Health inspection·January 26, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide one visually impaired resident (Resident 30) of two sampled residents assistance with eating when the Certified Nursing Assistant (CNA 4) did not assist Resident 30 with meal tray set-up and food positioning on the plate. Residents Affected - Few This failure caused Resident 3 confusion and challenges with eating. Findings: Review of the Significant change-Minimum Data Set (MDS -an assessment screening tool used to guide care), dated 1/12/24, indicated Resident 30's Basic Interview of Mental status (BIMS) score was 15 (meaning cognitively intact). Resident 30 had clear speech, able to make self-understood and able to understand others. Resident 30 had limited vision, and not able to see but could identify objects. Resident 30 needed touch assistance with eating, and a helper to provide verbal cues and contact guard assistance as resident completes activity. Resident 30's diagnoses included cataracts (clouding of normally clear lens of the eye, glaucoma (a group of eye conditions that can cause blindness), macular degeneration (an eye disease that causes vision loss. During a concurrent observation and interview on 1/22/24 at 11:48 a.m., Resident 30 was sitting up in bed in her room. Resident 30 stated she was visually impaired and during mealtimes, the Certified Nursing Assistants (CNAs) did not assist with meal tray set-up or food positioning. Resident 30 stated she gets confused with what's on her plate because staff will place the meal tray on her side table and leave without telling her what is on her plate and how to reach the food tray. Resident 30 further stated she had posted a sign in her room about her vision problem and staff knew she was legally blind and could not see. A sign posted on the wall next to Resident 30's bed indicated Resident 30 was visually impaired. During a concurrent observation and interview on 1/22/24 at 12:25 p.m., CNA 4 placed a lunch tray on Resident 30's side table in front of Resident 30 and left her room. CNA 4 stated Resident 30 known's what to do with her meal tray. CNA 4 stated she did not explain what was on the plate. During an interview on 1/22/24 at 1:04 p.m., the Director of Nursing (DON) stated the care plan intervention was for CNAs to assist Resident 30 with meal tray setup because of her visual impairment. Page 1 of 19 555082 555082 01/26/2024 Valley Pointe Nursing & Rehabilitation Center 20090 Stanton Avenue Castro Valley, CA 94546

F 0578 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of Resident 18's admission Records, indicated the facility admitted Resident 18 on 11/16/23. Residents Affected - Some During a concurrent interview and record review of Resident 18's admission records on 1/25/24 at 9:46 a.m., with SS, SS stated Resident 18 had no advance directive documentation or had followed up with the responsible party about advance directives. SS stated, I missed it. Review of the facility's policy and procedures, titled, Advance Directives revised September 2023, indicated, Prior to or upon admission of a resident, the social services director or designee inquires of the resident his/her family members and /or his or her legal representative, about the existence any written advance directives. Based on interview and record review, the facility failed to facilitate Advance Directives (a legal document that provide instructions for medical care that go into effect if you cannot communicate your own wishes) status, including the right to accept or refuse medical/surgical treatment for five out of five residents upon admission. These failures resulted in Residents 26, 32, 94, 192, and 193 or their responsible party (RP) not being aware of their right to participate in their medical and surgical care. Findings: During a review of Resident 26's admission Record, Resident 26 was admitted to the facility on [DATE]. During a review of Resident 32's admission Record, Resident 32 was admitted to the facility on [DATE]. During a review of Resident 192's admission Record printed on 01/23/24, the record indicated Resident 192 was admitted to the facility on [DATE]. During a review of Resident 193's admission Record, Resident 193 was admitted to the facility on [DATE]. During a concurrent interview and record review on 01/23/24 at 1:08 p.m., with Social Services Director (SS), of the Electronic Healthcare Record (EHR) and the paper chart for Residents 3, 24, 30, and 200 were reviewed for the presence of an Advance Directive. SS stated Advance Directives were not in either resident records, nor was there documentation that assistance was offered to Residents 26, 32, 192, 193, and 200. SS stated, Upon the resident's admission to the facility, I check if the resident has an Advance Directive in place, and this was not done for these residents. During a telephone interview on 01/23/24 at 2:35 p.m., with Responsible Party (RP 1) for Resident 26, RP 1 stated she was not asked about an Advance Directive during admission or at any time during Resident 26's stay. During an interview on 01/23/24 at 3:40 p.m., with Resident 32, Resident 32 stated she does not 555082 Page 2 of 19 555082 01/26/2024 Valley Pointe Nursing & Rehabilitation Center 20090 Stanton Avenue Castro Valley, CA 94546

