Other·January 30, 2020

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a recertification survey conducted on 1/23/2020. The facility was licensed for 38 beds. The census at the time of the survey was 30. A class "B" Citation was also issued (see

F755). Representing the California Department of Public Health: 39238, Health Facilities Evaluator Nurse; 38573, Health Facilities Evaluator Nurse; 39949, Health Facilities Evaluator Nurse.

F607 SS=D Develop/Implement Abuse/Neglect Policies CFR(s): 483.12(b)(1)-(3)

F607 02/28/2020 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to implement their abuse policy when a skin discoloration of unknown origin LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8F3J11 Facility ID: CA070000087 If continuation sheet 1 of 22 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555204 (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CHILDREN'S HEALTHCARE ORGANIZATION OF NORTHERN CALIFORNIA - SARATOGA PEDIATRIC SUBACUTE 13425 Sousa Ln Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE was not investigated to rule out abuse. This failure placed the resident at risk for abuse. Findings: During an observation 1/21/2020 at 9:17 a.m., Resident 18's right wrist had a purplishyellowish discoloration approximately a size of a quarter coin. During a concurrent observation and interview on 1/21/2020 at 4:12 p.m. with registered nurse A (RN A), RN A confirmed the above observation and stated the skin discoloration was fading. RN A confirmed there was no documentation regarding the skin discoloration. RN A further stated, she was not aware of what happen to the skin. During a review of Resident 18's weekly summary dated 1/19/2020, the weekly summary did not indicate a skin discoloration on the right wrist. During a review of Resident 18's progress notes dated 1/20/2020, the progress notes indicated "no new skin issues noted". During a concurrent interview and record review on 1/22/2020 at 2:09 p.m. with the director of nursing (DON), the DON reviewed Resident 18's clinical record and confirmed Resident 18 was not receiving anti-coagulant (blood thinner) medication. The DON further stated, there was no documentation regarding the right wrist purplish to yellowish skin discoloration. The DON stated, when blood draw was performed licensed nurses should be monitoring for bruising. During an interview on 1/23/2020 at 1:03 p.m. with the DON, the DON confirmed there was no incident report done for Resident 18's right FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8F3J11 Facility ID: CA070000087 If continuation sheet 2 of 22 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555204 (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CHILDREN'S HEALTHCARE ORGANIZATION OF NORTHERN CALIFORNIA - SARATOGA PEDIATRIC SUBACUTE 13425 Sousa Ln Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE wrist skin discoloration. The DON further added, bruise of unknown origin should have an incident report and should be reported to the appropriate agencies. During a review of the facility's undated policy and procedure, "Skin Program", indicated minor bruises and other minor skin conditions requires completion of incident report. Review of the facility's undated policy, "Suspected Abuse Management Policy and Procedure", indicated identifying abuse includes unexplained bruises, reports must be filed within the facility and with the state.

F755 SS=D Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 02/28/2020 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8F3J11 Facility ID: CA070000087 If continuation sheet 3 of 22 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555204 (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CHILDREN'S HEALTHCARE ORGANIZATION OF NORTHERN CALIFORNIA - SARATOGA PEDIATRIC SUBACUTE 13425 Sousa Ln Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to follow facility policy related to accountability and documentation of controlled substances (drugs with high potential for abuse and addiction) for four out of six sampled residents when: 1. For Resident 21, quantity of a controlled substance received from the pharmacy does not match what was documented. 2. For Resident 29, a controlled substance was delivered by a licensed nurse to a general acute hospital without obtaining permission to leave and missing documentation related to physician's order. 3. For Resident 1, a controlled substance was not properly documented. 