Health inspection·February 6, 2020

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement their policy on medication self-administration (resident takes medication without staff assistance) for one of 18 residents (Resident 48) when: Residents Affected - Few 1. The facility did not complete a medication self-administration assessment for Resident 48; 2. The facility did not obtain a physician's order for Resident 48 to self-administer medications; and 3. The facility did not ensure Resident 48's medication was kept in a locked container in his room. These failures had the potential to result in unsafe medication self-administration. Findings: Review of Resident 48's clinical record indicated he was admitted on [DATE] and had the diagnosis of chronic obstructive pulmonary disease (COPD, disease that causes obstructed airflow from the lungs). Review of Resident 48's minimum data set (MDS, an assessment tool), dated 12/23/19, indicated he had a brief interview for mental status (BIMS) score of 13 (a score of 13 to 15 indicates the resident is cognitively intact). During an observation and concurrent interview on 2/4/2020 at 8:47 a.m., Resident 48 was in his room eating breakfast. There was a Xopenex HFA inhaler (a hand held device containing medication that is inhaled to treat wheezing and shortness of breath) on Resident 48's over bed table. Resident 48 stated that he had the medication with him pretty much all the time and that he had been taking the medication for a long time. During an observation on 2/5/2020 at 8:02 a.m., Resident 48 was sitting in his room and the Xopenex HFA inhaler was on his over bed table. During an observation and concurrent interview on 2/5/2020 at 8:39 a.m., Resident 48 was sitting in his room and the Xopenex HFA inhaler remained on his over bed table. Resident 48 stated he had the medication with him since his admission to the facility. Resident 48 further stated he had been using the medication maybe once or twice a week as needed. Resident 48's clinical record was reviewed. There was no assessment indicating Resident 48 was safe to self- administer medications. There was no physician's order for resident 48 to self-administer medications. Also, there was no physician's order for resident 48 to receive Xopenex HFA inhaler as Page 1 of 12 555343 555343 02/06/2020 Saratoga Retirement Community Health Center 14500 Fruitvale Avenue Saratoga, CA 95070

F 0554 needed. Level of Harm - Minimal harm or potential for actual harm During an interview with the clinical nurse manager (CNM) on 2/5/2020 at 8:44 a.m., she explained that if a resident wanted to self-administer medications, the facility would need to do an assessment to determine that the resident was capable of self-administering the medications safely. The CNM also explained resident needed to have a physician's order to self-administer medications and the medications needed to be kept in a locked drawer in the resident's room. Residents Affected - Few During the same interview, the CNM went to Resident 48's room and confirmed he had a Xopenex HFA inhaler that was not kept in a locked drawer. The CNM reviewed Resident 48's clinical record and confirmed the facility did not complete a medication self-administration assessment. The CNM also confirmed Resident 48 did not have a physician's order to self administer medications and did not have an order to receive Xopenex HFA inhaler as needed. Review of the facility's policy, Medication Administration: Self Administration Program, revised 3/2015, indicated a resident's competence must be established with a self-administration of medications assessment. The policy further indicated the resident must have a physician's order to self-administer medications and the medications must be kept secured in the resident's room in a locked container. 555343 Page 2 of 12 555343 02/06/2020 Saratoga Retirement Community Health Center 14500 Fruitvale Avenue Saratoga, CA 95070