F 0578 recall being asked about an Advance Directive. Level of Harm - Minimal harm or potential for actual harm During a telephone interview on 01/23/24 at 3:43 p.m., with Responsible Party (RP 2) for Resident 192, RP 2 stated The nurse who admitted me did not ask me if my grandmother had an Advance Directive or provide any paperwork regarding Advance Directives. Residents Affected - Some During an interview on 01/23/24 at 4:00 p.m., with Resident 193, Resident 193 stated she does not recall being asked about an Advance Directive during admission. During a review of the facility's policy and procedure (P&P) titled Advanced Directives dated September 2022, indicated .The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment .1. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. 2. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if she or she chooses to do so. 3. Written information about the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive provided in a manner that is easily understood by the resident or representative. 555082 Page 3 of 19 555082 01/26/2024 Valley Pointe Nursing & Rehabilitation Center 20090 Stanton Avenue Castro Valley, CA 94546

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a baseline care plan within 48 hours, and provide three (Residents 18, 93, and 94) of 20 sampled residents and their representatives with a summary of the baseline care plan. This failure did not ensure the minimum healthcare information to plan care for each resident upon admission and provide the baseline care plan summary indicating residents and representatives were informed. Findings: Review of the admission Record, indicated, Resident 18 was admitted to the facility on [DATE] with diagnoses that included sepsis (a life-threatening complication of an infection). Review of the Resident 18's baseline care plan, dated 12/11/19, the care plan indicated, facility did not complete Resident 18's baseline care plan within 48 hours and provide Resident 18 and their representatives with a summary of the baseline care plan. Review of the admission Record indicated Resident 93 was admitted to the facility on [DATE] with diagnoses that included sepsis. Review of the Resident 93's baseline care plan dated 1/7/24 indicated the facility did not complete Resident 93's baseline care plan within 48 hours or provide Resident 93 and their representatives with a summary. Review of the admission Record indicated Resident 94 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis (stroke). Review of the Resident 94's baseline care plan dated 1/13/24 indicated the facility did not provide Resident 93 and their representatives with a written summary of the baseline care plan. During an interview 9/26/19 at 10:16 a.m., the Director of Nursing (DON), stated residents baseline care plans were not completed within 48 hours by the interdisciplinary team members (IDT). DON stated she was aware baseline care plan summaries were not provided to the residents and representatives. The facility's policy and procedure, titled, Care Plans-Baseline revised December 2022, indicated; A baseline plan of care should be developed for each resident within forty-eight (48) hours of admission. The resident and or representative should be provided a written summary of the baseline care plan . 555082 Page 4 of 19 555082 01/26/2024 Valley Pointe Nursing & Rehabilitation Center 20090 Stanton Avenue Castro Valley, CA 94546

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to two of 20 sampled residents (Residents 148 and 23) as follows. 1 a). Resident 148, identified as a high risk for falls, was not provided with a sitter after the resident was deemed needing one-one supervision to prevent further falls. This resulted in Resident 148 sustaining another serious fall injuries (a comminuted fracture that is broken in at least two pieces caused by trauma to the right clavicle (collarbone), and a subdural hematoma (condition when a pool of blood develops between the brain and its covering, usually from head trauma). b). Resident 148 eloped on 12/7/23 and was later found in a hospital emergency department (ED). This episode of elopement was not reported by the facility to the department. 2. The facility did not apply the ordered bed pad alarm (alerts staff of position movement out of bed) for Resident 23. For Resident 23, this had the potential for fall injuries. Findings: 1. Review of Resident 148's Facesheet (contains contact details, brief medical history at-a-glance), dated 1/25/24 indicated, Resident 148 was admitted to the facility on [DATE] with diagnoses that included history of falling, abnormalities of gait and mobility, epilepsy (condition that affects the brain and causes frequent seizures), insomnia (trouble sleeping), and need for assistance with personal care. Review of Resident 148's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 12/12/23 under Section C, indicated Resident 148's cognition was moderately impaired. The Functional Abilities and Goals indicated, Resident 148 needed staff supervision when moving from seated to standing position, walking, turning around, moving on and off toilet and during surface-to-surface transfer (such as when transferring between bed and chair or wheelchair). Review of Resident 148's Fall Risk observation/assessments dated 12/11/23 until 1/8/24, the score ranged from 18 to 22 (range of high risk for falls). Review of Resident 148's Departmental Notes indicated that Resident 148 had multiple falls from 12/11/23 through 1/25/24 with revised care plans after each episode. However, on 12/27/23, the resident was sent out to the emergency department (ED) and was diagnosed with a comminuted right clavicle fracture, after an unwitnessed fall, the resident's care plan did not indicate new interventions to prevent future falls. During an interview and concurrent review on 1/25/24 at 9:11 a.m., Resident 148's fall care plan was reviewed with the Minimum Data Set Coordinator (MDSC). MDSC stated, it was her responsibility to update the resident's fall care plan, and acknowledged there were no new fall interventions on 12/27/23. MDSC further stated the care plan should have been reviewed after each fall to evaluate if the interventions were effective in preventing future falls. MDSC stated, consistent and constant one-one 555082 Page 5 of 19 555082 01/26/2024 Valley Pointe Nursing & Rehabilitation Center 20090 Stanton Avenue Castro Valley, CA 94546

