagnoses which included muscle weakness, and cerebral infarction (stroke). The admission Record indicated Resident 39 had a family member, Responsible Party 1 (RP 1) for healthcare decisions. A review of Resident 5's admission Record dated 4/27/21, indicated Resident 5 was admitted to the facility in 2015 with diagnoses which included dementia with behavioral disturbance (a brain disorder that affects the ability to remember, think clearly, communicate, and perform daily activities and that may cause changes in mood and personality) and delirium (an acute mental disturbance characterized by confused thinking and disrupted attention usually accompanied by disordered speech). A review of the facility census dated 4/25/21, indicated Resident 39 and Resident 5 shared a room. During an observation and concurrent interview with Resident 39 on 4/26/21 at 11:55 a.m., Resident 39 was awake and seated on a geriatric chair (a geri-chair is a padded, reclining chair with casters) next to her bed. Resident 5 sat in a wheelchair in the room, talking or yelling continuously. Resident 39 complained she had not been able to get a good night's rest because her roommate yelled and screamed. During an interview with RP 1 on 4/26/21 at 2:30 p.m., RP 1 complained that she had called the facility to speak to Resident 39 on multiple occasions, and she always heard Resident 5 yelling and screaming in the background. RP 1 stated she had asked the facility to change Resident 39 to a different room. During an interview with the Restorative Nursing Assistant (RNA 1) on 4/26/21 at 9:00 a.m., RNA 1 stated Resident 5 yelled constantly. RNA 1 stated she had informed the licensed nurse that Resident 39 had complained she was unable to rest because Resident 5's yelling bothered her so much. During an interview with the Certified Nursing Assistant (CNA 3) on 4/27/21 at 10:00 a.m., CNA 3 stated Resident 5 constantly yelled and screamed, and Resident 39 had complained about it to the licensed nursing staff. 056475 Page 3 of 16 056475 04/29/2021 Vista Post Acute 3269 D Street Hayward, CA 94541

F 0584 Level of Harm - Minimal harm or potential for actual harm During a telephone interview with Licensed Vocational Nurse 5 (LVN 5) on 4/27/21 at 6:00 a.m., LVN 5 stated Resident 5 talked loudly enough to be heard at the nursing station. During an interview with the Social Services Director (SSD) on 4/28/21 at 10:00 a.m., SSD stated she had not received reports from the staff about Resident 39's complaint of Resident 5's noisy behaviors. Residents Affected - Few During a review of the facility policy titled, Quality of Life - Environment, dated May 2017, indicated Residents are provided with a safe, clean, comfortable and homelike environment .Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: .Comfortable noise levels. 2. During a review of Resident 11's admission Record dated 4/28/21, the admission Record indicated Resident 11 was admitted to the facility in 2014 with diagnoses that included glaucoma (an eye disease that causes vision loss). During a review of Resident 11's Minimum Data Set (MDS, an assessment tool used to direct care) dated 4/27/21, the MDS indicated Resident 11 was understood and could understand others. The MDS also indicated Resident 11 had moderately impaired vision. During an interview on 4/27/21 at 10:02 a.m., in a resident group meeting, Resident 11 stated his 40-inch television (TV) had been broken for almost a year and had not yet been replaced by the facility. Resident 11 stated he had impaired vision to his right eye which made it difficult for him to watch his favorite basketball games on the 20-inch television provided as a temporary replacement by the facility. Resident 11 stated the Administrator (ADM) had promised to replace his TV but had not yet done so. During a concurrent interview and record review on 4/27/21 at 12:28 p.m., with the Social Services Director (SSD), a Theft and Loss Report was reviewed. The Theft and Loss form was dated 3/31/21, and indicated Resident 11's personal 40-inch TV was broken. SSD stated she had completed the Theft and Loss form, but the TV had not yet been replaced. During an interview on 4/28/21 at 8:47 a.m., with the ADM, the ADM stated Resident 11's TV had broken when room changes were being made but could not remember the exact date Resident 11 had reported the broken TV. ADM stated he had promised to replace the TV but had not yet done so. During a review of the facility's policy and procedure (P&P) titled, Personal Property, revised September 2012, the P&P indicated, Residents are permitted to retain and use personal possessions and appropriate clothing, as space permits. The resident is encouraged to maintain his/her room in a home-like environment by bringing personal items (i.e., photographs, knickknacks, etc.) to place on nightstands, televisions, etc. The facility will promptly investigate any complaints of misappropriation or mistreatment of resident property. 056475 Page 4 of 16 056475 04/29/2021 Vista Post Acute 3269 D Street Hayward, CA 94541