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to identify and address potential complications related to indwelling catheter (flexible tube inserted and left in the bladder to drain urine) use for one of four residents (Resident 17). This failure had the potential to negatively affect the resident's health and well-being. Findings: Review of Resident 17's clinical record indicated he was admitted on [DATE] and had the diagnoses of benign prostatic hyperplasia (BPH, prostate gland enlargement that can block the flow of urine out of the bladder) and obstructive uropathy (urine cannot flow out of the bladder due to obstruction). Resident 17's record also indicated he had an indwelling catheter. Review of Resident 17's interdisciplinary (ID, staff from different disciplines who work together to plan and provide care) notes, dated 1/9/2020, indicated Resident 17 came back from a urology (branch of medicine concerned with the function and disorders of the urinary system) appointment where his indwelling catheter was replaced. The ID note further indicated Resident 17's indwelling catheter was draining clear, yellow urine at that time. During an observation on 2/5/2020 at 7:55 a.m., Resident 17 was lying in bed. The urine draining from Resident 17's indwelling catheter was yellow, but it was not clear and it had white sediments. During an interview with the clinical nurse manager (CNM) on 2/6/2020 at 8:13 a.m., she explained that for residents with an indwelling catheter, the urine should be yellow and clear. The CNM further explained that unclear urine with sediments could be an indication of infection. The CNM confirmed that licensed nurses should assess the characteristics of the urine every shift, report any abnormal findings to the resident's doctor, and initiating alert charting (licensed nurses on each shift monitor for specific conditions and document in the clinical record). During an observation and concurrent interview on 2/6/2020 at approximately 8:20 a.m., the CNM went into Resident 17's room and confirmed the urine draining from Resident 17's indwelling catheter was not clear and had white sediments. Certified nursing assistant F (CNA F) was also present in the room while the CNM assessed Resident 17's urine. CNA F stated Resident 17's urine was normally yellow and clear. During an interview and concurrent record review with the CNM on 2/6/2020 at approximately 8:25 a.m., the CNM reviewed Resident 17's clinical record and confirmed there was no documentation indicating the doctor was notified, there was no documentation of alert charting, and there was no other documentation indicating that Resident 17's unclear urine with white sediments had been identified and addressed. Review of Resident 17's indwelling catheter care plan, dated 2/6/2020, indicated to assess for adequate output, color, and odor of the urine. The care plan further indicated to notify the resident's doctor for abnormal urine clarity or consistency. Review of the facility's policy, Catheter: Use of Indwelling Urinary Catheter, revised 1/2020, 555343 Page 3 of 12 555343 02/06/2020 Saratoga Retirement Community Health Center 14500 Fruitvale Avenue Saratoga, CA 95070

F 0690 indicated Assessment should also include ongoing monitoring for changes in condition related to potential CAUTI's [catheter-associated urinary tract infections], recognizing, reporting and addressing such changes. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555343 Page 4 of 12 555343 02/06/2020 Saratoga Retirement Community Health Center 14500 Fruitvale Avenue Saratoga, CA 95070

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure the necessary care and treatment was provided for one of one sampled resident (Resident 64) in accordance with professional standards when the registered nurse (RN) failed to use the proper technique of flushing the peripherally inserted central catheter (PICC, a long, slender, flexible tube inserted into a peripheral vein, typically in the upper arm, and advanced until the catheter tip terminates in a large vein in the chest near the heart to obtain intravenous access) line. Residents Affected - Few The dynamic of the injection flow plays a pivotal role in adequate and correct flushing. Flushing using a so-called push-pause, pulsatile, or turbulent technique enhanced the rinsing effect in the catheter and helps prevent catheter occlusion. Findings: During an observation and concurrent interview on 2/4/2020 at 6:40 a.m. with registered nurse E (RN E), Resident 64's PICC line was flushed after completion of the intravenous Vancomycin (medication for infection) dose. RN E flushed the PICC line using a continuous slow technique with 10 ml. (milliliter, unit of measurement) pre-filled syringe of normal saline solution. RN E confirmed she did not use the push, pause/stop turbulent technique when flushing Resident 64's PICC line. A review of the facility's undated policy and procedure, Catheter Insertion and Care, indicated flushing to maintain patency of catheter includes slowly administer appropriate amount of normal saline flush using the push-pause technique. 555343 Page 5 of 12 555343 02/06/2020 Saratoga Retirement Community Health Center 14500 Fruitvale Avenue Saratoga, CA 95070