4. For Resident 30, 4.6ml (milliliters, a unit of measurement) of a controlled substance was not accounted for and not reported immediately to responsible supervisor. These failures had a potential for diversion of highly controlled substances. Findings: 1. For Resident 21, quantity of a controlled substance received from the pharmacy does not match what was documented. During a review of Resident 21's Admission FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8F3J11 Facility ID: CA070000087 If continuation sheet 4 of 22 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555204 (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CHILDREN'S HEALTHCARE ORGANIZATION OF NORTHERN CALIFORNIA - SARATOGA PEDIATRIC SUBACUTE 13425 Sousa Ln Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Record, dated 1/22/2020, indicated Resident 21 was admitted on 8/12/19 with the following diagnoses including congenital (occurring before birth) malformation of musculoskeletal system (affecting the body's bones and muscle), exotropia (is a form of eye misalignment in which one or both of the eyes turn outward) and chronic respiratory failure (is a condition that results in the inability to effectively exchange carbon dioxide and oxygen). During an observation with licensed vocational nurse G (LVN G) on 1/22/2020 at 11:18 a.m., indicated on Resident 21's Diazepam's (a schedule IV-controlled substance used for anxiety) pharmacy label was a quantity of 30. LVN G confirmed pharmacy label indicated 30 which was the amount pharmacy dispensed. During a record review on 1/22/2020 at 11:20 a.m., Resident 21's-controlled drug record, indicated, Diazepam 5mg (milligram, a unit of measurement) /5ml (milliliter, a unit of measurement) give 2mg (2ml) via GT (gastrostomy tube) twice a day as needed for muscle spasm amount received 31 ml. It further indicated that on 12/14/19 at 11:19 a.m., 2 ml of Diazepam was administered to Resident 21 and 29 ml was left on the bottle. During an interview on 1/22/2020 at 11:41 a.m., with the director of nursing (DON), the DON stated facility staff should follow the quantity dispensed by the pharmacy to match controlled drug record documentation. The DON also stated she was not aware about this discrepancy until today. 2. For Resident 29, a controlled substance was delivered by a licensed nurse to a general acute hospital without obtaining permission to leave and missing documentation related to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8F3J11 Facility ID: CA070000087 If continuation sheet 5 of 22 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555204 (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CHILDREN'S HEALTHCARE ORGANIZATION OF NORTHERN CALIFORNIA - SARATOGA PEDIATRIC SUBACUTE 13425 Sousa Ln Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE physician's order. During a review of Resident 29's Admission Record, dated 1/22/2020, indicated Resident 29 was admitted on 4/11/17 with following diagnoses including bronchopulmonary dysplasia (is a form of chronic lung disease that affects newborns), hypertension (high blood pressure), epilepsy (a disorder in which nerve cell activity in the brain is distributed, causing seizures) and spastic quadriplegic cerebral palsy (difficulty in controlling movements in the arms and the legs). During an interview on 1/22/2020 at 2:56 p.m., with the minimum data set nurse (MDSN), the MDSN stated Resident 29 was hospitalized 1/5/2020 and returned on 1/8/2020. During an interview on 1/22/2020 at 3:45 p.m. with registered nurse H (RN H), RN H stated Resident 29's Clobazam (a schedule IVcontrolled substance used to treat seizures) was delivered by another licensed nurse to a general acute care hospital on 1/5/2020. RN H stated that there was no documentation in Resident 29's health records related to a physician's order to send medication to general acute. RN H also stated she did not notify the DON related to Resident 29's-controlled medication being sent to a general acute care hospital. During an interview on 1/22/2020 at 3:54 p.m., with the DON, the DON stated she was not notified a licensed nurse left the facility and delivered controlled medication to a general acute care hospital for Resident 29. During an interview on 1/23/2020 at 12:01 p.m. with the DON, he DON stated license nurses are not allowed to leave the facility to transfer medication out to a general acute hospital FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8F3J11 Facility ID: CA070000087 If continuation sheet 6 of 22 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555204 (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CHILDREN'S HEALTHCARE ORGANIZATION OF NORTHERN CALIFORNIA - SARATOGA PEDIATRIC SUBACUTE 13425 Sousa Ln Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE without the permission of the DON or administrator (ADMIN). The DON also stated she was not able to find documentation in Resident 29's health records related to