F 0689 supervision should have been considered as a fall prevention intervention for Resident 148. Level of Harm - Actual harm Review of Resident 148's Interdisciplinary Team (IDT, a group of individuals representing different departments of the facility) meeting notes, dated 1/8/24 indicated, Resident 148's new intervention for a witnessed fall incident that happened on 1/5/24, at 5:10 p.m., was to place the resident on one-one supervision. Residents Affected - Few Review of Resident 148's IDT meeting notes, dated 1/12/24, indicated, Resident 148 had an unwitnessed fall on 1/12/24 at 7:59 a.m., in another resident's room, and was found in a supine (back) position, with a big skin tear in her right forearm. Resident was sent out to the hospital. During an interview 01/25/24 at 8:37 a.m., with Director of Nursing (DON), DON stated, the facility was not the one who should provide a one-one sitter to the resident. DON further stated, it was Resident 148's family who was responsible for paying for the resident's one-one sitter. Review of Resident 148's Hospitalist (physician specialist in hospital care) Discharge Summary and Transfer Instruction, dated 1/18/24 indicated, Resident 148 was admitted to the hospital on [DATE] and stayed in the hospital until 1/18/24, due to a right subdural hematoma caused by the fall and was discharged . Review of Resident 148's Face Sheet dated 1/25/24 indicated Resident 148 was re-admitted to the facility on [DATE]. During an interview on 1/25/24 at 10:35 a.m., with the Director of Rehab (DOR), stated, Resident 148 had no safety awareness, and with one-one supervision, the resident's falls could be avoided. During an interview on 1/25/24 10:56 a.m., with the Medical Doctor (MD), stated, after Resident 148's third fall, the only way to prevent the resident from falling in the facility was one-one supervision which was having someone very closely supervising the resident. During a review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, dated March 2018, the P&P indicated, Based on previous evaluations and current data, staff may identify interventions related to the resident's specific risks and causes in the attempt to reduce falls and minimize complications from falling .Resident centered fall prevention plans should be reviewed and revised as appropriate .If the resident continues to fall, the situation should be reevaluated to determine whether it would be appropriate to continue or change current interventions. b). Review of Resident 148's Nurses Notes, dated 12/7/23, indicated, Resident was missing on 12/7/23 at around 6:30 p.m., and was found at a hospital's ED at 8:00 p.m. Resident 148 was brought back to the facility at 11:30 p.m. Review of the resident's Elopement Risk assessment dated [DATE], indicated, a score of 16. The elopement risk assessment indicated a score of more than 10 would be considered at risk for elopement. During an interview on 1/25/24 at 1:03 p.m., with DON, stated Resident 148 eloped on 12/7/23 and ended in the hospital ED. Stated the resident's elopement risk score was 16 and resident had a risk of eloping. DON further stated she did not report the resident's incident of elopement to the department. 555082 Page 6 of 19 555082 01/26/2024 Valley Pointe Nursing & Rehabilitation Center 20090 Stanton Avenue Castro Valley, CA 94546

F 0689 Level of Harm - Actual harm Residents Affected - Few A review of the facility's policy and procedure (P&P) titled, Unusual Occurrence Reporting, dated 2007, the P&P indicated, As part by federal or state regulations, our facility reports unusual occurrences or other reportable evens which affect the health, safety or welfare of our residents .1. Our facility will report the following events to appropriate agencies: .Other occurrences that interfere with facility operations and affect the welfare, safety, or health of residents .Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations. A written report detailing the incident and actions by the facility after the event shall be sent or delivered to the state agency within forty-eight (48) hours of reporting the event or as required by federal and state regulations . 2. Review of Resident 23's Facesheet, dated 1/25/24, indicated, the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), history of falling, dementia (memory loss and impaired decision-making capacity), and weakness. Review of Resident 23's MDS dated [DATE] indicated Resident 23's cognition was moderately impaired. The Functional Abilities and Goals indicated Resident 23 was not steady, and was only able to stabilize with staff assistance when moving from seated to standing position, moving on and off toilet and during surface-to-surface transfer (between bed and chair or wheelchair). Review of Resident 23's Fall Risk observation/assessments dated 9/24/23, showed the score was 24. The Fall Risk observation/assessments' score dated 10/11/23 was 26. These scores were in the range of high risk for falls. Review of Resident 23's Situation, Background, Assessment, Recommendation (SBAR) notes indicated, Resident 23 had unwitnessed falls on the dates 7/27/23, 9/24/23, 10/10/23, and 12/20/23. During an interview on 1/22/24 at 11:25 a.m., with Resident 23's responsible party (RP) 2, stated he was concerned about the resident's frequent falls and if the staff were applying the resident's pad alarm. Review of Resident 23's active monthly physician order for January 2024 indicated an order dated 9/22/23, for a bed pressure pad alarm when in bed to alert staff of resident's attempts to rise unassisted. During a concurrent observation and interview on 1/24/24 2:09 p.m., with Certified Nursing Assistant (CNA) 11, confirmed Resident 23 had no bed alarm while lying in bed. Further observation and interview on 1/26/24 at 8:15 a.m., CNA 11 confirmed Resident 23 still had no bed alarm while in bed. During a concurrent observation and interview on 1/26/24 at 8:20 a.m., DON verified Resident 23 was lying in bed with no bed pad alarm. DON stated nursing staff should follow the physician's order to apply the bed alarm to prevent falls and injuries. DON further stated the facility had no policy and procedure on bed alarms. 555082 Page 7 of 19 555082 01/26/2024 Valley Pointe Nursing & Rehabilitation Center 20090 Stanton Avenue Castro Valley, CA 94546

