Health inspection·July 23, 2021

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interviews and record review, the facility failed to ensure one (Resident 20) of 12 sampled residents were free from unnecessary drugs when the interdisciplinary team did not evaluate Resident 20's use of Quetiapine {(seroquel) an antipsychotic drug} for appropriateness, adequate clinical rational and indication for continued usage. This failure had the potential for Resident 20 to receive unnecessary drugs and suffer adverse medication side effects. Findings: During a review of Resident 20's Physician Orders (PO) dated 7/9/20, the PO indicated Quetiapine (Seroquel) 50 mg(milligrams) tablet by mouth in the evening for Bipolar (A disorder associated with episodes of mood swings ranging from depressive lows to manic highs). During a review of the Annual Minimum Data Set - (MDS - an assessment screening tool used to guide care), dated 5/9/21, indicated Resident 20's Basic Interview of mental status (BIMS) score was 01 meaning poor cognitive impairment. Resident 20 had no delusions or hallucinations and had not exhibited wandering. Resident 20's diagnoses included Alzheimer's Dementia (loss of mental ability severe enough to interfere with normal activities of daily living). During a review of the Medication Administration Record (MAR), dated May, June and July 2021, indicated Resident 20 was administered Seroquel 50 mg tablet by mouth in the evening for behavior manifestations(abstract ideas) that included screaming, yelling, wandering and combativeness. During a review of the behavior care plan initiated 1/4/2020 ,indicated Resident 20 had Alzheimer dementia (memory disorders) with behavior of wandering, entering offices, resident rooms, combative and hitting staff. During an interview on 7/21/21, at 11:30 a.m., Certified Nursing Assistant (CNA1) stated Resident 20 was Spanish speaking and was able to communicate. CNA1 stated Resident 20 was pleasantly confused, and able to feed herself. CNA1 stated Resident 20 wanders in and out of rooms. During an interview on 7/21/21, at 12:56 p.m., the Director of Nursing (DON) stated he would need to clarify the order with the physician. DON stated staff had not met to review Resident 20's use of psychotropic medication since 2020 because of COVID-19 pandemic. Page 1 of 6 555341 555341 07/23/2021 Canyon Creek Post-Acute 22103 Redwood Road Castro Valley, CA 94546

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 7/22/21, at 9:11 a.m., the Director of Nursing (DON), stated Interdisciplinary Team ( multiple disciplines) (IDT) did not evaluate Resident 20's use of Seroquel for appropriate clinical indication. According to the manufacturer, Seroquel is not approved for use in older adults with dementia-related psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Although causes of death varied, most of the deaths appeared to relate to cardiovascular (e.g. heart failure, sudden death). [Reference: https://www.drugs.com/pro/seroqueul.html]. 555341 Page 2 of 6 555341 07/23/2021 Canyon Creek Post-Acute 22103 Redwood Road Castro Valley, CA 94546

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interviews and record review the facility failed to ensure the person designated to serve as Dietary Supervisor (DS) of food and nutrition services had the federal and/or state educational qualifications for the position. This deficient practice had the potential for lack of competency and skill set necessary to carry out all the functions of the food and nutrition services. Findings: During an interview with DS on 7/20/21, at 9:06 a.m., (DS) stated she did not have a dietary supervisor certificate. DS stated she was enrolled in a dietary program. DS stated the Registered Dietitian (RD) visits the facility twice a month to complete residents' nutrition assessments, review weekly weights and inspects kitchen sanitation. During an interview with Registered Dietician (RD) on 7/20/21, at 11:27 a.m., RD stated she was not full time staff at the facility. RD stated she visits the facility twice a month as a contracted Dietician Consultant. RD stated her responsibilities included review of admissions, significant weight changes, and inspect kitchen sanitation During an interview with Administrator (ADMIN) on 7/22/21, at 10:00 a.m., Admin stated the DS had no certificate as dietary supervisor but was enrolled in school. Admin stated the facility had a dietician that visits twice a month. 555341 Page 3 of 6 555341 07/23/2021 Canyon Creek Post-Acute 22103 Redwood Road 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 Based on observation, interviews and record review the facility failed to ensure food was served at a safe temperature when during lunch tray line curry lemon chicken was not served at appropriate temperature. Residents Affected - Few This deficient practice placed residents at risk of non appetizing food temperature and a potential for food borne illness. Findings: During tray line observation on 7/20/21, at 11:08 a.m., the [NAME] (CK) in the presence of the Dietary Supervisor (DS) and Registered Dietician (RD) prepared and served for lunch mashed potato with gravy, curry chicken and puree chicken . The curry chicken's temperature was 146 -151 degrees Fahrenheit (F). During an interview on 7/20/21, at 11:27 a.m., the RD stated the chicken temperature of 145-151 degree (F) could be served but stated the chicken may be cold by the time it got to the resident. During an interview on 7/20/21, at 11:39 a.m., CK stated he had adjusted the oven to 180 to 200 degrees when cooking the chicken and he was sorry. During an interview on 7/21/21, at 12:08 p.m., DS stated the CK adjusted the oven down to 180 degrees, DS stated kitchen staff are not expected to adjust the oven gauge. DS said the CK was nervous that was why the gauge was turned down to 180 instead of 200 degrees. Review of the facility record titled, Recipe: Curry Lemon Chicken; indicated , Internal temperature must reach 165 F for 15 seconds when cooking. Serve on trayline at the recommended temperature of 160-180 degree F. 555341 Page 4 of 6 555341 07/23/2021 Canyon Creek Post-Acute 22103 Redwood Road Castro Valley, CA 94546

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interviews and record review, the facility failed to store and prepare food under sanitary conditions when the hand washing sink had a pinkish brownish substance around the faucets and the trash cart had a brownish substance around the open area. These failures had the potential to result in food borne illnesses. Findings: During the initial tour of the kitchen on 7/19/21, at 9:33 a.m., accompanied by the Dietary Supervisor (DS), the hand washing sink was observed with pinkish brownish substance around the faucet and one trash can with brownish substance around the open area. During an interview on 7/19/21, at 9:33 a.m., DS stated the pinkish material accumulated around the faucet may be dirt or mold. During an interview on 7/21/21, at 12:08 p.m., DS stated dietary staff are expected to keep the hand washing sink and other items in the kitchen clean, but staff are not particularly assigned to clean the hand washing sink. 555341 Page 5 of 6 555341 07/23/2021 Canyon Creek Post-Acute 22103 Redwood Road 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 and interviews, the facility had two resident (Rt) rooms (Rooms A and B) with multiple beds that provided less than 80 square feet (sq. ft) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents' belongings. Findings: During an observation on 7/22/21, at 8:38 a.m., the following rooms and corresponding square footage (sq. ft) per bed were identified: Room Activity Room Size Floor Area A Rt room [ROOM NUMBER].5 sq. ft 79.08 sq. ft/bed B Rt room [ROOM NUMBER].52 sq ft 79.56 sq. ft/bed During random observations of care and services from 7/19/21, to 7/22/21, there was sufficient space for the provision of care for the residents in all rooms. There were no heavy equipment kept in the rooms that might interfere with residents care. Each resident had personal space and privacy. There were no complaints from residents regarding insufficient space for their belongings There were no negative consequences attributed the decreased space and safety concerns in the seven rooms. During an interview on 7/22/21, at 8:55 a.m., Resident 4 and 18 stated they had enough space in room B for privacy and provision of care. During an interview on 7/22/2,1 and 9:51 a.m., Certified Nursing Assistant (CNA 2), stated there was enough space for providing residents care in room A and 15. CNA 2 stated residents in room A and B are ambulatory. 555341 Page 6 of 6