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide needed assistance with nail care for one of 22 sampled residents (Resident 1) when Resident 1's fingernails were untrimmed with sharp, chipped edges and black substance beneath the nail tips. Residents Affected - Few This failure resulted in Resident 1 appearing poorly groomed with the potential to cause emotional distress and physical discomfort from injuries resulting from scratched skin from chipped nails. Findings: During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct care) dated 3/27/21, the MDS indicated Resident 1 had a diagnosis of cerebrovascular accident (CVA, impaired blood flow to the brain, commonly called a stroke) and was totally dependent on one person for assistance with personal hygiene. During a concurrent observation and interview on 4/27/21, at 9:50 a.m., with Certified Nursing Assistant 4 (CNA 4), Resident 1's right hand maintained a passive position of his fingers curled inward towards his palm (contracted). CNA 4 opened Resident 1's left hand and uncurled the contracted right hand to show Resident 1's fingernails were untrimmed with sharp, chipped edges, and black substance beneath the tips of the nails. CNA 4 stated Resident 1's fingernails needed to be clipped to prevent the nails from poking into the skin or palm of Resident 1's hand. CNA 4 stated two people were needed to clip Resident 1's fingernails, or to apply the right-hand splint (an aid used to maintain correct position or alignment of a body part). CNA 4 opened Resident 1's nightstand drawer and showed the drawer contained his right hand splint. During an interview on 4/29/21, at 9:17 a.m., with the Director of Staff Development (DSD), DSD stated resident hand hygiene was important to help prevent infection and injury. During a review of the facility's policy and procedure (P&P) titled, Fingernails/Toenails, Care of, revised February 2018, the P&P indicated, The purposes of this procedure are to clean the nail bed, keep nails trimmed, and to prevent infections Nail care includes cleaning and regular trimming Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. 056475 Page 5 of 16 056475 04/29/2021 Vista Post Acute 3269 D Street Hayward, CA 94541

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, for two residents (Resident 56 and Resident 39) the facility failed to inform residents and their responsible parties regarding the current facility visitation policy when: Residents Affected - Few 1. The facility did not notify Resident 56 and her family that in-person visitation was allowed. 2. The facility did not notify Resident 39's Responsible Party 2 (RP 2, an individual responsible for health care decisions for a resident without capacity to make decisions) that in-person visitation was allowed. These failures resulted in feelings of depression and social isolation for Residents 56 and 39. Findings: 1. A review of Resident 56's admission Record on 4/26/21 at 11:00 a.m., indicated Resident 56 was admitted In February 2020 included diagnoses of anxiety, muscle weakness, and a broken right foot. During an observation and concurrent interview with Resident 56 on 4/26/21 at 11:46 a.m. Resident 56 complained the facility was not allowing her spouse to visit her in-person. Resident 56 stated she had seen other residents with visitors inside the facility last Sunday but had never been told in-person visitation was allowed. Resident 56 stated she was depressed and felt lonely as she has not seen her spouse for months. During an interview with the Administrator (ADM) on 4/28/21 at 11:45 a.m., ADM stated the facility followed current State and Federal guidelines for visitation during COVID-19 pandemic (a globally wide-spread infectious respiratory disease that can result in serious illness or death), which meant in-person visitation was allowed. ADM stated the Social Services Director (SSD) was responsible for notifying families that in-person visitation was now allowed. During an interview with SSD on 4/28/21 at 11:45 a.m., SSD stated the facility was now open for in-door visitation, and that the Activity Director was responsible for notifying the residents and their responsible parties. During an interview with the Activity Director (AD) on 4/28/21 at 11:57 a.m., AD confirmed the facility opened for in-door visitation on March 26, 2021. AD stated she had only told Resident 56 the facility was opened for in-person visitation. A review of the AD Room Visit Log, dated week of March 29-April 2, 2021, for Resident 56 indicated, Resident was also let known abt [about] visitation, letting her know she can schedule a visit. A review of the facility policy and procedure titled, Visitation - COVID Policy and Procedure, undated, indicated, Family members will be updated with changes visitation policy and operating status. A review of the facility policy titled, Communication: COVID Activity, revised August 2018, indicated, Facility staff will provide updates to residents and family on status of facility and updates to operations in regards to COVID-19 . 056475 Page 6 of 16 056475 04/29/2021 Vista Post Acute 3269 D Street Hayward, CA 94541

