Health inspection·January 30, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff performed hand hygiene and wore gloves during eye drop administration for 1 (Resident #35) of 6 residents observed for medication administration. Residents Affected - Few Findings included: A facility policy titled, Infection Prevention & Control Program, revised 01/2024, indicated, Treat all human blood, bodily fluids and other potentially infectious materials as if they are infections. SP [standard precautions] include but are not limited to hand hygiene; use of gloves, gowns, masks, eye protection or face shields when contact with any blood or moist body fluids (secretions and excretions) is likely, room placement; injection and medication safety practices, respiratory hygiene/cough etiquette; environmental cleaning and disinfection; and safe management of textiles and laundry. A policy titled, Medication Administration Eye Drops, dated 01/2023, indicated, Policy To administer ophthalmic solution into eye in a safe and accurate manner. The policy specified, 8. With a gloved finger, gently pull down lower eyelid to form pouch, while instructing resident to look up. An admission Record revealed the facility admitted Resident #35 on 11/17/2023. According to the admission Record, the resident had a medical history that included diagnoses of Alzheimer's disease with late onset, unspecified visual loss, and bilateral, severe primary open-angle glaucoma. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/20/2025, revealed Resident #35 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. Resident #35's care plan included a focus area initiated 11/18/2023, that indicated the resident had impaired visual function related to glaucoma and visual loss. Interventions directed staff to administer medication as ordered. Resident #35's Order Summary Report which contained active orders as of 01/28/2025, revealed an order dated 11/18/2023, for timolol maleate ophthalmic solution 0.5 %, instill one drop in both eyes one time a day for glaucoma. During medication administration observation on 01/28/2025 at 8:27 AM, Licensed Vocational Nurse (LVN) #2 instilled one drop of timolol maleate ophthalmic solution in each of Resident #35's eyes. On 01/28/2025 at 8:29 AM, LVN #2 stated she did not wash or sanitize her hands and did not wear gloves when she administered eye drops to Resident #35. LVN #2 stated gloves should be worn during eye drop administration to help prevent infections. On 01/29/2025 at 10:04 AM, the Director of Staff Development stated nurses were expected to follow the facility infection control policy, to include handwashing and glove use during administration of eye drops. On 01/29/2025 at 1:48 PM, the Director of Nursing (DON) stated nurses were expected to complete hand hygiene prior to and after care. The DON stated nurses must wear gloves during eye drop (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555156 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555156 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Webster House 437 Webster Street Palo Alto, CA 94301 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 administration due to the potential contact with mucous membrane. Level of Harm - Minimal harm or potential for actual harm On 01/30/2025 at 9:22 AM, the Executive Director stated the expectation was for the facility nurses to wear gloves and wash their hands when it was required. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555156 If continuation sheet Page 3 of 3