physician's order to send medication out to a general acute care hospital. During an interview on 1/23/2020 at 2:08 p.m. with the ADM, the ADM stated he did not give permission to license nurse to leave premise and deliver medication to a general acute care hospital. During a review of the facility's policy, dated 4/25/15, "Controlled Substances", indicated remaining controlled substances not authorized by the physician to go with the patient at the time of discharge will not be surrender to any other person for any reason. During a review of the facility's policy, dated 4/18, "Employee Handbook", indicated failing to obtain permission to leave work for any reason during normal working hours is a prohibited conduct. 3. For Resident 1, a controlled substance was not properly documented. During a review of Resident 1's Admission Record, dated 1/22/2020, indicated Resident 1 was admitted on 4/4/19 with following diagnoses including spina bifida (a birth defect in which there is incomplete closing of the spine and membranes around the spinal cord during early development in pregnancy), epilepsy, hydrocephalus (is the buildup of fluid in the cavities deep within the brain) and hypotension (low blood pressure). During a review of Resident 1's Controlled Drug Record, received on 1/3/2020, indicated Clobazam 10 mg tablet dose number 60 has no FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8F3J11 Facility ID: CA070000087 If continuation sheet 7 of 22 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555204 (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CHILDREN'S HEALTHCARE ORGANIZATION OF NORTHERN CALIFORNIA - SARATOGA PEDIATRIC SUBACUTE 13425 Sousa Ln Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE date and time of administration. During an interview on 1/23/2020 at 12:28 p.m. with the DON, the DON confirmed Resident 1's-controlled drug record for Clobazepam has missing documentations During a review of the facility's policy, dated 4/25/15, "Controlled Substances", indicated separate records will be maintained on all Schedule II, III, and IV drugs. This will be in the form of a declining inventory record. Such records will be accurately maintained and will include: 1. The name of the patient 2. The name of the prescriber 3. The prescription number 4. The drug name and form of the medication 5. The strength and dose administration 6. The date of administration 7. The amount remaining 8. The signature of the person administering the drug 4. For Resident 30, 4.6ml (milliliters, a unit of measurement) of a controlled substance was not accounted for and not reported immediately to responsible supervisor. During a review of Resident 30's Admission Record, dated 1/22/2020, indicated Resident 30 was admitted on 12/6/17 with following diagnoses including congenital malformation of brain (a group of brain defects or disorders that develop in the womb and are present at birth), hearing loss, congenital hypertonia (is characterized as contractures or stiffness of all voluntary muscles usually present from birth) and convulsion (is a medical condition where body muscles contract and relax rapidly and repeatedly, resulting in uncontrolled actions of the body). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8F3J11 Facility ID: CA070000087 If continuation sheet 8 of 22 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555204 (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CHILDREN'S HEALTHCARE ORGANIZATION OF NORTHERN CALIFORNIA - SARATOGA PEDIATRIC SUBACUTE 13425 Sousa Ln Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During a review of Resident 30's Controlled Drug Record, indicated on 1/19/2020 at 11:00 p.m., 1.8 ml of Diazepam (a schedule IVcontrolled substance used to treat anxiety, muscle spasms and seizures) was documented, and 364.8 ml was remaining in the bottle. It also indicated on 1/19/2020 at 11:00 p.m., "received amount" was 360 ml and it was signed by two licensed nurses. During an interview on 1/23/2020 at 12:14 p.m., with the DON, the DON confirmed the discrepancy of 4.8 ml for Resident 30'scontrolled substance above. The DON stated she was not notified about the discrepancy and there was no documentation in Resident 30's progress notes that the facility staff notified the consultant pharmacist about above discrepancy. During a review of the facility's policy, dated 4/25/15, "Controlled Substances", indicated any discrepancy in the count is to be reported in writing immediately to the responsible supervisor and a signed entry is recorded on the page where the discrepancy is found. It also indicated that the consultant pharmacist will be notified immediately of any discrepancy of controlled medications.

