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. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 6 Event ID: 555341 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 555341 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canyon Creek Post-Acute 22103 Redwood Road Castro Valley, CA 94546 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)