Health inspection·October 21, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview, and record review, the facility failed to ensure respect and dignity was maintained for two residents (Residents 12 and 42) when staff provided feeding assistance while standing. This failure had the potential to affect the emotional and psychosocial well-being of the residents. Findings: 1. Review of Resident 12's minimum data set (MDS, an assessment tool) dated 7/25/22 indicated her cognition was moderately impaired and she needed one-person physical assistance for eating. During a lunch meal observation on 10/17/22 at 12:18 p.m., Resident 12 was sitting in her wheelchair in her room. Certified nursing assistant B (CNA B) stood beside her while providing spoon-feeding assistance to Resident 12. During a concurrent interview with CNA B she confirmed she was standing while feeding Resident 12. She stated she should be sitting down when she feeds the residents. During an interview with the director of staff development (DSD) on 10/18/22 at 10:35 a.m., he stated he provides inservices to nursing staff and staff are trained to be at eye level when they are feeding residents. The DSD stated when residents are in the wheelchair, staff should be seated in a chair and at eye level with the resident. Review of an Inservice Lesson Plan dated 8/17/22, indicated Proper feeding to the residents was a topic covered in the inservice. A checklist for this skill included being positioned at eye level with the resident. CNA B had signed the attendance sign in sheet for the inservice on 8/17/22. 2. During a breakfast meal observation on 10/18/22 at 9:02 a.m., CNA E was observed standing over Resident 42 while feeding. During an interview with CNA E on 10/18/22 at 9:02 a.m., CNA E confirmed she was standing while feeding Resident 42 and stated she should sit down when feeding the residents. During an interview with the DSD on 10/18/22 at 10:33 a.m., the DSD confirmed staff should sit down and be at eye level with the residents. Review of facility's Caregiver/CNA Competency Checklist Skill: Dining Room included 11. Sit next to residents while assisting them to eat, rather standing over them. Page 1 of 11 555343 555343 10/21/2022 Saratoga Retirement Community Health Center 14500 Fruitvale Avenue Saratoga, CA 95070

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for one of four sampled residents (Resident 39). This failure had a potential to endanger the health or safety of the resident. Residents Affected - Few Findings: A review of Resident 39's admission Record indicated that Resident 39 was admitted with diagnoses including sequelae (a condition which is the consequence of a previous disease or injury)of cerebral infarction (A lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), multiple sites of muscle wasting and atrophy (body tissue or an organ waste away), need for assistance with personal care, and pain in the left arm. A review of Resident 39's Minimum Date Set (MDS, a standardized assessment tool) dated 10/22 indicated her cognition was intact. During an observation on 10/18/2022 at 12:44 P.M., in Resident 39's room, Resident 39 was sitting in her wheelchair with the bed to her left. The call light was placed on the bed. Resident 39 was reaching for the call light with her right hand but could not get it. Resident 39 stated her left side was weak and she could not move her left arm. She further stated the call light was placed too far for her right hand to reach. During a concurrent observation and interview with the Licensed Vocational Nurse (LVN) D on 10/18/2022 at 12:46 P.M., in resident 39's room. The LVN D confirmed that Resident 39 could not reach the call light with her right hand when the light was placed on her left weak side, and he stated the call light should be within reach all the time. During an interview with the Director of Nursing (DON) on 10/21/2022 at 9:30 A.M., the DON stated the call light should be placed on residents' strong side and should be within reach all the time. A review of the facility's Policy revised on 1/2020 titled Call light indicated it is the policy of the company to assure that residents always have a method of calling for assistance and that staff answers the residents' calls in a timely and professional manner .when leaving the room, place the call light within easy reach of the resident in bed or chair. 555343 Page 2 of 11 555343 10/21/2022 Saratoga Retirement Community Health Center 14500 Fruitvale Avenue Saratoga, CA 95070