F759 SS=D Free of Medication Error Rts 5 Prcnt or More CFR(s): 483.45(f)(1)

F759 02/28/2020 §483.45(f) Medication Errors. The facility must ensure that its§483.45(f)(1) Medication error rates are not 5 percent or greater; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8F3J11 Facility ID: CA070000087 If continuation sheet 9 of 22 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555204 (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CHILDREN'S HEALTHCARE ORGANIZATION OF NORTHERN CALIFORNIA - SARATOGA PEDIATRIC SUBACUTE 13425 Sousa Ln Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE review, the facility had 8% medication error rate when two medication errors out of 25 opportunities were observed during medication pass. This failure resulted in Resident 30 not getting his medications as ordered by the physician. Findings: 1. During medication pass observation on 1/21/2020 at 4:56 p.m. with Registered Nurse B (RN B), RN B did not give the half remaining portion of crushed glycopyrrolate (medication used to reduce drooling in children ages 3 to 16 who have certain medical conditions, such as cerebral palsy) in the medication cup. During an interview on 1/21/2020 at 6:00 p.m. with RN B, he acknowledged the above observation. RN B further stated that he forgot to give the half remaining portion of the medication to complete the dose as ordered by the physician. During a review of the physician order, dated 12/5/2019, indicated Resident 30 was to receive glycopyrrolate half tablet of 1 milligram (mg, a unit of measurement) 0.5 mg. via gastrostomy tube (GT, a tube inserted through the abdomen into the stomach) every eight hours for secretion reduction daily at 1:00 a.m., 9:00 a.m., 5:00 p.m. 2. During medication pass observation on 1/21/2020 at 5:07 p.m., RN B administered three milliliters (ml, a unit of measurement for volume) of Ferrous sulfate (iron Medication) 75 mg (equivalent to 15 mg. Iron) per one ml. from house supply bottle via GT. During a review of the physician order, dated 1/8/2020, indicated Resident 30 was to receive ferrous sulfate drops 75 mg. (equivalent 15 mg. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8F3J11 Facility ID: CA070000087 If continuation sheet 10 of 22 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555204 (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CHILDREN'S HEALTHCARE ORGANIZATION OF NORTHERN CALIFORNIA - SARATOGA PEDIATRIC SUBACUTE 13425 Sousa Ln Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE iron/1 ml.) give 225 mg- iron 45 mg(3ml) via GT daily at 5:00 p.m. During a concurrent interview and record review with the director of nursing (DON) on 1/22/2020 at 10:12 a.m., the DON stated ferrous sulfate house supply that was given by RN B to Resident 30 on 1/21/2020 had wrong contents and the DON further stated that Resident 30 has his own supply from the pharmacy with the right components as ordered by the physician. Review of the facility's undated policy, "Medication Administration", indicated All iron and calcium doses will be ordered as "elemental", e.g., elemental iron and elemental calcium .... Orders will specify the amount of the elemental components. Review of the facility's undated policy and procedure, "Medication AdministrationPhysician Order", indicated the five rights will be followed when administering medication ...Right patient, right medication, right dose, right route, and right frequency ... To assure administration accuracy the nurse will cross check the following reference points: Physician's Order- I-MAR, I-MAR- Rx label, Label on drug container- Physician's Order.