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to consistently complete post dialysis (the clinical purification of blood as a substitute for the normal function of the kidney) assessments on the Nursing Facility/Dialysis Center Communication Report for one resident (Resident 17) who received dialysis services. Failure to assess had the potential to compromise the facility's ability to identify and address potential complications after dialysis. Residents Affected - Few Findings: Review of Resident 17's clinical record indicated he was admitted on [DATE] and had the diagnosis of end stage renal disease (kidneys are no longer able to work as they should to meet the body's needs). The clinical record further indicated Resident 17 received dialysis on Mondays, Wednesdays and Fridays. Review of Resident 17's dialysis binder indicated the Nursing Facility/Dialysis Center Communication Report was not completed consistently. The bottom portion that was to be completed by facility nurses upon Resident 17's return from dialysis was left blank. This portion was to be completed with information including the time the resident returned to the facility, his vital signs (temperature, heart rate, respirator rate and blood pressure) upon returning to the facility, assessment of the dialysis access site, any changes in orders, and whether the doctor was notified of these changes. This portion of the Nursing Facility/Dialysis Center Communication Report was left blank on 11/1/2019, 11/8/2019, 12/6/2019, 12/13/2019, 12/20/2019, 12/27/2019, 1/10/2020, 1/31/2020, 2/3/2020, and one other day in which the facility nurse did not fill out the date (total of ten days). During an interview and concurrent record review with the clinical nurse manager (CNM) on 2/6/2020 at 11:26 a.m., she reviewed Resident 17's dialysis binder and confirmed the facility nurses did not consistently complete the Nursing Facility/Dialysis Center Communication Report. The CNM acknowledged the nurses should have completed the bottom section of the report when Resident 17 returned from dialysis. Review of the facility's policy, Dialysis Services, revised 8/2013, indicated the plan of care shall include follow-up care, observation and monitoring. 555343 Page 6 of 12 555343 02/06/2020 Saratoga Retirement Community Health Center 14500 Fruitvale Avenue Saratoga, CA 95070

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review, the facility failed to ensure controlled medications had been accurately accounted for one of four Controlled Drug Medication Carts, that were checked, when the licensed nurse did not timely document/log the morphine sulfate (MSO4- opioid pain medication) that was dispensed and administered to Resident 25. This failure had the potential to create problems related to accounting of controlled medications. Findings: During an inspection of Nursing Station 1's medication cart on 2/3/2020 at 1:37 p.m., with registered nurse C (RN C), RN C confirmed MSO4 solution indicated an amount of less than 21 ml. (milliliter, unit of measurement) remaining in the bottle. During the concurrent review and interview with RN C, the Narcotic Count Sheet # 045 for MSO4 indicated the amount should be 21.25 ml. RN C asked the licensed nurses who worked in Station 1 and confirmed/verified licensed vocational nurse D (LVN D) administered the medication to Resident 25. The Narcotic Count sheet #045 and the medication administration record (MAR) did not indicate MSO4 was dispensed and administered to Resident 25. RN C stated, any controlled medication dispensed should be recorded as soon as medication was dispensed and documented in the MAR once given. A review of the facility's revised 2/2015 policy and procedure, Medication Administration-Controlled Drugs, indicated when a controlled medication is administered, the person administering the medication must record on the narcotic record form or narcotic record book the date, time, the amount administered, the amount remaining, and sign the sheet. 555343 Page 7 of 12 555343 02/06/2020 Saratoga Retirement Community Health Center 14500 Fruitvale Avenue Saratoga, CA 95070

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a monthly review of antipsychotics (drugs used to treat mental health disorders) and psychotropics (drugs that affect behavior, mood, thoughts or perception) by a licensed pharmacist for one of five residents (Resident 3) reviewed for unnecessary medications, which had the potential to result in the physician not acting upon the medication irregularities. Findings: During review of Resident 3 's clinical record, Resident 3 was admitted on [DATE] with diagnoses included dementia (memory loss), anxiety, depression and pseudobulbar affect (PBA, uncontrollable laughing or crying). During review of Resident 3 's physician order dated 11/06/18, indicated the following antipsychotics and psychotropics: (1) Geodon (antipsychotic) 20 milligram (mg, unit of dose) po (by mouth). Give 1 capsule (cap) po q (every) 12 hours for psychotic disorder with delusion due to known physiological condition. (2) Nuedexta (drug to treat PBA) 20/10 mg - 1 cap by mouth for inappropriate uncontrollable laughing & screaming. (3) Wellbutrin SR (Bupropion HCl, psychotropic) 100 mg tablet sustained release for depression manifested by reduced social interaction. (4) Paxil 20 mg tablet (Paroxetine HCl, psychotropic) 1 tab by mouth for anxiety manifested by (m/b) inappropriate verbal sexual advances towards staff and resisting help with activities of daily living (ADLs). During review of Resident 3's monthly drug regimen review record for the period of 1/2019 to 12/2019 revealed no recommendations written by licensed pharmacist showed for Resident 3's use of Geodon, Nuedexta, Wellbutrin and Paxil. During interview with the registered pharmacist (RPh) on 2/6/2020 at 11:07 a.m., RPh stated he did not conduct a monthly drug review of Resident 3's antipsychotics and psychotropics for the period of 1/2019 to 12/2019. RPh also stated that the physician who prescribed the medications did not respond to pharmacy note on 2/15/19. During review of the facility's policy and procedure (P&P), Psychotropic Medication Management revised date 9/2018, indicated 6. Evaluation and Medication Review: .b. The Pharmacist will review each resident's medication regimen at least once a month. C. The pharmacy medication review recommendation will be acted upon in a timely manner . 555343 Page 8 of 12 555343 02/06/2020 Saratoga Retirement Community Health Center 14500 Fruitvale Avenue Saratoga, CA 95070