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. A review of Resident 39's admission Record on 4/26/21 at 11:00 a.m., indicated Resident 39 was admitted in 2015 with included diagnoses of muscle weakness, and cerebral infarction (stroke). The admission Record indicated Resident 39 had a family member, Responsible Party (RP 1) for healthcare decisions. During an observation and concurrent interview with Resident 39 on 4/26/21 at 11:55 a.m., Resident 39 sat in a geri-chair (a geri-chair is a padded, reclining chair with casters) next to her bed. Resident 39 stated she was sad because she had not seen her family for month and she missed her family. During an interview with the Responsible Party 1 (RP 1) on 4/26/21 at 2:30 p m., RP 1 stated she has been calling the facility to speak Resident 39 and to the staff. RP 1 stated she had not been notified she could visit Resident 39 in-person. During an interview with the Activity Director (AD) on 4/28/21 at 11:57 a.m., AD was not able to provide documentation that Resident 39 and RP1 were informed the facility now allowed in-person visits. A review of the facility policy and procedure titled, Visitation - COVID Policy and Procedure, undated, indicated, Family members will be updated with changes visitation policy and operating status. A review of the facility policy titled, Communication: COVID Activity, revised August 2018, indicated, Facility staff will provide updates to residents and family on status of facility and updates to operations in regards to COVID-19 . 056475 Page 7 of 16 056475 04/29/2021 Vista Post Acute 3269 D Street Hayward, CA 94541

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. During an observation, with Director of Nursing (DON) and Licensed Vocational Nurse 3 (LVN 3), on 4/26/21, at 1:00 p.m., the Station 2 wound care treatment cart was parked in the nursing station 2 hallway. The Station 2 treatment cart was unlocked, unsupervised and unattended. LVN 3 stated the treatment cart should not be left unlocked for safety reasons and to avoid unauthorized access. A review of the facility policy and procedure (P & P) titled, Treatment Cart, dated 4/2007, the P & P indicated, any treatment carts with medication or sharps items, must be securely locked at all times when out of the nurse's view. Based on observation, interview, and record review, the facility failed to keep two of three treatment carts (a portable cart containing supplies needed for wound care) locked when not in the view of a licensed nurse. This failure had the potential to result in injury to residents, staff, or visitors from unauthorized use of injection needles, scissors, and suture supplies (needles and surgical thread used to sew wounds closed). Findings: During an observation on 4/26/21 at 11 a.m., at nursing station 3, on the ground floor of the facility, was an unlocked, unsupervised treatment cart. The second drawer of the cart was unlocked and contained surgical scissors, injection needles, and suture materials. There was no licensed nurse present at nursing station 3, or on the ground floor. Certified Nursing Assistant 2 (CNA 2) was the only nursing staff present on the ground floor and was not in view from the nursing station. During a continual observation on 4/26/21 from 11 a.m. to 12:25 p.m., the treatment cart was unlocked and unsupervised. During an interview on 4/26/21 at 11:17 a.m., with CNA 2, CNA 2 stated she had no knowledge about the treatment cart; she did not even know if it was used for resident care. During an interview on 4/26/21 at 12:20 a.m., Director of Staff Development (DSD), DSD stated she had not yet checked or used the treatment cart at nursing station 3. DSD stated the treatment carts were always to be kept locked, when not actually in use by licensed staff. DSD stated the treatment carts contained sharp equipment that could cause result injury. During an interview on 4/26/21 at 12:17 a.m. with Licensed Nurse 1 (LVN 1), LVN 1 stated she was the charge nurse for the ground floor nursing station, but she had not checked the treatment cart at nursing station 3 and had not known it was unlocked. LVN 1 stated the cart should be kept locked to prevent unauthorized access. 056475 Page 8 of 16 056475 04/29/2021 Vista Post Acute 3269 D Street Hayward, CA 94541

