Health inspection·January 28, 2022

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, the facility failed to ensure one of 12 sampled residents (Resident 19)'s room was homelike, when Resident 19's room had multiple paint nicks, black scrapes on the wall. This failure resulted in Resident 19 feeling depressed and feeling her environment was not homelike. Findings: During a record review of Resident 19's admission Record dated 1/27/22 which indicated Resident 19 was admitted on [DATE]. During a record review of Resident 19's Minimum Data Set (MDS, an assessment tool used to guide care) dated 12/14/21, the MDS indicated Resident 19's Brief Interview for Mental Status (BIMS, a screening tool used to assess cognition) score was 14, meaning no cognitive impairment. During a concurrent observation and interview on 1/25/22, at 2:12 p.m., in Resident 19's room, there were black scrape marks on the lower end of all four walls. There were white patches of paint on both sides of at the head and foot of the bed. Resident 19 stated the walls were dirty and had black markings and chipped paint. Resident 19 stated her room was not homelike for her and it made her feel depressed. During a subsequent interview on 1/27/22, at 9:56 a.m., Resident 19 stated the walls with dirty, black markings and chipped paint had been there since she was admitted to the facility. Resident 19 stated she asked the facility staff to repair the walls in her room. During a concurrent observation and interview on 1/27/22, at 9:36 a.m., in Resident 19's room, with Maintenance Supervisor (MS), MS stated the walls had a good amount of black abrasions (scrapes) and paint nicks. MS stated that it was not okay to have resident's rooms with chipped paint or markings because it is the resident's right to have a clean house and could make the residents feel uncomfortable and want to leave the facility. During a record review of the facility's policy and procedure (P&P) titled, Homelike Environment, and revised 02/2021 indicated, Residents are provided with a safe, clean, comfortable and homelike environment . Page 1 of 8 555082 555082 01/28/2022 Valley Pointe Nursing & Rehabilitation Center 20090 Stanton Avenue Castro Valley, CA 94546

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS-Resident Assessment and Care Screening tool used to guide care), was accurate for one ( Resident 3) of 12 sampled residents when Resident 3's weight loss was not coded accurately. Residents Affected - Few This failure had the potential for Resident 3 to not receive care to manage unintended weight loss. Findings: Review of the Resident 3's Minimum Data Set, MDS - resident assessment tool used to guide care, dated 1/7/22, indicated section K 0300 weight loss of 10% or more in the last 6 months was coded zero - no weight loss. Resident 3 diagnoses had included Non-Alzheimer's Dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). Record review of the nutritional risk care plan dated 1/11/22 indicated Resident 3's weight on 7/5/21 was 133.8 pounds and weight recorded on 1/4/22 was 120.2 pounds. Resident 3 lost 13.6 pounds in six months. During an interview on 1/26/22 at 8:59 a.m., the MDS Coordinator (MDS) stated Resident 3's MDS section K was not accurately coded because the wrong date was used for the weight loss calculation. MDS further stated Resident 3 had more than 10% weight loss in six months. The facility's policy and procedure titled, Certifying Accuracy of the Resident Assessment revised November 2019 indicated, Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment. 555082 Page 2 of 8 555082 01/28/2022 Valley Pointe Nursing & Rehabilitation Center 20090 Stanton Avenue Castro Valley, CA 94546

F 0675 Honor each resident's preferences, choices, values and beliefs. 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 record review, the facility failed to provide hearing aids for one of 19 sampled residents (Resident 13) for a period of six (6) weeks after they were discovered missing. Residents Affected - Few This failure resulted in Resident 13 feeling sad, frustrated, and embarrassed about her hearing impairment and had the potential to lose interest in activities. Findings: During a record review of Resident 13's admission Record dated 1/26/22 showed Resident 13 was admitted to the facility on [DATE]. During a record review of Minimum Data Set (MDS- An assessment used to guide care) dated 12/7/21 indicated, Resident 13 required hearing aids to manage her hearing difficulty. During a record review of Resident 13's baseline care plan dated 12/4/21, indicated her preferred activities including watching television, puzzles, solitaire, and spending time with family. During an observation and interview, on 1/25/22 at 9:58 a.m., Resident 13 was in bed looking at the television in her room and consistently asked to repeat loudly what was said Resident 13 stated her hearing aids had been missing for a while and it was very hard to ask everyone to speak louder so she could hear and understand Resident 13 further stated she missed hearing the daily news on the television and was able to respond to written questions, but she did not have writing materials for communication available at her bedside. During an observation on 1/27/22, at 10:44 a.m., with Certified Nursing Assistant (CNA 2), CNA 2 looked through Resident 13's bedside stand drawers and searched the bedside surfaces. CNA 2 stated she could not locate Resident 13's hearing aids. During an interview on 1/28/22, at 1:23 p.m., CNA 2 stated Resident 13 was very upset that her hearing aids went missing not only once, but twice. CNA 2 stated Resident 13 became frustrated and sad because she could not hear anything. During an interview on 1/27/22, at 12:00 p.m., the Director of Nursing, (DON) stated the potential consequences of Resident 13's hearing aid loss included a decline in interest for activities, poor appetite and subsequent weight loss. During a telephone interview with Resident 13's Family Representative (FR 1) on 1/26/22, at 12:39 p.m., FR 1 stated Resident 13's hearing aids went missing about two weeks after her admission at the facility (approximately 12/15/21). FR 1 stated he then brought a single hearing aid (cannot remember the date) that Resident 13 had extra at home, and it went missing approximately 3 days after he brought it in. FR 1 stated he did not add the single hearing aid on Resident 13's property inventory list and notified the Administrator (ADM) about Resident 13's missing hearing aids. During an interview on 1/25/22 1:30 p.m.,the Administrator (ADM) stated he was aware of Resident 13's lost hearing aids but they were not replaced yet. 555082 Page 3 of 8 555082 01/28/2022 Valley Pointe Nursing & Rehabilitation Center 20090 Stanton Avenue Castro Valley, CA 94546

