Health inspection·November 18, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to treat residents with respect and dignity, and care for each resident in a manner and in an environment that promoted their rights that enhanced their quality of life for four of of 23 sampled residents (Resident 36, 39,102, and 162) when 1. For Resident 102, the primary care physician (PCP, her attending physician) called her as, too heavy to reach your goal, the interdisciplinary team (IDT, facility staff members from different departments who coordinate care provided to residents) did not invite her to participate during the care planning conference, and she was categorized as incontinent (having no or insufficient voluntary control over urination or defecation) which resulted to her feeling insulted and angry; 2. For Resident 162, staff did not update him or his responsible party (RP, decision maker) of his rehabilitation therapy schedule; 3. Certified Nursing Assistant M (CNA M) did not provide the privacy to Resident 36 before cleaning her; and 4. Resident 39 was covered with a blanket which had three big holes. Findings: 1. A review of Resident 102's facesheet indicated admission on [DATE] with diagnoses of fracture (break in the continuity of the bone) of upper and lower end of left fibula (calf bone-smaller bone of the lower leg). Her minimum data set (MDS, an assessment tool) dated 10/8/22 indicated a brief interview for mental status (BIMS, an assessment tool for cognition) score of 15 (intact cognition). During the interview on 11/14/22 at 1:40 p.m., Resident 102 was awake sitting at the edge of there bed and she stated her doctor (MD) told her, you're too heavy to reach your goal of going home. Resident 102 claimed feeling insulted and angry and stated, it's like saying you're too fat, now I can walk with walker and able to bear weight, reached my goal. During an interview with the PCP on 11/18/22 at 4:09 p.m., she confirmed she told Resident 102 that she was too heavy to reach your goal of going home. During an interview on 11/15/22 at 2:03 p.m., Resident 102 claimed she was not informed or invited to participate during the care conference done by the facility. Resident 102 stated, they did not involve me at all regarding my care. Page 1 of 43 555444 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with the social services worker(SSW) on 11/16/22 at 12:15 p.m., the SSW confirmed Resident 102 was not invited during the interdisciplinary team (IDT, facility staff members from different departments who coordinate care provided to residents) meeting was done on 10/12/22. The SSW confirmed Resident 102 had no restriction and was capable of participating in the IDT care planning conference and had the right to participate and be involved. The SSW concurred that including the resident during the care planning would make resident to be more involved, and she could discuss her goals with the team. During a record review and concurrent interview with the licensed vocational nurse L (LVN L) on 11/16/22 at 11:19 a.m., she reviewed Resident 102's admission assessment that indicated resident was continent of Bowel and bladder (B/B, able to control her bladder and/or bowel). LVN L also reviewed Resident 102's October and November task completed every shift by certified nursing assistants (CNA's) and it indicated resident was continent of B/B. LVN L also reviewed Resident 102's urinary care plan for incontinence dated 10/4/22 and confirmed the care plan was not applicable for Resident 102 since she was continent. During an interview with Resident 102 on 11/16/22 at 1:02 p.m., residents claimed she could tell staff when to urinate, she just needed assistance to get up but she could walk to the bathroom using a FWW (front wheel walker) in order to urinate. Resident 102 also stated, she was still young to be incontinent and this was degrading, 2. A review of Resident 162's facesheet indicated he was admitted on [DATE], his physician's order dated 11/11/22 included physical therapy (PT) and occupational therapy (OT) evaluation and treatment. During the interview with Resident 162's RP on 11/14/22 at 12:05 p.m., she stated staff did not update her or the resident regarding resident's therapy schedule. Resident 162's RP pointed to the whiteboard inside resident's room which did not indicate the schedule for his therapy (it was left blank). The RP stated until today nothing was updated and nobody care yet to explain what's going on. I am here almost everyday to check but no updates regarding his therapy. During an interview with registered nurse C (RN C) on 11/14/22 at 12:18 p.m., RN C confirmed Resident 162 had a physician's order for PT and OT and admitted he did not discuss with family or resident regarding therapy schedule. RN C also stated therapy department should discuss the therapy schedule with either the family or resident. During the interview with the director of rehab department (DRD) on 11/14/22 at 12:38 p.m., the DRD stated, the schedule of therapy should have been written on the resident's whiteboard located in his room, and she would tell her staff to update and write the date and time of therapy. A review of the facility's policy and procedure dated October 15, 2016 titled, Your Resident Rights, indicated the resident has the right to a dignified existence . A facility must treat each resident with respect and dignity has a right to be informed of, participate in, his or her treatment. 3. Review of Resident 36's admission Record indicated she was admitted to the facility on [DATE]. During an observation on 11/16/22 at 10:25 a.m., Resident 36 was standing in front of the commode, and her pants were folded down to her feet. CNA M was wiping her coccyx and applying cream on it. Resident 36's room door was opened, and the curtain was not closed. Resident 36's body from the waist 555444 Page 2 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

F 0550 down was exposed and could be seen from the hallway. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview with CNA M, she acknowledged that she should provide the privacy to Resident 36 before cleaning her. Residents Affected - Some 4. Review of Resident 39's admission Record indicated she was admitted to the facility on [DATE] with dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) diagnosis. Review of Resident 39's Minimum Data Set (MDS, a clinical assessment tool), dated 10/14/22, indicated her cognition was severely impaired. During an observation and interview with licensed vocational nurse N (LVN N) on 11/14/22 at 1:30 p.m., Resident 39 was lying in bed and covered with a blanket. The blanket had three big holes on it. LVN N stated she would discard the blanket and provide another one to Resident 39. Review of the facility's policy, Your Resident Rights, dated 10/15/16, indicated A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, . 555444 Page 3 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