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 provide care and service in accordance with professional standards of practice for four of 16 sampled residents (Resident 33, 28, 21 and 9) when: Residents Affected - Few 1. Resident 33's dermasaver to legs and wound dressing on left second toe were not administered as ordered; 2. staff did not document behavior observation and medication side effects monitoring on time for Resident 28, 21, and 9. These failures had the potential to affect the residents' care and jeopardize their health and well-being. Findings: 1.a. Review of Resident 33's clinical record indicated she was admitted [DATE] and had the diagnoses of pneumonia (lung infection), peripheral vascular disease (PVD, a condition in which narrowed blood vessels reduce blood flow to the limbs), scabies (a skin condition caused by the mites), seborrheic dermatitis (a skin disease that causes a rash), and squamous cell carcinoma of skin of upper/lower limb (a type of skin cancer of arm/leg). Review of Resident 33's physician order dated 9/30/22, indicated Wound care to left second digit toe r/t PVD: 1. Cleanse with normal saline. 2. Pat dry. 3. Apply gentamycin. 4. Cover with calcium alginate. 5. Secure with dry dressing. As needed for wound care AND every day shift. During an observation on 10/18/22 at 11:47 a.m. in Resident 33's room, while Resident 33 was sitting up in her wheelchair, the resident had an open wound on her left second toe with clear drainage. There was no treatment dressing observed on left second toe wound. During an observation on 10/18/22 at 3:18 p.m., while Resident 33 was lying in her bed, there was dried blood stains on the top bed sheet and no treatment dressing observed on the left second toe wound. During a concurrent observation and interview with registered nurse F (RN F) on 10/18/22 at 3:18 p.m., RN F confirmed the observation. RN F further reviewed Resident 33's physician order and confirmed Resident 33 should have the treatment dressing on her left second toe wound. During a concurrent interview and record review with licensed vocational nurse G (LVN G) on 10/18/22 at 3:24 p.m., LVN G stated she did not do Resident 33's left second toe wound treatment today. LVN G further reviewed Resident 33's physician order and confirmed Resident 33 should have the treatment dressing on her left second toe wound. 1.b. Review of Resident 33's physician order dated 9/02/22, indicated Apply Geri sleeves to upper extremities and dermasaver to lower extremities daily due to prone to bruising easily, severe fragile skin related to PVD. During an observation on 10/20/22 at 10:20 a.m. in Resident 33's room, while Resident 33 was 555343 Page 3 of 11 555343 10/21/2022 Saratoga Retirement Community Health Center 14500 Fruitvale Avenue Saratoga, CA 95070

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sitting up in her wheelchair, she was wearing the Geri sleeves to arms, but there was no dermasaver applied to legs. During a concurrent observation and interview with LVN D on 10/20/22 at 10:31 a.m., LVN D confirmed the observation. LVN D further reviewed Resident 33's physician order and confirmed Resident 33 should have the dermasaver applied to legs. During an interview with the director of nursing (DON) on 10/20/22 at 12:08 p.m., the DON acknowledged Resident 33 should have the dermasaver applied to legs and stated she could not find the dermasaver in the resident's room. Review of the facility's policy Medication and Treatment Administration, revised 01/2020, indicated, Medications and treatments shall be administered as prescribed. 2. A review of Resident 28's October Medication Administration Record (MAR) indicated behavior monitoring related to depression, behavior monitoring related to delusion( a belief or altered reality that is persistently held despite evidence or agreement to the contrary, generally in reference to a mental disorder), side effects monitoring for anticoagulant(commonly known as blood thinner, a chemical substance that prevents or reduces coagulation of blood, prolonging the clotting time) medication, antidepressant medication and antipsychotic(a class of psychotropic medication primarily used to manage psychosis, principally in schizophrenia but also in a range of other psychotic disorders.) medication were not documented on 10/12/2022 evening shift. A record review of Resident 21's October MAR indicated behavior monitoring related to depression and side effects monitoring related to anticoagulant medication were not documented on the 10/12/2022 evening shift. A record review of Resident 9's October MAR indicated behavior monitoring related to depression and side effects monitoring related to antidepressant medication were not documented on the 10/12/2022 evening shift. During a phone interview with the Licensed Vocational Nurse (LVN) I on 10/20/2022 at 1:45 P.M., she stated that she forgot to document the monitoring for medication side effects and behavior observation for station 3 residents, including Resident 28, Resident 9, and Resident 21 on 10/12/2022 evening shift. During an interview with the Assistant Director of Nursing (ADON) on 10/21/2022 at 9:30 A.M., the ADON confirmed the above missed documentations and stated that the staff should finish the documentation on time. A review of the facility's Policy revised 1/2020 titled Documentation indicated all documentation is expected to be legible (if handwritten), accurate, understandable, timely, pertinent, and held in confidence. A review of the facility's Policy revised 6/2021 titled Psychotropic Medication Management indicated monitoring and accurate documentation of the resident's response to the medication and evaluation of the effectiveness of any non-pharmacological approaches. 555343 Page 4 of 11 555343 10/21/2022 Saratoga Retirement Community Health Center 14500 Fruitvale Avenue Saratoga, CA 95070