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to ensure that one (Resident 11) of 22 sampled residents, received sevelamer (a medication that helps control blood phosphorus levels) according to physician orders. The failure to ensure Resident 11 received the correct dose of sevelamer had the potential to result in increased levels of phosphorus in the blood which can lead to decreased bone strength and broken bones. Findings: During a review of Resident 11's admission Record, dated 4/28/21, the admission Record indicated Resident 11 was admitted to the facility in 2014 with included diagnoses of end-stage renal disease (ESRD) requiring dialysis three times a week. (Dialysis, a process by which dissolved substances are removed from a patient's body by diffusion from one fluid compartment to another across a semipermeable membrane. Dialysis is used for the treatment of end stage renal disease, the stage of kidney impairment that appears irreversible and permanent and requires a regular course of dialysis or kidney transplantation to maintain life.) During a review of Resident 11's Minimum Data Set (MDS, an assessment tool used to direct care) dated 1/25/21, the MDS indicated Resident 11's was understood and could understand others. During a review of Resident 11's Physician Order Summary Report dated 4/28/21, the Report indicated an order to administer sevelamer 800 milligrams (mg), three times a day at 6 a.m., 12 p.m., and 6 p.m., with a start date of 4/25/21. During a concurrent interview and record review on 4/29/21, at 9:51 a.m., with the Licensed Vocational Nurse 4 (LVN 4), Resident 11's Medication Administration Record (MAR) dated April 2021, was reviewed. The MAR showed no checkmarks in the administered box for Resident 11's sevelamer 800 mgs on 4/26/21 at 12 p.m., or 4/28/21 at 12 p.m. LVN 4 stated Resident 11 had not received sevelamer during lunch or prior to leaving for dialysis on 4/26/21 and 4/28/21. During an interview on 4/29/21 at 9:55 a.m., with Resident 11, Resident 11 confirmed Licensed Nurses had not administered sevelamer or any other medications whenever he takes an early lunch and/or prior to dialysis treatment. During an interview on 4/29/21, at 9:58 a.m., with the Director of Nursing (DON), the DON stated sevelamer was a phosphorus-binding medication. DON stated phosphorus levels could increase if not administered as ordered for residents with ESRD. During a review of the facility's policy and procedure (P&P) titled Administering Medications, revised April 2019, the P&P indicated, Medications are administered in accordance with the prescriber orders, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. Enhancing optimal therapeutic effect of the medication; b. preventing potential medication or food interactions . 056475 Page 9 of 16 056475 04/29/2021 Vista Post Acute 3269 D Street Hayward, CA 94541

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 ensure to drugs used to control pain and anxiety were labeled with the correct physician orders for 8 of 11 sampled residents (Residents 51, 106, 52A, 52B, 10, 308, 16, 24, and 7). These failures had the potential to result in Residents 51, 106, 52A, 52B, 10, 308, 16, 24, or 7 receiving incorrect medication doses with resultant overdosage or underdosage causing oversedation or ineffective treatment of pain and/or anxiety. Findings: During an observation on 04/27/21 at 12:16 p.m., Licensed Vocational Nurse 1 (LVN 1) picked up Resident 51's multidose medication package labeled Hydrocodone-Acetaminophen 5-325 milligrams (a combination pain reducing medication subject to government regulations due to five milligrams of an opium-based ingredient with 325 milligrams of acetaminophen). The label indicated, 1 tablet every 6 hours as needed for pain. LVN 1 removed one tablet from the package and administered the tablet to Resident 51. During a review of Resident 51's Physician Order Summary Report dated 4/3/21, the Report reflected an order for, hydrocodone-acetaminophen tablet 5-325 mg (milligrams) give one tablet by mouth every 6 hours for severe pain (Routine) . During an interview with LVN 1 on 04/27/21 at 12:16 p.m. LVN 1 stated there was a discrepancy between the pharmacy order on the package and the physician's order and stated she had not noticed that discrepancy before. A review of physician orders and medication package labels for eleven residents receiving controlled medications (substances that have an accepted medical use, but also have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) reflected the following discrepancies: Resident 106: Order dated 3/17/21, indicated, hydrocodone-acetaminophen 10-325 mg 1 tablet every 4 hours as needed for moderate pain. Medication package label dated 3/4/21, indicated, hydrocodone-acetaminophen 10-325 mg . 1 tablet every 8 hours as needed for moderate to severe pain . Resident 52B: Order dated 4/18/21, indicated, Oxycodone 10 mg 1 tablet every 6 hours for severe pain (routine). Medication package label dated 4/6/21, indicated, Oxycodone 10 mg .1 tablet every 4 hours as needed for pain . 056475 Page 10 of 16 056475 04/29/2021 Vista Post Acute 3269 D Street Hayward, CA 94541