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to complete a performance review of every nurse aide at least once every 12 months when; Residents Affected - Some - Five of five Certified Nursing Assistants' (CNAs) annual performance evaluations were not completed. - Three of five licensed nursing staff did not receive ongoing in-service training for the use of personal protective equipment (PPE) and isolation precautions during a COVID-19 outbreak. This failure had the potential for the spread of infection due to unknowledgeable staff about managing and caring for residents during a COVID 19 outbreak. Findings: During a review of the employee files on 1/24/24 at 12:29 p.m., in the presence of the Infection Preventionist/Director of Staff Development (IP/DSD), the Certified Nursing Assistants'(CNAs) annual performance evaluations were not completed for CNA 6 hired 4/2/95, CNA 7 hired 2/7/11, CNA 8 hired 2/11/22, CNA 9 hired 11/6/22, and CNA 10 hired 12/1/21. During a review of the in-service training records titled, COVID Outbreak, dated 12/5/23, on 1/24/23 at 12:29 p.m., in the presence of the Director of Nursing (DON) and IP/DSD indicated, Registered Nurse (RN 2), Licensed Vocational Nurse (LVN 2) and CNA 2 had not received in-service re-training on Infection Control and use of PPE during the COVID outbreak. During an interview on 1/25/24 at 9:01 a.m., IP/DSD stated the facility had not completed the performance evaluation of their CNAs at least once every 12 months. During an interview on 1/25/24 at 10:09 a.m., Administrator (Admin) stated, he was not aware that CNAs performance evaluations were not completed annually. Review of the facility's policy and procedur, titled, Performance Evaluations, revised September 2020 indicated, A performance evaluation will be completed on each employee at the conclusion of his/her 90 day probationary period, and at least annually thereafter. The performance evaluation meeting will occur at the same time as the employee's compensation review. 555082 Page 8 of 19 555082 01/26/2024 Valley Pointe Nursing & Rehabilitation Center 20090 Stanton Avenue Castro Valley, CA 94546

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to label medications and properly dispose of expired medications for two of 20 sampled residents (Resident 17 and Resident 12), for medication cart one: 1. Resident 17's three open inhalers (devise used for inhaling medicine into the lungs) were found with no open date labels. 2. Resident 12's one bottle of acetaminophen (pain and fever medication) caplets was expired. This failure could potentially expose residents to the expired medications loss of potency and efficacy. Findings: 1. Resident 17 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing related problems). During a concurrent observation and interview on 1/23/24, at 2:00 p.m., with Registered Nurse (RN) 1, while inspecting medication cart one, Resident 17 had two opened medication boxes which contained Breyna or Budesonide-Formoterol-Fumarate inhalers with no open date labels.(Breyna is a medication indicated for the treatment of air flow obstruction in patients with COPD). The two Breyna inhaler boxes from the facility's pharmacy indicated, each box should contain an inhaler with 120 inhalations. The instructions on the box indicated to dispose of the inhaler after 90 days from the opening date. RN 1 confirmed, inside one of the two opened Breyna medication boxes, there were two opened Breyna inhalers found, and one of the two opened inhalers had 108 inhalations left in the counter (shows doses remaining) and the other inhaler had 46 inhalations left. RN 1 also confirmed that inside one of the two opened Breyna medication boxes, was one opened inhaler with 83 inhalations left in the counter. RN 1 acknowledged; all the three inhalers were opened and there were no open date labels on the two Breyna opened medication boxes or the three opened inhalers. RN 1 stated the inhalers were supposed to be disposed 90 days from the date of opening. RN 1 stated, the risk of giving an expired medication is for the resident receiving inhalation medications with less potency. Review of Resident 17's monthly physician order for January 2024 indicated an order, dated 12/21/23, for Budesonide-Formoterol-Fumarate inhalation for the diagnosis of COPD. Review of Resident 17's Medication Administration Record (MAR) indicated Budesonide-Formoterol-Fumarate or Breyna inhaler was last given on 1/23/24 at 5:00 p.m. During an interview on 1/25/24 at 8:27 a.m., with the Director of Nursing (DON), DON stated, the medication nurse who initially opened the inhalers should have written the open date labels to make sure the facility could discard the medication as recommended by the manufacturer. During a telephone interview on 1/26/24 at 10:52 a.m., with the Consultant Pharmacist (CP), stated 555082 Page 9 of 19 555082 01/26/2024 Valley Pointe Nursing & Rehabilitation Center 20090 Stanton Avenue Castro Valley, CA 94546