F761 SS=D Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 02/28/2020 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8F3J11 Facility ID: CA070000087 If continuation sheet 11 of 22 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555204 (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CHILDREN'S HEALTHCARE ORGANIZATION OF NORTHERN CALIFORNIA - SARATOGA PEDIATRIC SUBACUTE 13425 Sousa Ln Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure medications and biologicals were stored and labeled appropriately when: 1. Several medications were expired in the medication room; 2. Unauthorized personnel had access to the medication room; 3. Undated liquid bottles of medications. These failures had the potential for drug diversion and residents to receive expired, contaminated, or deteriorated medications and biologicals. Findings: 1. During a medication room observation on 1/21/2020 at 9:26 a.m. with the Director of Staff Development (DSD), the following were observed: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8F3J11 Facility ID: CA070000087 If continuation sheet 12 of 22 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555204 (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CHILDREN'S HEALTHCARE ORGANIZATION OF NORTHERN CALIFORNIA - SARATOGA PEDIATRIC SUBACUTE 13425 Sousa Ln Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1a. 11 heparin lock syringe (blood thinner to prevents clots) 50 units/5 ml (units, milliliters, unit of measurement) expired on 10/31/19; 1b. 14 sodium chloride 3% (medication, that can be used to dilute other medications through a nebulizer) vials expired on December 2019. 1c. one opened and one unopened pack of ipratropium bromide 0.02% (medication used to prevent and control symptoms of wheezing and shortness of breath caused by ongoing lung diseases). The DSD confirmed the above observation and stated regular checking of the medroom was night shift licensed nurse's responsibility. Review of the facility's undated policy, "Storage of Medications", indicated expired medications shall not be kept. 2. During a breathing treatment observation on 1/21/2020 at 5:41 p.m. with respiratory therapist C (RT C), RT C had a medication room key to get Resident 4's respiratory medications inside the medication room without the facility licensed nurse present. During an interview on 1/21/2020 at 6:04 p.m. with RT C, RT C acknowledged the above observation. RT C further stated she had her own key to enter the medication room without the facility licensed staff present. During a breathing treatment observation on 1/21/2020 at 4:40 p.m. with RT F, RT F had a medication room key to get Resident 12' s respiratory medications inside the medication room without the facility licensed nurse present. During an interview on 1/21/2020 at 5:31 p.m. with RT F, RT F confirmed the above FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8F3J11 Facility ID: CA070000087 If continuation sheet 13 of 22 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555204 (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CHILDREN'S HEALTHCARE ORGANIZATION OF NORTHERN CALIFORNIA - SARATOGA PEDIATRIC SUBACUTE 13425 Sousa Ln Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE observation. RT F stated he had his own key to go inside the medication room without facility licensed staff present. During an interview on 1/23/2020 at 12:43 p.m. with the administrator (ADM), he stated only licensed nurses should have the key to the medication room. He further stated respiratory therapists should not have keys to the medication room and could not access the medication room without the presence of a licensed nurse. Review of the facility's undated policy and procedure, "Medication AdministrationPhysician Order", indicated only licensed personnel are assigned responsibility for preparing, administering, and recording of medications or have access to the drug storage areas ... (Cart and Medication room). 3. Undated liquid bottles of medications During an observation and interview on 1/22/2020 at 11:18 a.m. with licensed vocational nurse G (LVN G), LVN G confirmed the following bottles were opened and had no date when opened: 1. Poly Vi Sol (multivitamin supplement) 2. Poly Vi Sol with Iron 3. Loratadine (used to treat allergy symptoms and hives) oral solution 4. Liquid Pain Relief 5. Iron Supplement 6. Pedialyte (advanced hydration rehydration drink) During an observation and interview on 1/22/2020 at 11:46 a.m. with registered nurse K (RN K), RN K confirmed the following bottles were opened and had no date when opened: 1. Loratadine oral solution FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8F3J11 Facility ID: CA070000087 If continuation sheet 14 of 22 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555204 (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CHILDREN'S HEALTHCARE ORGANIZATION OF NORTHERN CALIFORNIA - SARATOGA PEDIATRIC SUBACUTE 13425 Sousa Ln Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2. Allergy relief 3. Liquid pain relief During an interview on 1/22/2020 at 11:58 a.m. with RN K, RN K stated all liquid bottles of medication should be dated when opened. During a review of the facility's undated policy, "Medication Administration", indicated when using a new liquid medication for the first time, the bottle will be marked with the date opened.