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation on 10/17/22 at 9:40 a.m., Resident 1 was in his wheelchair with a Wanderguard (a device that activates an alarm when a resident attempts to leave a safe area) on his right ankle. Resident 1 was going and up and down the hallway by self propelling his wheelchair with his legs. Review of Resident 1's clinical record indicated he was admitted on [DATE] with diagnoses of dementia (a decline in mental capacity affecting daily function), depression, weakness, unsteadiness on feet, and abnormalities of gait (manner of walking) and mobility. Review of Resident 1's Minimum Data Set (MDS, assessment tool), dated 7/10/22, indicated Resident 1 had severely impaired cognitive skills for daily decision making and for activities of daily living (ADL) he required extensive assistance on transfer, walking in room and corridor, and locomotion on and off unit. Review of Resident 1's Wandering Risk Assessment, dated 10/7/22, indicated Resident 1 was at moderate risk for wandering (wandering resident, actively and purposely looks to leave a facility or inadvertently attempts to leave a facility due to a cognitive impairment). Review of Resident 1's care plan Resident wanders/at risk for elopement dated 7/5/21, indicated to monitor Wanderguard alarm and document and trend resident's wandering behavior. During an interview with licensed vocational nurse A (LVN A) on 10/19/22 at 9:26 a.m., she stated Resident 1 had a Wanderguard device on his right ankle and if he went out of any exit door the device would alarm. When asked how staff ensures the device is functioning properly, LVN A stated she believed the ward clerk checks that. When asked if nurses monitored episodes of exit seeking behaviors of Resident 1, LVN A stated there was no shift monitoring by the licensed nurses for episodes of elopement. LVN A further stated there was no monitoring by the licensed nurses for the functioning of the Wanderguard in Resident 1's medical record. During an interview with the director of nursing (DON) on 10/19/22 at 9:48 a.m., she stated the expectation was for the nurses to test the function of the Wander Guard bracelet attached to Resident 1 every shift. The DON further stated there should be orders to monitor placement and function of the Wanderguard and documentation to reflect episodes of attempting to leave the facility. The DON confirmed there was no documentation in Resident 1's medical record by the licensed nurses that Resident 1's Wanderguard was being monitored every shift. The DON further confirmed the licensed nurses did not document episodes of Resident 1 attempting to leave the facility. Review of the facility's policy titled Wandering Resident Management: Wanderguard indicated facilities will provide devices to assist in monitoring the whereabouts of wandering residents and prevention of elopement from the facility. Staff will monitor the Wanderguard for proper placement and function every shift and will be documented on the medication administration record (MAR) or treatment administration record (TAR). Based on observation, interview, and record review, the facility failed to ensure residents were free of accidents and hazards for two of 16 sampled residents (Resident 42 and 1) when: 555343 Page 5 of 11 555343 10/21/2022 Saratoga Retirement Community Health Center 14500 Fruitvale Avenue Saratoga, CA 95070

F 0689 1. Resident 42 was not provided adequate supervision as indicated in her fall care plan and fall mats were not in place as ordered; Level of Harm - Minimal harm or potential for actual harm 2. Resident 1's wandering alert system was not monitored. Residents Affected - Few These failures had the potential to result in serious injury to the residents in the facility. Findings: 1. Review of Resident 42's clinical record indicated she was admitted on [DATE] and had diagnoses of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), fracture of right femur neck, osteoporosis (a condition in which bones become weak), difficulty in walking, and dementia (a group of symptoms affecting thinking and social abilities interfering with daily functioning). Review of Resident 42's Minimum Data Set (MDS, an assessment tool) dated 4/06/22, indicated she had a brief interview of mental status (BIMS, a structured cognitive test) scoring 03 (severe impairment). Review of Resident 42's fall risk evaluation, dated 4/07/22, indicated, score: 22, at risk. Review of Resident 42's Physician order, dated 6/02/22, indicated, Special low bed with BIL floor mats to lessen the impact of injury in case of a fall. Review of Resident 42's care plan, titled, The resident is at high risk for unavoidable falls, date initiated 4/02/22, indicated one of the interventions was 1:1 sitter at all times. Do not leave unattended. During an observation on 10/19/22 at 9:50 a.m., Resident 42 was lying in bed. Certified nursing assistant H (CNA H) was caring for Resident 42's roommate. The curtain was drawn completely around Resident 42's roommate to provide privacy. There was no fall mat observed on the left side of Resident 42's bed. During a concurrent observation and interview on 10/19/22 at 9:50 a.m., certified nursing assistant H (CNA H) confirmed the observation. CNA H stated Resident 42 should have fall mats on both sides of her bed. CNA H further stated she could not provide 1:1 sitter care to Resident 42 while providing a care to Resident 42's roommate. During a concurrent observation and interview on 10/19/22 at 9:56 a.m., licensed vocational nurse D (LVN D) confirmed the observation. LVN D reviewed Resident 42's physician order and confirmed Resident 42 should have fall mats on both sides of her bed as ordered. LVN D confirmed CNA H was assigned to Resident 42 and her roommate. During an interview with CNA E on 10/21/22 at 8:23 a.m. in Resident 42's room, CNA E stated she was assigned to Resident 42 and Resident 42's roommate. During an interview with the assistant director of nursing (ADON) on 10/21/22 at 10:00 a.m., ADON stated the CNA would not be considered a 1:1 sitter if one CNA was assigned to care for two residents. ADON stated the CNA assigned for Resident 42 as a 1:1 sitter should not be assigned to care for 555343 Page 6 of 11 555343 10/21/2022 Saratoga Retirement Community Health Center 14500 Fruitvale Avenue Saratoga, CA 95070