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 17 should not have three open Breyna inhalers that were being used by the resident at the same time. CP also stated, there should not be two open Breyna inhalers inside one open box of Breyna inhaler amd should have followed the manufacturer's guidelines for discarding medications. Review of Lexicomp (professional pharmacist resource) for Breyna inhaler, dated 5/24/23 indicated, Throw away any part not used 3 months after taking out of foil package. 2. Record review showed Resident 12 was admitted to the facility on [DATE]. During a concurrent observation and interview with RN 1, while inspecting medication cart one, an expired bottle of acetaminophen 500 milligrams (mg) caplets that belonged to Resident 12 was found. RN 1 confirmed the bottle of acetaminophen caplets indicated an expiry date of 10/31/23. RN 1 stated the medication should have been disposed of because of the risk for the resident of accidentally receiving expired medications and experiencing adverse side-effects (unwanted and undesirable effects). Review of Resident 12's monthly physician order, for January 2024, indicated there was no current order of acetaminophen 500 mg. for the resident. During an interview on 1/25/24 at 8:27 a.m., DON stated the licensed nurses should have checked and disposed of the expired acetaminophen from the medication cart because the acetaminophen 500 mg was discontinued on 12/1/23. During a telephone interview on 1/26/24 at 10:52 a.m., CP stated the risk of keeping the expired medication in the cart was giving the resident a medication with less potency. A review of the facility's policy and procedure (P&P) titled, Discarding and Destroying Medications, dated 2022, indicated, Non- controlled and Scheduled V (non- hazardous) controlled substances are disposed of in accordance with state regulations and federal guidelines regarding disposition of non-hazardous medications. 555082 Page 10 of 19 555082 01/26/2024 Valley Pointe Nursing & Rehabilitation Center 20090 Stanton Avenue Castro Valley, CA 94546

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an interview on 1/22/24 at 9:50 a.m., Resident 7 stated the facility served cold meals and the breakfast was cold. Resident 7 further stated he felt the facility served frozen food that was not appetizing. Residents Affected - Some Review of the admission Minimum Data Set (MDS -an assessment screening tool used to guide care), dated 12/19/23, indicated Resident 7's Basic Interview of Mental status (BIMS) score was 15 (meaning cognitively intact). Resident 7 diagnoses included malnutrition (lack of proper nutrition caused by not having enough to eat, not eating enough of the right things, or being unable to use the food one eat). During an interview on 1/22/24 at 10:15 a.m., Resident 30 stated breakfast and food meals are served cold. Review of the Significant change MDS, dated [DATE], indicated; Resident 30's Basic Interview of Mental status (BIMS) score was 15. Review of the Resident Council Minutes, dated 10/18/23, 11/29/23, and 12/21/23, indicated concerns about food not being good, food in general hasn't been great, meat has been tough and not a lot of variety and too much of the same thing. During an interview on 1/23/24 at 12:47 p.m., RD stated she was aware of food concerns, including concerns about cold food and the meat too tough. RD stated she verbally gave in-service training to dietary staff but did not have any documentation of the in-service training. RD stated the facility had no dietary supervisor. Based on observation, interview, and record review, the facility failed to ensure residents were served palatable food when food was served at a low temperature. This failure had the potential for 48 of 48 residents to consume a decreased amount of nutrients leading to weight loss and/or nutrient related medical complications. Temperature of the food was not palatable. Findings: During an interview on 01/22/24 at 10:09 a.m., with Resident 11, Resident 11 stated meals served at the facility were often cold and not palatable. During a telephone interview on 01/22/24 at 01:55 p.m., with Responsible Party (RP) for Resident 26, RP stated the food served to Resident 26 is often cold and not palatable. During an observation on 01/23/24 at 12:00 p.m., a meal delivery cart holding resident lunch trays, including one test lunch tray was transported from the kitchen. During a concurrent observation and interview on 01/23/24 at 12:30 p.m., with Registered Dietician (RD), in the activities/dining room, a regular diet lunch test tray was sampled immediately following the delivery of the last resident tray. The regular tray contained middle eastern chicken, rice, and herbed zucchini. Temperatures of the food were measured with the surveyor's calibrated 555082 Page 11 of 19 555082 01/26/2024 Valley Pointe Nursing & Rehabilitation Center 20090 Stanton Avenue Castro Valley, CA 94546