F880 SS=E Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 02/28/2020 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8F3J11 Facility ID: CA070000087 If continuation sheet 15 of 22 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555204 (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CHILDREN'S HEALTHCARE ORGANIZATION OF NORTHERN CALIFORNIA - SARATOGA PEDIATRIC SUBACUTE 13425 Sousa Ln Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8F3J11 Facility ID: CA070000087 If continuation sheet 16 of 22 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555204 (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CHILDREN'S HEALTHCARE ORGANIZATION OF NORTHERN CALIFORNIA - SARATOGA PEDIATRIC SUBACUTE 13425 Sousa Ln Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE review, the facility failed to ensure proper infection control practices were followed when: 1. Housekeeper (HK E) did not change gloves and did not perform hand hygiene; 2. Resident 4's oxygen nasal cannula tubing (a device used to deliver supplemental oxygen or airflow) was touching the bedside table; 3. Resident 4's oxygen connector was exposed and touching the side rail; 4. Medication cart garbage next to the Resident 4's bedside table was over flowing; 5. Certified nursing assistant M (CNA M) did not change gloves and did not perform hand hygiene; 6. Ambu bags were not stored inside the equipment containers. These failures had the potential to spread infection in the facility. 1. During an observation on 1/21/2020 at 1:12 p.m. HK E exited room 6 with gloves then proceeded to room 5 without changing or removing gloves. HK E exited room 5 with the same gloves, proceeded to collect the medcart garbage and entered room 18 without changing gloves and without performing hand hygiene. HK E confirmed the above observation and stated, they [house keeping] are not required to change gloves when they go room to room to collect garbage. During an interview with the Pediatric Services Coordinator/Infection Preventionist (PSC/IP) on 1/23/2020 at 2:14 p.m., the PSC/IP stated staff should remove gloves and do hand hygiene every time they enter the room. Review of the facility's policy, "Hand Hygiene Program and Procedure", indicated hand hygiene should be done after handling contaminated items and gloves should not be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8F3J11 Facility ID: CA070000087 If continuation sheet 17 of 22 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555204 (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CHILDREN'S HEALTHCARE ORGANIZATION OF NORTHERN CALIFORNIA - SARATOGA PEDIATRIC SUBACUTE 13425 Sousa Ln Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE worn in the hallway. 1a. During an observation on 1/21/2020 at 1:20 p.m., HK E was wearing gloves in the hallway, entered room 12 then exited the room with the same gloves on then proceeded to enter room 14 without changing or removing gloves. HK E exited rooms 14, 15, 17, 18 and 19 with the same gloves, proceeded to collect garbage from rooms 14, 15, 17, 18, 19 without changing gloves and without performing hand hygiene. During a concurrent observation and interview on 1/21/2020 at 1:26 p.m. with HK E, HK E confirmed the above observations and stated they [house keeping] are not required to change gloves when they go room to room to collect garbage and they can wear gloves in the hallway. 2. During an initial tour observation on 1/21/2020 at 7:53 a.m., Resident 4's oxygen nasal cannula tubing was touching the bedside table. During a concurrent observation and interview on 1/21/2020 at 7:54 a.m. with licensed vocational G (LVN G), she confirmed the above observation. During an observation on 1/21/2020 at 7:58 a.m., Resident 4's oxygen connector was touching the side rail. During a concurrent observation and interview on 1/21/2020 at 7:59 a.m. with LVN G, she confirmed the above observation. 3. Not performing handwashing between removing and donning gloves. During an observation on 1/22/2020 at 4:12 p.m. with licensed vocational nurse L (LVN L), LVN L pulled the curtain, removed gloves, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8F3J11 Facility ID: CA070000087 If continuation sheet 18 of 22 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555204 (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CHILDREN'S HEALTHCARE ORGANIZATION OF NORTHERN CALIFORNIA - SARATOGA PEDIATRIC SUBACUTE 13425 Sousa Ln Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE placed used gloves on Resident 10's bedside table and donned new gloves without performing hand hygiene. During an interview on 1/22/2020 at 4:18 p.m., LVN L confirmed she did not perform hand hygiene between removing and donning gloves. During an interview on 1/23/2020 at 12:50 p.m. with the director of nursing (DON), the DON stated facility staff should perform hand hygiene between removing and donning gloves. During a review of the facility's undated policy, "Hand Hygiene Program & Procedure", indicated "5. Hand hygiene shall be done at the following times: k after taking off gloves sterile or unsterile" 4. During an observation on 1/21/2020 at 8:06 a.m., the medication cart side garbage bag next to Resident 4's bedside table was overflowing. During a concurrent observation and interview on 1/21/2020 at 7:59 a.m. with LVN G, she confirmed the above observation. She further stated the garbage bag should not be overflowing due to infection control issues. 