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of five residents reviewed was free from unnecessary psychotropics, when: (1) There was no adequate indication for Resident 3's use of Geodon, Neudexta, Wellbutrin and Paxil, and (2) There was no GDR (gradual dose reduction) attempts in two separate quarter within the first year for Geodon, Wellbutrin and Paxil. These failures had the potential to cause medication adverse effects. Findings: 1. During review of Resident 3 's clinical record, Resident 3 was admitted on [DATE] with diagnoses included dementia (memory loss), anxiety, depression and pseudobulbar affect (uncontrollable laughing or crying). During review of Resident 3 's physician order dated 11/06/18, indicated the following antipsychotics and psychotropics: (1) Geodon 20 milligram (mg, unit of dose) po (by mouth). Give 1 capsule po q (every) 12 hours for psychotic disorder with delusion due to known physiological condition. [Date started 11/06/18]. (2) Neudexta 20/10 mg - 1 cap by mouth for pseudo bulbar affect (inappropriate uncontrollable laughing & screaming). [Date started 12/18/19]. (3) Wellbutrin SR (Bupropion HCl) 100 mg tablet sustained release for depression manifested by reduced social interaction. [Date started 11/23/18]. (4) Paxil 20 mg tablet (Paroxetine HCl) 1 tab by mouth for anxiety m/b inappropriate verbal sexual advances towards staff and resisting help with activities of daily living (ADLs). [Date started 10/31/18] During an observation with Resident 3 on 2/4/2020 at 1:20 pm, Resident 3, while lying on bed, was alert, oriented and with irregular periods of tongue movement. During review of Resident 3's behavioral monitoring record dated 11/2018 to 2/2019, indicated the following: (1) There was no targeted behavior for the use of Geodon. Hence, behavior log for 11/18 revealed there was no documented indication for the initiation of or prescribing Geodon. (2) Nuedexta was indicated for uncontrollable laughing and screaming. However, behavior log for 12/18 revealed there was no documented indication for the initiation of or prescribing Nuedexta. (3) Wellbutrin was indicated for depression as m/b reduced social interaction. However, behavior log for the month of 11/2018 revealed only one episode on 11/01/18, 11/18/18 and 11/19/18. (4) Paxil was indicated for anxiety m/b inappropriate verbal sexual advances towards staff and resisting help with ADLS. However, behavior logs for 11/18 revealed staff were able to redirect the resident. During an interview with LVN G on 02/04/2020 at 4:25 pm, LVN G stated Resident 3 did not manifest any disruptive behaviors in the past. LVN G also stated Resident 3 did not have any uncontrollable laughing nor screaming during his encounters with him. During an interview with CNA H on 2/04/20 at 4:26 pm, CNA H stated there was only one incident she could recall with Resident 3 when he screamed but after he was redirected he kept quiet. During interview with the CNM (clinical nurse manager) on 02/05/2020 at 09:20 a.m., the CNM confirmed the behavior log had no documented clear indication for the initiation of or prescribing Geodon, 555343 Page 9 of 12 555343 02/06/2020 Saratoga Retirement Community Health Center 14500 Fruitvale Avenue Saratoga, CA 95070