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some thermometer. The middle eastern chicken was 140 Fahrenheit (°F), rice was 138 °F and the herbed zucchini was128 °F. The regular chicken parmesan was dry and regular pasta was very bland and dry. RD stated middle eastern chicken was just warm and not hot enough to serve to the residents. RD also stated the middle eastern chicken, rice and herbed zucchini tasted unappetizing and not palatable. During an observation on 01/24/24 at 07:42 a.m., a meal delivery cart holding resident breakfast trays and one test breakfast tray left the kitchen. During a concurrent observation and interview on 01/24/24 at 08;00 a.m., with RD in the activities/dining room, a regular diet breakfast test tray was sampled immediately following the delivery of the last resident tray. The regular tray contained a fried egg and a slice of toast bread. Temperatures of the food were measured with the surveyor's calibrated thermometer. The fried egg was 114.3 Fahrenheit (°F), and the toast bread was 86 °F. RD tasted the egg, and stated the fried egg was very cold, not palatable, unappetizing, and not hot enough to serve to the residents. [Reference:The safe minimum internal temperature for cook egg dishes 160 degree Fahrenheit-www.fsis.usda.gov] During an interview on 01/25/24 at 08:59 a.m., with RD, RD stated she was aware of resident complaints about unpalatable food during resident council meetings and had provided in-services to the kitchen staff to ensure palatability of meals served. Review of the policy and procedure titled, Food and Nutrition Services dated 2001, showed each resident is provided with a palatable diet. 555082 Page 12 of 19 555082 01/26/2024 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, staff interview, and record review, the facility failed to store and prepare food in accordance with professional standards for safety when: Residents Affected - Some 1. Food was opened, unlabeled and undated. 2. The blender container was cloudy and dirty. 3. The bottom shelf of two-door freezer had crusted food and ice buildup. 4. Two dry food storage bins containing food were dirty, unlabeled, undated. 5. Cutting boards were dirty and ready for use. These failures put the facility at increased risk for food contamination and food borne illness for 48 residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview during the initial kitchen tour on 01/22/24 at 09:45 a.m., with Dietary [NAME] (Cook), two opened loaves of bread and one opened bag of bagel were on the kitchen counter, without a label and a date. [NAME] stated she had used the bread and bagel for residents' breakfast and had forgotten to label and date the items. [NAME] stated, the risk for not labeling and dating food is not knowing if the food is expired and cross contamination. According to the 2022 Federal Food Code, food-contact surfaces are to be clean to sight and touch, the food-contact surfaces of cooking equipment and pans are to be kept free of encrusted grease deposits and other soil accumulations, and nonfood-contact surfaces of equipment is to be kept free of an accumulation of food residue and other debris. 2. During an observation and concurrent interview during the initial kitchen tour on 01/22/24 at 09:47 a.m. with Cook, the blender container was cloudy and dirty. There was yellow residue on the bottom of the blender. [NAME] stated she used the blender to make puree meal for residents. [NAME] stated the cloudiness does not come off after washing. According to the 2022 Federal Food Code, food-contact surfaces are to be clean to sight and touch, the food-contact surfaces of cooking equipment and pans are to be kept free of encrusted grease 555082 Page 13 of 19 555082 01/26/2024 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 deposits and other soil accumulations, and nonfood-contact surfaces of equipment is to be kept free of an accumulation of food residue and other debris. 3. During a concurrent observation and interview, during the initial kitchen tour, on 01/23/24 at 09:50 a.m., with Cook, the two-door freezer has crusted food and ice buildup on the bottom shelf. Also, food crumbs were on the bottom shelf. [NAME] stated she was the sole individual responsible for cooking, cleaning, and ordering food, and that she had not cleaned the kitchen for over three months. [NAME] stated there was no schedule for cleaning of the refrigerators and freezers in the kitchen. During a review of the facility's policy and procedure (P&P) titled Refrigerators and Freezers dated 2022, indicated This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines .11. Refrigerators and freezers are kept clean, free of debris, and disinfected with sanitizing solution on a scheduled basis and more often as necessary. 4. During a concurrent observation and interview on 01/22/24 at 10:00 a.m., with Cook, two dry storage bins were not labeled and dated. [NAME] stated she was not aware the dry storage bins were unlabeled and undated. According to the 2022 Federal Food Code, food-contact surfaces are to be clean to sight and touch, and nonfood-contact surfaces of equipment is to be kept free of an accumulation of food residue and other debris. During a review of the facility's policy and procedure (P&P) titled Canned and Dry Good Storage dated 2023, indicated All the food and non-food items purchased by the department of food and nutrition services will be stored properly .9. Metal, plastic containers (with tight fitting lids and NSF approved), .will be used for staples and opened packages of items such as pastas, rice, dry cereals, etc. 5. During a concurrent observation and interview on 01/22/24 at 10:30 a.m., with Cook, five of five selected cutting boards had deep knife cut marks and sticky yellow grime on the surface. [NAME] stated she cleaned the cutting boards earlier today, and agreed the cutting boards were sticky and should have been washed again. [NAME] verified the presence of deep, knife cut marks on the cutting boards. According to the 2022 Federal Food Code, food-contact surfaces are to be clean to sight and touch, and nonfood-contact surfaces of equipment is to be kept free of an accumulation of food residue and other debris. During a review of the facility's policy and procedure (P&P) titled Sanitizing Equipment, food and Utility Carts dated 2023, indicated .4. All kitchen equipment and surfaces which come in contact with food will be cleaned and sanitized after each use. 5. Food and utility carts will be cleaned and sanitized after each meal or use. 555082 Page 14 of 19 555082 01/26/2024 Valley Pointe Nursing & Rehabilitation Center 20090 Stanton Avenue Castro Valley, CA 94546

