Health inspection·January 30, 2025

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, record review, and facility policy review, the facility failed to ensure medications were properly stored for 1 (Resident #31) of 6 residents observed for medication administration. Findings included: A facility policy titled, Storage of Medication, dated 01/2024, indicated, The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. An admission Record revealed the facility admitted Resident #31 on 09/29/2017. According to the admission Record, the resident had a medical history that included diagnoses of essential hypertension and hemiplegia and hemiparesis following cerebral infarction. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/17/2024, revealed Resident #31 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. During medication administration observation on 01/28/2025 at 8:35 AM, Licensed Vocational Nurse (LVN) #2 left medication that belonged to Resident #31 in a medication cup on top of an unattended medication cart when she left the unit to find another nurse. On 01/28/2025 at 8:46 AM, LVN #2 stated Resident #31 medications were left in a cup unsecured on top of the medication cart and confirmed she walked away, and the medication cart was out of her sight. On 01/29/2025 at 10:04 AM, the Director of Staff Development stated medications should be secured and under the supervision of a licensed personnel. On 01/29/2025 at 1:48 PM, the Director of Nursing (DON) stated the nurses must not leave medications unattended. Per the DON, nurses must ensure medications were locked and secured when they stepped away from the medication cart. On 01/30/2025 at 9:22 AM, the Executive Director stated the expectation was for nurses not to leave medication unsecured. Page 1 of 3 555156 555156 01/30/2025 Webster House 437 Webster Street Palo Alto, CA 94301

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 555156 Page 2 of 3 555156 01/30/2025 Webster House 437 Webster Street Palo Alto, CA 94301

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 555156 Page 3 of 3