F 0689 another resident. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 10/21/22 at 11:20 a.m., the director of staff development (DSD) reviewed CNA assignments from 10/01/22 to 10/20/22 and confirmed one CNA was assigned to Resident 42 and her roommate. The DSD stated 1:1 sitter was not provided as indicated in Resident 42's fall care plan. Residents Affected - Few During a concurrent interview and record review on 10/21/22 at 11:54 a.m., the DSD reviewed Documentation Survey Report (CNA documentation of daily task, like bed mobility, dressing, personal hygiene, toilet use, and transferring) and confirmed one CNA provided all daily care to Resident 42 and her roommate. Review of facility's policy, Fall Reduction and Management Program revised 2/2021, indicated Care planning and implementation: Based on resident fall evaluation, an individualized care plan with the goal to prevent falls and/or minimize serious injury if fall occurs will be developed, implemented, monitored and modified as needed. Review of facility's policy, 1:1 Sitters provided by the DSD, indicated 1:1 CNA will provide all care for resident and monitor for risks and safety awareness issues. Review of the facility's policy Medication and Treatment Administration, revised 01/2020, indicated, Medications and treatments shall be administered as prescribed. 555343 Page 7 of 11 555343 10/21/2022 Saratoga Retirement Community Health Center 14500 Fruitvale Avenue Saratoga, CA 95070

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, and record review, the facility failed to store and dispose of multiple expired and unlabeled medications properly in one of two medication rooms, and one of two medication carts. These failures had the potential to result in unsafe administration of medications. Findings: During a concurrent observation and interview with the Licensed Vocational Nurse (LVN) A on 10/17/2022 at 9:51 A.M., in nursing station 1's medication room, observed that two boxes of eight vials of Epoetin alfa (a man-made version of human erythropoietin) in the medication refrigerator did not have a label. The LVN A stated all the medications should be labeled with residents' name, date of birth , room number, and doctor's order. During a concurrent observation and interview with the LVN A on 10/17/2022 at 10:10 A.M., in nursing station 1's medication room, observed that a vial of Aplisol (tuberculin PPD, diluted) in the medication refrigerator was opened on 9/9/2022. The LVN A confirmed this medication was expired after 30 days of opening, and the last day to use it should be 10/9/2022. During a concurrent observation and interview with the LVN A on 10/17/2022 at 10:15 A.M., in nursing station 1's medication room, observed that three boxes of 21 patches of Neupro (a prescription medicine used to treat Parkinson's disease and moderate-to-severe primary Restless Legs Syndrome), provided by Resident 24's family,were expired in 7/2022. The LVN A stated those expired patches should be discarded in 7/2022. During a concurrent observation and interview with the LVN A on 10/17/2022 at 10:27 A.M., in nursing station 1's medication cart 1, the open date of an Albuterol (a drug used to treat asthma) inhaler for Resident 30 was 8/29/2022, and the expiration date was 9/29/2022.The LVN A confirmed it was expired and should be removed from the cart. During a follow-up interview with the LVN A on 10/19/2022 at 2:59 P.M., she stated residents could be sick if they have expired medications, and medications without labels could cause wrong medication administration. During an interview with the Director of Nursing (DON) on 10/21/2022 at 9:30 A.M., She stated medications should be labeled and dated, and the expired medications should be moved from the storage room and medication carts on time. A review of the facility's Policy and Procedure revised 5/16/2018 titled Medication Storage in The Faculty indicated all expired medication will be removed from the active supply and destroyed in the facility, regardless of the amount remaining. 555343 Page 8 of 11 555343 10/21/2022 Saratoga Retirement Community Health Center 14500 Fruitvale Avenue Saratoga, CA 95070