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm During an observation on 1/24/24 at 7:20 a.m., the entry door was open to the shared room (Room B) of Resident 28 and Resident 149. On the wall adjacent to Room B was a posted sign which indicated, Stop Red Room. Residents Affected - Many During an observation on 1/24/24 at 7:50 a.m., Certified Nursing Assistant 5 (CNA 5), Registered Nurse 2 (RN 2) and Certified Nursing Assistant 3 (CNA 3) were passing the breakfast meal trays from the meal tray delivery cart to resident rooms. RN 2, CNA 3, and CNA 5 entered the Room B without donning PPE. RN 2, CNA 3, and CNA 5 exited Room B and did not perform hand hygiene. During an interview on 1/24/24 at 7:53 a.m., with Infection Preventionist/Director of Staff Development (IP/DSD), IP/DSD stated the residents in Room B (Resident 28 and Resident 149) both had COVID. IP/DSD stated the door to their shared room should be kept closed at all times. IP/DSD stated when the door was not closed there was a risk for the spread of infection to other residents. The facility policy and procedure titled, Coronavirus Disease (COVID-19), revised 3/1/2023, indicated, For a resident with known or suspected COVID-19: Staff working with symptomatic-exposed and isolated residents must wear eye protection during resident care encounters or procedures. Facility will also follow guidance from County Public Health. Eye protection (face shields, goggles) is required as PPE during all resident care during an outbreak and when caring for symptomatic-exposed and isolated residents. For resident with known or suspected COVID-19 staff wear gloves, isolation gown, face shield and N95 or higher-level respirator. Based on observation, interview and record review, the facility failed to implement the facility infection control program policy and procedure for 48 of 48 residents (all facility residents) when: 1. The facility did not report an outbreak of Coronavirus Disease (COVID-19, a respiratory infection which can result in breathing difficulty and other complications, including death.) to the California Department of Public Health (CDPH). This failure had the potential to result in lack of communication and oversight between the facility and CDPH during an infectious disease (COVID-19) outbreak. 2. Four nursing staff: Registered Nurse (RN 2), Certified Nursing Assistants 2, 3, and 5 (CNA 2, CNA 3, and CNA 5) did not use appropriate personal protective equipment (PPE, protective items or garments worn to protect the body or clothing from hazards that can cause injury.) when they entered the posted isolation rooms of residents with COVID-19. These failures had the potential to result in the spread of COVID-19, and COVID-19 related complications, and death. Findings: 1. During an interview on 1/22/24 at 11:29 a.m., with the Infection Preventionist/ Director of Staff Development (IP/DSD), IP/DSD stated the facility had two staff and a total of six residents test positive for COVID-19 at the onset of a COVID-19 outbreak in December. The IP/DSD stated the six residents had tested positive on 12/5/23. IP/DSD stated she did not know if the resident cases of COVID-19 had been reported to CDPH. 555082 Page 15 of 19 555082 01/26/2024 Valley Pointe Nursing & Rehabilitation Center 20090 Stanton Avenue Castro Valley, CA 94546