F 0761 Resident 10: Level of Harm - Minimal harm or potential for actual harm Order dated 5/20/2019, indicated, Tramadol 50 mg 1 tablet every 6 hours for severe pain (routine) Residents Affected - Some Medication package label dated 12/8/20, indicated, Tramadol 50 mg .1 tablet every 4-6 hours as needed for pain. Resident 308: Two orders: Order 1 dated 11/4/18, indicated, Oxycodone 5 mg 1 tablet by mouth every 6 hours as needed for moderate pain. Order 2 dated 11/6/18, indicated, Oxycodone 5 mg 2 tablets by mouth every 6 hours as needed for severe pain. Medication package label dated 9/29/20, indicated, Oxycodone 5 mg .2 tablets (10mgs) by mouth daily at bedtime . Resident 16: Order dated 4/21/21, indicated, .5 mg Escitalopram (medication for depression and anxiety) 1 tablet by mouth one time a day . Medication package label dated 4/12/21, indicated, Escitalopram 5 mg 2 tablets by mouth every day . Resident 24: Two orders: Order 1 dated 4/19/21, indicated, Hydrocodone-Acetaminophen 5-325 mg 1 tablet every 8 hours as needed for pain. Order 2 dated 4/19/21, indicated, Hydrocodone-Acetaminophen 5-325 mg give 1 tablet by mouth in the morning for pain prior to ADLs (activities of daily living such as hygiene and bathing). Medication package label dated 3/24/21, indicated, Hydrocodone-Acetaminophen 5-325 mg .1 tablet by mouth every day prior to ADLs (Activity of Daily Living) and 1 tablet every 6 hours as needed for pain. Resident 7: Order dated 3/2/21, indicated, Hydrocodone-Acetaminophen 10-325 mg 1 tablet by mouth two times a day for severe pain. Medication package label dated 4/19/21, indicated, Hydrocodone-Acetaminophen 10-325 mg .1 tablet every 12 hours as needed for pain . 056475 Page 11 of 16 056475 04/29/2021 Vista Post Acute 3269 D Street Hayward, CA 94541

F 0761 Resident 52A: Level of Harm - Minimal harm or potential for actual harm Two orders: Order 1 dated 4/19/21, indicated .Lorazepam (Ativan) 0.5 mg 1 tablet by mouth twice a day . Residents Affected - Some Order 2 dated 4/27/21, indicated, Lorazepam 0.5 mg every 2 hours as needed for anxiety . Medication package label dated 4/19/21, indicated, 0.5 mg Ativan, 1 tablet twice a day . The label did not reflect the order for as needed medication. During an interview with LVN 1 on 04/28/21 at 08:29 a.m., LVN 1 stated when nurses found when a discrepancy between the physician order and the medication package label, the nurses were expected to call the pharmacist for clarification. LVN 1 stated it was important to provide pain medication according to physician orders so that residents did not suffer from unmanaged pain or have ill effects from too much medication. During an interview on 04/28/2 at 10:00 a.m., with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated nurses had a responsibility to inform the pharmacy when the physician changed a medication order so that the pharmacy could send new labels with the correct instructions for medication administration. LVN 4 stated it could be confusing if the label instructions did not agree with the physician order. During an interview with Pharmacist 1 (PH 1) on 04/27/21 at 01:14 p.m., PH 1 stated pharmacy staff were expected to call the facility to clarify discrepancies in resident medication orders. During an interview and record review with Director of Nursing (DON) on 04/28/21 at 12:04 p.m., the medication orders for the residents with controlled medication discrepancies were reviewed (Residents 51, 106, 52A, 52B, 10, 308, 16, 24, and 7). DON stated the process for receipt of new orders was for nursing staff to enter the new order in the computer. The pharmacy would receive a copy of the new order and would compare it to the medication currently in stock for the resident at the facility. The pharmacy and nursing staff were expected to communicate if any discrepancies were noted to resolve any issues. After resolution, the pharmacy would send new labels for nursing staff to apply to the medication packages or provide new medication packages. DON stated there was a possibility of nurses administrating the wrong dose of medications if they didn't have the right instructions on the medication packet, which could result in a resident receiving insufficient medication or too much medication. During a review of the facility's policy and procedure, Administering Medications revised April 2019, indicated, . Medications are administered in accordance with prescriber orders, including any required time frame . During a review of the facility's policy and procedure (PNP), labeling of Medication Containers, revised April 2019, the PNP indicated, All medication maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations Any medication packaging or containers that are inadequately or improperly labeled are returned to the issuing pharmacy. Labels for individual resident medications include all necessary information, such as: .appropriate accessory and cautionary statements .directions for use. 056475 Page 12 of 16 056475 04/29/2021 Vista Post Acute 3269 D Street Hayward, CA 94541