F 0675 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a record review of Resident 13's Inventory of Personal Items dated 12/1/21 indicated Resident 13 had a pair of hearing aids upon admission to the facility. During a record review of the facility's policy and procedures, Hearing Impaired Resident Care dated 2/2018 reflected, Staff will help residents who have lost or damaged hearing devices in obtaining services to replace the devices. 555082 Page 4 of 8 555082 01/28/2022 Valley Pointe Nursing & Rehabilitation Center 20090 Stanton Avenue Castro Valley, CA 94546

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 maintain proper sanitation practices when: Residents Affected - Some a. The hand washing sink had a cracked surface. b. One staff (Cook) did not know how to operate the three compartment manual washing sink that included washing, rinsing and sanitizing. c. Floor tiles had brownish- black discoloration. d. The two compartment sink had brownish-black buildup around the faucet. e. Low - Temperature dishwasher chemical sanitization final rinse was not tested for proper functioning. f. Sanitation assessment records were not available. These deficient practices did not ensure a sanitary kitchen environment and had the potential for foodborne illness from not knowing how to wash dishes using the compartment sinks during an emergency. Findings: During the initial tour of the kitchen on 1/24/22 at 10:35 a.m., accompanied by the Dietary Manager (DM), the following was observed: Hand washing sink with cracked surface area , kitchen floor tiles with brownish black discoloration, and the two compartment sink had brownish black build up around the faucet. During an interview on 1/24/22 at 10:35 a.m., DM stated the hand washing sink was cracked and will be followed up. DM stated she was a new hire to the facility and so were the dietary staff. During an observation on 1/24/22 at 10:55 a.m., the Dietary Assistant (DA) operated the low temperature dishwasher to wash dishes. The sanitizer final rinse was tested with a test strip and did not register for proper functioning. During an interview on 1/24/22 at 10:55 a.m., DA stated stated he used the low temperature dishwasher to wash plates in the morning and did not remember if the sanitizer was tested for proper functioning. During an interview on 1/24/22 at 11:12 a.m., the Dietary Staff (DS) stated she used the dishwasher earlier to wash plates but did not remember if she used the test strip to check the sanitizer for proper functioning. Review of the sanitizer test log did not show test records for 1/24/22 . During an observation on 1/25/22 at 9:29 a.m., the [NAME] (CK) did not know how to operate the 555082 Page 5 of 8 555082 01/28/2022 Valley Pointe Nursing & Rehabilitation Center 20090 Stanton Avenue Castro Valley, CA 94546

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some three compartment manual washing sink that included washing, rinsing and sanitizing. CK stated she was not provided an in-service on how to use the three compartment process. (The manual three compartment sink is used when the dishwasher is out of service or an emergency power outage). During an interview on 1/25/22 at 10:43 a.m., DM stated she did not have a sanitation assessment report for the kitchen. The facility's policy and procedure, Sanitation revised October 2008 indicated, The food service area shall be maintained in a clean and sanitary manner. The Food Service Manager will be responsible for scheduling staff for regular cleaning of kitchen. 555082 Page 6 of 8 555082 01/28/2022 Valley Pointe Nursing & Rehabilitation Center 20090 Stanton Avenue Castro Valley, CA 94546

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to ensure the garbage was disposed of and kept covered which had the potential to attract pests. Residents Affected - Few Findings: During an observation on 1/25/22 at 10:45 a.m., in the presence of the Dietary Manager (DM), there were several bagged trash stored in an opened dumpster. During an observation and concurrent interview on 1/25/22 at 10:53 a.m., with the Maintenance Supervisor (MS) the dumpster located by the facility's side driveway was full of trash bags and was not closed. MS stated the dumpster should be closed because when it rains the water gets into the container. 555082 Page 7 of 8 555082 01/28/2022 Valley Pointe Nursing & Rehabilitation Center 20090 Stanton Avenue Castro Valley, CA 94546

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility had three resident rooms (Room numbers 19, 20, 21) and total of 12 licensed beds that were occupied by 11 residents, that provided less than 80 square feet (sq. ft.) per resident. This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff and for the lack of sufficient space for storage of resident belongings. Findings: During a concurrent observation and interview on 1/27/22, at 10:48 a.m., in room [ROOM NUMBER], with the Maintenance Supervisor (MS), MS measured room [ROOM NUMBER] and confirmed it was less than 80 sq. ft. per resident. MS stated he was aware rooms [ROOM NUMBER] were less than 80 sq. ft. per resident. MS stated residents and staff never complained about the room size and staff have enough room to do their job. During random observations of care and services from 1/24/22 to 1/27/22, there was sufficient space for the provision of care for the residents in all rooms. There was no heavy equipment kept in the rooms that might interfere with residents' care, and each resident had adequate personal space and privacy. During a record review of the Client Accommodations Analysis dated 1/26/22, showed the following resident rooms and corresponding square footage for each four occupancy resident beds. room [ROOM NUMBER] had 280 sq. ft. and 70 sq. ft. of space per resident. room [ROOM NUMBER] had 280 sq. ft. and 70 sq. ft. of space per resident. room [ROOM NUMBER] had 280 sq. ft. and 70 sq. ft. of space per resident. There were no complaints from residents regarding insufficient space for their belongings and no negative consequences attributed to the decreased space and/or safety concerns in the three identified rooms. Granting of the room size waiver recommended. 555082 Page 8 of 8