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to ensure the planned menu was followed for seven residents on Pureed diet (texture modified diet for people who have difficulty chewing and swallowing) and nine residents on Mechanical soft diet (texture modified diet for people who have difficulty chewing and swallowing). This failure had the potential to result in not meeting the nutritional needs of the residents. Findings: Review of the facility menu California Diet Guide Sheet for Tuesday 10/18/2022 lunch indicated the followings; sweet chili roasted chicken pureed # 8 Scoop (1/2 cup) for the Pureed diet and 4 oz (ounce, a unit of weight) for the Mechanical soft diet. During an observation of the lunch meal service on 10/18/22 at 11:52 a.m. in the kitchen, food service worker J (FSW J) used # 12 scoop (1/3 cup, 2.7 oz) to serve the pureed and the mechanical soft sweet chili roasted chicken. During a concurrent observation and interview on 10/18/22 at 12:15 p.m., FSW J confirmed the observation. During an interview and concurrent record review on 10/18/22 at 12:20 p.m., the registered dietitian (RD) confirmed above observation and reviewed the facility menu California Diet Guide Sheet for Tuesday 10/18/22 lunch. The RD confirmed FSW J did not follow the menu for serving sizes. The RD acknowledged the planned menu should be followed. 555343 Page 9 of 11 555343 10/21/2022 Saratoga Retirement Community Health Center 14500 Fruitvale Avenue Saratoga, CA 95070

F 0812 Level of Harm - Minimal harm or potential for actual harm 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 facility document review, the facility failed to follow proper sanitation and food handling practices when: Residents Affected - Some 1. There were food remains on a food container in dry storage area; 2. There was an outdated food item in dry storage area; and 3. Steam table pans were stacked and stored wet. These failures had the potential to cause food contamination and food-borne illness to 63 of 64 residents who received their food from the kitchen. Findings: 1. During the initial kitchen tour on 10/17/22 at 9:50 a.m., a plastic container of peanut butter with peanut butter remains on the lid and opening area were observed in the dry storage area of the kitchen. The registered dietitian (RD) confirmed the observation and stated food containers in dry storage area should be maintained free from food remains. Review of the facility policy General Food storage Standards revised 10/2022, indicated All storage areas should be maintained (good sanitation standards and basic cleanliness and environmental upkeep) to prevent rodent and insect infestation. 2. During the initial kitchen tour on 10/17/22 at 9:59 a.m., a light Italian dressing with an expiration date of 7/12/22 observed in the dry storage area of the kitchen. The RD confirmed the observation and stated the dressing should have been discarded. Review of the facility policy General Food storage Standards revised 10/2022, indicated Any food items that reach their expiration date will be discarded. 3. During the initial kitchen tour on 10/17/22 at 10:04 a.m., three metal steam table pans of various sizes were observed stacked on the counter under the steam table. One pan was upside down and stored by itself. Two pans were upside down and stacked on top of other pans. All three pans were wet on the outside surfaces of the pans. The RD confirmed the pans were wet and she stated the pans should have been air dried before stacked and stored. Review of the facility policy Dish Room Operations revised 10/2022, indicated Clean dish storage: This is the cart and shelves used to store clean items prior to being put away for use. Dishes should remain in this area, unstacked, until completely dry. According to the 2017 Food and Drug Administration (FDA) Food Code, Section 4-901.11 Equipment and Utensils, Air-Drying Required, After cleaning and sanitizing, equipment and utensils: shall be air-dried . According to the FDA Food Code 2017 Annex 4-901.11 items must be allowed to drain and to air-dry before being stacked or stored. 555343 Page 10 of 11 555343 10/21/2022 Saratoga Retirement Community Health Center 14500 Fruitvale Avenue Saratoga, CA 95070

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, and record review, the facility failed to ensure infection control practices were implemented when staff did not wash or sanitize her hands between changing gloves for one of four sampled residents (Resident 36). This failure could potentially result in infection transmission in the facility. Residents Affected - Few Findings: During a medication administration observation with the Licensed Vocational Nurse (LVN) C on 10/18/2022 at 9:44 A.M., in Resident 36's room, The LVN C did not wash or sanitize her hands before putting on gloves to give eye drops and nasal spray. She also did not wash or sanitize her hands between glove changes. During a follow-up interview with LVN C on 10/18/2022 at 9:57 A.M., the LVN C stated she should wash or sanitize her hand during glove changes to prevent cross-contamination. During an interview with the Director of Nursing (DON) on 10/21/2022 at 9:30 A.M., the DON stated staff should wash or sanitize their hands between tasks and between changing gloves. A review of the facility's Policy revised 11/2017 indicated all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .in most situations, the preferred method of hand hygiene is with an alcohol-based hand rub, before donning gloves and after removing gloves . 555343 Page 11 of 11