5. During an observation on 1/21/2020 at 9:18 a.m., CNA M was carrying used linens after providing activities of daily living (ADL's) care to Resident 28 with gloves on and she disposed the linens inside the dirty yellow bin inside the room then touched the side rail of Resident 28 without changing gloves and without performing hand hygiene. CNA M was wearing the same gloves when she picked up a used paper towel on Resident 28's bedside, then proceeded to the bathroom touching the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8F3J11 Facility ID: CA070000087 If continuation sheet 19 of 22 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555204 (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CHILDREN'S HEALTHCARE ORGANIZATION OF NORTHERN CALIFORNIA - SARATOGA PEDIATRIC SUBACUTE 13425 Sousa Ln Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE bathroom handle with the same gloves and without performing hand hygiene. During a concurrent observation and interview with LVN G, she acknowledged the above observation. She further stated CNA M should have changed gloves and performed hand hygiene in every procedure. 6. During an observation on 1/21/2020 at 9:04 a.m., Resident 20's ambu bag was exposed and was not inside the plastic bag. During an observation on 1/21/2020 at 8:15 a.m., Resident 5's ambu bag and mask was exposed and was not inside the plastic bag. During a concurrent observation and interview on 1/21/2020 at 8:38 a.m. with the director of respiratory therapy (DRT), he acknowledged the above observations. The DRT stated all ambu bags, masks and other oxygen delivery devices should be kept inside a plastic bag. He further stated he was checking and putting all the ambu bags and masks inside a plastic bag for each resident in the facility. Review of the facility's policy and procedure, "Equipment Cleaning Policy", dated February 20, 2018, indicated the Respiratory Care Department participates in the hospital-wide infection control program, following the guidelines and procedures detailed in the approved hospital infection Control Manual ... .... Oxygen delivery devices such as simple mask, cannulas, oxygen tubing, nebulizers and etc. These items will be stored in equipment containers.

F921 SS=D Safe/Functional/Sanitary/Comfortable Environ CFR(s): 483.90(i)

F921 02/28/2020 §483.90(i) Other Environmental Conditions FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8F3J11 Facility ID: CA070000087 If continuation sheet 20 of 22 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555204 (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CHILDREN'S HEALTHCARE ORGANIZATION OF NORTHERN CALIFORNIA - SARATOGA PEDIATRIC SUBACUTE 13425 Sousa Ln Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure aerosol disinfectant was stored properly when the chemical disinfectant was found at the bed side of Resident 4. This failure had the potential for Resident 4 to access the hazardous chemical and jeopardize his health and safety. Findings: During breathing treatment observation on 1/21/2020 at 5:41 p.m. with respiratory therapist C (RT, a specialized healthcare practitioner trained in pulmonary medicine in order to work therapeutically with people suffering from pulmonary disease), a one 19 oz. disinfectant aerosol bottle was found at the bedside table next to the breathing treatment machine and suction machine for Resident 4. During a concurrent observation and interview with RT C on 1/21/2020 at 5:51 p.m., RT C acknowledged the above observation. She further stated Resident 4 could easily grab the aerosol bottle and it should not be kept at the bedside for Resident 4's safety. During a concurrent observation and interview with registered nurse B (RN B) on 1/21/2020 at 5:54 p.m., he acknowledged the above observation. He further stated the aerosol bottle should not be kept at the bedside for Resident 4's safety. During a concurrent observation and interview with certified nursing assistant D (CNA D) on 1/21/2020 at 5:55 p.m., she acknowledged the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8F3J11 Facility ID: CA070000087 If continuation sheet 21 of 22 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555204 (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CHILDREN'S HEALTHCARE ORGANIZATION OF NORTHERN CALIFORNIA - SARATOGA PEDIATRIC SUBACUTE 13425 Sousa Ln Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE above observation. CNA D further stated she forgot to put away the aerosol bottle after she used it. Review of the facility's undated policy, "Housekeeping Guidelines" indicated all staff should always keep cleaning chemicals out of reach of children ... No cleaning chemicals should be stored or left on residents/patients ... make sure all cleaning chemicals are always stored and locked in the housekeeping closet/cart when not in use. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8F3J11 Facility ID: CA070000087 If continuation sheet 22 of 22