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a review of the facility line list (a list of residents which indicates their infection status over time) dated 12/5/23, the line list indicated a total of six residents had tested positive for COVID-19. During a review of Resident 30's admission Record, the admission Record indicated Resident 30 was admitted to the facility in September 2023 with acute respiratory failure with hypoxia (inadequate breathing which results in insufficient oxygen supply to the body). During a review of the facility COVID-19 test log dated 12/5/23, the test log indicated Resident 30 had tested positive for COVID-19 on 12/5/23. During an interview on 1/22/24 at 10:15 a.m., with Resident 30, Resident 30 stated she was upset because she had caught COVID at the facility and needed to be transferred to the hospital for treatment. During an interview on 1/23/24 at 1:06 p.m., with the Admin, the Admin stated the COVID-19 outbreak had not been reported to the California Department of Public Health because the Admin thought the facility only needed to report the COVID 19 outbreak to the county (local) public health department. During an interview on 1/23/24 at 1:38 p.m., with the DON, the DON stated she thought the facility was only required to report COVID-19 outbreaks to the county public health department. During a review of the facility policy and procedures (PNP) titled, Infection Control Policies and Procedures, revised October 2018, the PNP indicated, The objectives of our infection control policies and practices are to prevent, detect, investigate, and control infections in the facility The facility reports confirmed COVID-19 infections, along with other communicable disease data to the local and state health department as required by state law. 2. During an observation on 1/22/24 at 12:13 p.m., in the hallway of the Red Zone (an area dedicated to quarantined residents with active COVID-19 infections), CNA 2 picked up a meal tray from the lunch tray delivery cart and entered resident Room A without performing hand hygiene, or wearing gloves, gown, or face mask. Posted on the wall adjacent to the entry door of Room A were two signs. One sign indicated, STOP- Contact/Airborne isolation, (Airborne precautions are actions taken to prevent or minimize the transmission of infectious agents/organisms that remain infectious over long distances when suspended in the air. These infectious particles can remain suspended in the air for prolonged periods of time and can be carried on normal air currents in a room or beyond, to adjacent spaces or areas receiving exhaust air. Contact precautions are measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment.) the sign indicated visitors/staff upon entering the room, were to don face shield and N95 respirator (N95 respirators are barrier face coverings that offer particle filtration and protection from fluids), perform hand hygiene, and don gown and gloves. The sign indicated visitors/staff exiting the room were to doff gown and gloves and perform hand hygiene. The second sign indicated, Red Zone. You must wear the following PPE when entering this room: N95 respirator, gown, gloves, eye protection (glasses or goggles and face shield). In the hallway adjacent to the entry door of Room A was a cart stocked with gowns, gloves, face shields, and N95s. CNA 2 exited Room A without performing hand hygiene and returned to the meal tray cart area. During an interview on 1/22/24 at 12:13 p.m., with CNA 2, CNA 2 stated the residents in Room A had COVID-19, so gowns, gloves, and a face shield should be worn when entering the residents' room. CNA 555082 Page 16 of 19 555082 01/26/2024 Valley Pointe Nursing & Rehabilitation Center 20090 Stanton Avenue Castro Valley, CA 94546

F 0880 2 stated she had forgotten to don the necessary PPE when delivering the meal tray to Room A. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 555082 Page 17 of 19 555082 01/26/2024 Valley Pointe Nursing & Rehabilitation Center 20090 Stanton Avenue Castro Valley, CA 94546

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation and interviews, the facility failed to maintain the facility's ventilation system in a safe operating condition when the heating, vacuum, air conditioning (HVAC) in the broiler room did not have the required MERV 13 filtration recommended for healthcare settings during a COVID-19 outbreak. (MERV filters reduces up to 75% of large airborne particles including: dust and lint, dust mite debris, pollen, per dander, mold spores, bacteria and virus carriers). Residents Affected - Many This failure had the potential to spread airborne infections during COVID-19 outbreak. Findings: During an observation and concurrent interview on 1/25/24 at 8:09 a.m., accompanied by Maintenance Supervisor (MS), the filter from the HVAC system in the broiler had black dust in the filter spaces dated 9/6/23. MS stated he was aware the facility had a COVID outbreak. but had not checked the HVAC system. MS stated he had not checked the HVAC system or changed the filters. MS stated the filter in the HVAC is not the required filter for virus, bacteria filtration. MS further stated the MERV 8 filter was the recommended filter. Review of the local county public health recommendations, dated 1/19/24 included use of MERV-13 filter for the facility's HVAC ventilation system. During an interview on 1/25/24 at 10:13 a.m., with Administrator (Admin), Admin stated the filter in the HVAC in the broiler room was not of the required filteration to be used in the facility's HVAC. During a review of facility's policy and procedure (P&P) titled, Maintenance Services, revised December 2009, which indicated; The maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. The recommendation for MER-13 filtration is based on updated recommendations for healthcare settings from the Americans of Heating, Refrigeration, and Air-Conditioning Engineers (ASHORE). If the system cannot tolerate a MER-14 or greater filter, then use the highest rated filter tolerated. {www ventilation-CDPH-Ago}. 555082 Page 18 of 19 555082 01/26/2024 Valley Pointe Nursing & Rehabilitation Center 20090 Stanton Avenue Castro Valley, CA 94546

F 0912 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 12 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 an observation on 1/22/24 at 11:00 am, rooms [ROOM NUMBER] were observed to have four beds in each room. Each room measured less than 80 sq. ft. 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. room [ROOM NUMBER] had 280 sq. ft. and 70 sq. ft. of space per resident. During random observations of care and services from 1/22/24 to 1/26/24, residents and staff never complained about the room size and staff have enough room to do their job. 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. 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 is recommended. 555082 Page 19 of 19