F 0758 Nuedexta, Wellbutrin and Paxil. Level of Harm - Minimal harm or potential for actual harm During an interview with the physician (MD) on 2/6/2020 at 10:30 a.m., the MD acknowledged the indications written for those psychotropic were off-label use. The MD stated his behaviors were a mess and behavior parameters for each medication should have been clarified. Residents Affected - Few 2. During a review of Resident 3's clinical record, there was no evidence of physician justification related to GDR's clinical contraindications for use of Geodon, Wellbutrin and Paxil, in two separate quarter within the first year. During an interview with the CNM on 2/05/2020, at 9:21 a.m., the CNM confirmed there was no evidence of physician justification related to GDR's clinical contraindications for use of Geodon, Wellbutrin and Paxil. During an interview with the RPh on 2/6/2020, at 11:07 a.m., RPh stated he was not able to write GDR recommendation for the psychotropic. RPh also stated the GDR should have started with Geodon last 2/2019. During an interview with the MD on 2/6/20 at 10:30 a.m., the MD stated it would be hard to tell which of those medications to reduce first because there were no clear behavior parameters for each of the psychotropic. During a review of the facility's policy and procedure (P&P), Psychotropic Medication Management, revised date 9/2018, indicated 4. Duration: a. Antipsychotic GDR/Tapering will be initiated and continued as follows: a.1. First year after admission or initiation: GDR/tapering in two separate quarters with at least one month in between, unless clinically contraindicated. a.2. After first year: GDR annually, unless clinically contraindicated. 555343 Page 10 of 12 555343 02/06/2020 Saratoga Retirement Community Health Center 14500 Fruitvale Avenue Saratoga, CA 95070

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility had a 6.45 percent error rate when two medication errors out of thirty-one opportunities were observed during a medication pass. Residents Affected - Few These failures resulted in the medications not being administered according to the physician's orders and manufacturer's specifications. Findings: A review of Resident 43's physician order indicated Fluticasone (medication used to treat nasal congestion, sneezing, runny nose, and itchy or watery eyes caused by seasonal or year-round allergies) 50 mcg. (micrograms, unit of measurement) nasal spray inhale one spray to each nostril every day for allergy. During the medication pass observation on 2/4/2020 at 10:27 a.m., licensed vocational nurse A (LVN A) had allowed Resident 43 to administer two sprays per nostril. During the medication reconciliation on 2/4/2020 at 12:13 p.m. with LVN A, she confirmed the above observation and reviewed Resident 43's physician's order that indicated one nasal spray per nostril. LVN A stated the physician's order was not followed and wrong dose was given. A review of Resident 56's physician's order indicated Timolol (eye drop solution to reduce pressure in the eyes) 0.25% eye drops one drop both eyes. During the medication pass observation on 2/3/2020 at 9:00 a.m., licensed vocational nurse B (LVN B) administered one drop to both eyes of Resident 56. Resident 56 was provided with a previously used tissue paper to rub and wipe his eyes right away. During the concurrent interview with LVN B, she confirmed the above observation and stated she should have instructed Resident 56 to close and not rub his eyes to ensure effectiveness of the eye medication administered. During a review of the revised facility's 2/2015 policy, Medication and Treatment Administration, indicated medications shall be administered as prescribed and observe the seven rights of medications that includes .right dose, and right manufacturer/pharmacy recommendations. 555343 Page 11 of 12 555343 02/06/2020 Saratoga Retirement Community Health Center 14500 Fruitvale Avenue Saratoga, CA 95070

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and document review, the facility failed to ensure food was stored and prepared under sanitary conditions when kitchen staff used expired test strips to test the kitchen surface sanitizer and scooped ice from ice machine not using ice scooper. These failures had the potential to spread food-borne illness to 69 of 72 residents who received food from the kitchen. Findings: During an observation on 2/3/2020 at 10:22 a.m., accompanied by the registered dietician (RD), one kitchen aide (KA) demonstrated kitchen surface sanitizer test with an expired test strips. The RD confirmed the Ecolab sanitizer 146 multi quart strip test strips had 3/31/2018 expiration date. The RD disposed of the expired strips and brought an unopened strip dated 11/30/2020. Both staff stated expired strips should not be used because readings could be inaccurate. During an observation on 2/3/2020 at 11:28 a.m., the nutritional aide (NA) used a big white pitcher to scoop ice from the ice machine, and her gloved right hand and bare arm touched the ice in the ice machine. The NA confirmed this observation when this was reported to the dietary supervisor (DS), Chef and RD. Both the DS and RD counseled the staff and stated staff should use the ice scooper at all times to prevent possible contamination. 555343 Page 12 of 12