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure one of 22 sampled residents (Resident 16) received a meal at a nourishing and palatable temperature. Residents Affected - Few The failure of dietary staff (Cook 2) to check the temperature of hot food items before plating and serving the meal to Resident 16 had the potential to result in scalds or burns from excessively hot food, or decreased intake and/or food borne illness from a meal cooked and/or served at an inadequate temperature. Findings: A review of Resident 16's admission Record showed an admission in June 2020 with included diagnoses of end stage renal disease and dependency on dialysis. (Dialysis is a process by which dissolved substances are removed from a patient's body by diffusion from one fluid compartment to another across a semipermeable membrane. Dialysis is used for the treatment of end stage renal disease, the stage of kidney impairment that appears irreversible and permanent and requires a regular course of dialysis or kidney transplantation to maintain life.) During an observation on 4/27/21 at 11:38 a.m., in the kitchen with Dietary Manager (DM), [NAME] 2 prepared an early lunch tray for Resident 16, who was scheduled to leave the facility for dialysis. [NAME] 2 plated and served Resident 16's meal without checking the temperature of hot food items. During an interview on 4/27/21 at 11:45 a.m., with DM, DM confirmed [NAME] 2 had not checked the temperature of the hot food items of Resident 16's lunch meal. During a review of the facility's policy and procedure (PNP) titled, Meal Service, dated 2018, the PNP indicated, Meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner, and served at the appropriate temperatures The Food and Nutrition services staff member will take the food temperatures prior to service of the meal with a thermometer that has been cleaned and sanitized. 056475 Page 13 of 16 056475 04/29/2021 Vista Post Acute 3269 D Street Hayward, CA 94541

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 store, prepare, and serve food under sanitary conditions when: Residents Affected - Some 1. Several food items in the kitchen refrigerator were unlabeled and undated. 2. Expired nutritional supplements were stored on the same shelf as nutritional products designated for current consumption. These failures had the potential to cause food contamination or food borne illness. Findings: 1. During an observation in the kitchen on 4/26/21 at 9:45 a.m., the refrigerator had the following unlabeled and undated items: two cups of apple sauce, an opened plastic bag of vegetables, and a tray containing twelve assorted drinks in glasses. During an interview with the Dietary Manager (DM) on 4/26/21 at 11:00 a.m., DM confirmed that the items were not dated and did not have a use by date. 2. During an observation in the hallway storage room on 4/28/21 at 11:03 a.m., a shelf contained the following expired items: one 8 Fluid ounce carton of Jevity (nutritional formula), expiration date of 2/19/2021; seven cans of Two-Cal HN (nutritional formula), expiration date of 2/19/2020. The shelf also contained nutritional supplements designated for current consumption. During an interview with the DON on 4/28/21 at 11:45 a.m., the DON stated the expired nutritional supplements should not be stored with nutritional supplements designated for current consumption. During a review of the facility policy titled, Food Receiving and Storage, dated October 2017 indicated, Foods shall be received and stored in a manner that complies with safe and food handling practices All foods in the refrigerator or freezer will be covered, labeled, and dated (use-by date). 056475 Page 14 of 16 056475 04/29/2021 Vista Post Acute 3269 D Street Hayward, CA 94541

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of records the facility failed to ensure infection control policies and procedures were followed for three of six sampled residents (Resident 52, 306, and 307) when: Residents Affected - Some 1. Licensed Vocational Nurse 1 (LVN 1) failed to perform necessary hand hygiene during wound care for Resident 52, and did not disinfect scissors used for the wound treatment before storing the scissors. 2. The facility failed to provide required Personal Protective Equipment (PPE, protective items or garments worn to protect the body or clothing from hazards that can cause injury) readily available outside the residents room per policy and procedure, and that staff wore the necessary PPE for two of two residents (Resident 306 and 307). These failures had the potential to result in infection or spread of infection for Resident 52, 306, and 307 and increased exposure for all facility residents and staff. Findings: 1. During a review of Resident 52's admission Record, the Record indicated Resident 52 was admitted to the facility with diagnoses which included a fracture (broken bone) of the right lower leg. During a review of Resident 52's Physician Order Summary dated 4/26/21, the Summary indicated, .rinse with normal saline, apply triple antibiotic ointment then wrap with rolled gauze every evening shift for surgical pin sites . During an observation in Resident 52's room, on 4/27/21 at 12:00 p.m., LVN 1 provided wound care for Resident 52's right lower leg. LVN 1 donned gloves, used nonsterile scissors to remove the old dressing, then directly placed the scissors in the pocket of her pants. LVN 1 cleaned the wound, applied ointment, then applied a new sterile dressing without changing gloves and intervening hand hygiene. During an interview with LVN 1 on 4/27/21 at 12:20 p.m., LVN 1 stated the scissors in her pocket needed to be cleaned to prevent the potential spread of contaminated material to other locations. During an interview with the Director of Nursing (DON) on 04/29/21 at 11:59 a.m. DON stated it was standard nursing practice to change the gloves and do hand hygiene after removal of an old dressing, and before applying a new dressing during the wound care. During a review of the facility's policy and procedure Hand washing/Hand hygiene, revised August 2019 indicated .use an alcohol-based hand rub .After handling used dressing, contaminated equipment . During a review of the facility's policy and procedure Wound care, revised October 2010 indicated .Wipe reusable supplies with alcohol as indicated (i.e., outside of containers that were touched by unclean hands, scissor blades, etc.) . 2. A review of Resident 306's admission Record indicated Resident 306 was admitted to the facility on [DATE]. 056475 Page 15 of 16 056475 04/29/2021 Vista Post Acute 3269 D Street Hayward, CA 94541

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 306's Order Summary Report showed an order, start date 4/22/21, for nursing staff to monitor Resident 306 for symptoms of COVID-19 (a an infectious respiratory disease that can result in serious illness and death), on every shift, for 14 days. A review of Resident 306's care plan titled, Droplet Isolation, dated 4/27/21, indicated Resident 306 was on droplet isolation precautions for COVID-19. (Droplet isolation precautions are actions designed to reduce/prevent the transmission of organisms spread through close respiratory or mucous membrane contact with secretions,) A review of Resident 307's admission Record showed Resident 307 was admitted to the facility on [DATE]. A review of Resident 307's Order Summary Report indicated a physician order dated 4/21/21, for Resident 307 to be in quarantine (isolation) for possible COVID-19 infection for 14 days. The Order Summary showed an order, start date 4/22/21, for nursing staff to monitor Resident 307 for symptoms of COVID-19, on every shift. A review of Resident 307's droplet isolation care plan, dated 4/27/21, indicated Resident 307 was on droplet isolation for possible COVID-19 exposure related to recent hospitalization. The care plan also indicated to inform staff/caregivers of the isolation protocol. A review of the facility census dated 4/25/21 showed Resident 306 and 307 shared a room. During an observation on 4/26/21 at 10 a.m., posted on the wall adjacent to the door of the shared room of Residents 306 and 307 was signage which indicated, You must wear the following PPE prior to entry to this room: gown, N95 respirator, eye protection [goggles or face shield], and gloves. During an observation on 04/26/21 at 12:15 p.m., Certified Nursing Assistant 1 (CNA 1) entered the shared room of Resident 306 and 307 wearing only a surgical mask for facial/eye protection. During an observation on 4/26/21 at 9:45 a.m., the isolation supply cart located outside the door of the shared room of Resident 306 and 307 had no face shields or face masks. An observation of the same cart later that day, at 12:17 p.m., still showed no face shields or face masks. During an interview on 4/26/21 at 12:20 p.m., with CNA 1, CNA 1 stated the shared room of Resident 306 and 307 required use of a face shield and N95 respirator, but the isolation supply cart outside the room had not contained any face shields or N95's, so he had not worn either a face shield or N95 before he entered the room. During an interview on 4/27/21 at 11:00 a.m., with the Infection Preventionist (IP), the IP stated isolation signs informed staff of the PPE requirements needed for care provision for the room residents in order to provide protection against infection and the spreading of infection. The IP also stated isolation carts with isolation supplies were located outside the rooms of residents in isolation. A review of the facility policy and procedure (P & P) titled, Personal Protective Equipment (PPE)-COVID Observation, revised 10/2018, the P & P indicated, PPE required for COVID observation is maintained outside and inside the resident's room, as needed. 056475 Page 16 of 16