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 residents' needs were accommodated for three sampled residents (Residents 31, 9, and 40 ) and one non-sampled resident (Resident 60) when: Residents Affected - Few 1. Bedside call light or equipment was not placed within reach for Resident 31, 9 and 40, which could potentially result to resident's inability to access assistance to meet his needs. 2. Call light was not answered in a timely manner for Resident 60, which had the potential to result in the delay of responding to residents' needs. Findings: 1. During a concurrent observation and interview on 11/14/22 at 9:30 a.m., Resident 31 was lying in bed and her call light was hanging on the left side wall and touching the floor. Resident 31 stated I'm right handed and I can't reach it now. Registered Nurse A( RN A) came and placed Resident 31's call light within reach. During a concurrent observation and interview on 11/16/22 at 12:25 p.m., certified nursing assistant G (CNA G) assisted Resident 31 with her lunch tray. Resident 31 was sitting on the wheelchair and her call light was pinned to her bed sheet, not within Resident 31's reach. Licensed Vocational Nurse D (LVN D) positioned Resident 31's wheelchair closed to her bed and call light. LVN D stated Resident 31 call light should have been within reach. Review of Resident 31's minimum data set (MDS, tool assessment ) indicated she had a brief interview for mental status (BIMS) score of 15, meaning she's cognitively intact, and has one sided upper extremity impairment. During a concurrent observation and interview on 11/24/22 at 9:45 a.m., Resident 9 was lying in bed and her call light was inside the bedside drawer. LVN D stated Resident 9 used a bell instead of a call light. LVN D tried to locate for the bell and was not able to find it. Review of Resident 9's medical record indicated she was admitted to the facility with a diagnosis of major depressive disorder. During an observation on 11/14/22 at 10:05 a.m., Resident 40 was lying in bed and his call light was hanging by the wall. Review of Resident 40's medical record indicated he was admitted to the facility with a diagnosis of dementia (impaired ability to remember, think, or make decisions ) During an interview with the Assistant Director of Nursing (ADON) on 11/17/22 at 1:22 p.m., she stated staffs should make sure resident call lights are within reach. 2. During an observation on 11/26/22 at 12:48 p.m. in Station 1, Resident 60's call light was on. LVN E was alone sitting in the nursing station and charting in her computer. LVN D went to Resident 60's room at 10:58 a.m. and stated Resident 60 did not need anything. LVN E confirmed she could hear the call light and Resident 60 was in her assignment. LVN E stated she was from the registry and 555444 Page 4 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

F 0558 Level of Harm - Minimal harm or potential for actual harm does not work in the facility. LVN E stated she would answer the call light since it was brought to her attention now. During an interview with the director of staff development (DSD) on 11/18/ 22 at 8:30 a.m., she stated call light was everyone's responsibility. Residents Affected - Few Review of the facility's policy, Call light , dated 10/2020, indicated Answer call lights in a prompt, calm, and courteous way. All staff, regardless of assignments answer call lights. Always position call light conveniently for use and within reach. 555444 Page 5 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an advance directive (AD, a written instruction, such as a living will or durable power of attorney for health care when the individual was incapacitated) accurately reflect on the Physician Order for Life-Sustaining Treatment (POLST, a document signed by the resident and by the physician which indicated the types of medical treatment the resident wished to receive towards the end of life) and the physician order for one sampled resident ( Resident 27). This failure had the potential for the facility to provide treatment and services that was against the resident's wishes. Findings: Review of Resident 27's admission record report indicated she was admitted to the facility on [DATE] with a diagnosis including dementia (impaired ability to remember, think, or make decisions). Review of Resident 27's POLST dated [DATE], indicated attempt Resuscitation/CPR (cardiopulmonary resuscitation, person would allow all interventions needed to get their heart started) and full treatment (primary goal of prolonging life by all medically means). The AD section indicated AD dated [DATE] available and reviewed. The POLST was signed by Resident 27's family member (FM). Review of Resident 27's AD dated [DATE], indicated under health instructions that all treatments other than those needed to keep comfortable be discontinued, withheld and physician (s) allows to die as gently as possible. Resident 27 signed the AD .The AD also indicated Resident 27 did not sign under the statement that her life will be prolonged as long as possible within the limits of generally accepted health care standard. Review of Resident 27's physician order dated [DATE] , indicated Resident 27 was Full Code (FC, person would allow all interventions needed to get their heart started). During an interview with the social service coordinator (SSC) on [DATE] at 10:54 a.m., she verified Resident 27's AD, POLST and physician order did not match. SSC stated she missed to review the POLST and AD, if needed to make changes, she should have coordinated with the FM. Review of the facility's policy, Advance Directives, Long Term Care, dated [DATE] , indicated Review the advance directive with the resident, and confirm that it still reflects the resident's wishes. 555444 Page 6 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN, a notice that transfers potential financial liability) to two of three residents (Resident 89 and 92) in timely manner. Residents Affected - Few This failure had the potential to compromise the residents' right to appeal (apply for reversal of) the facility's decision to discontinue Medicare Part A services (skilled treatments paid for by Medicare). This failure also had the potential to result in the residents or residents' representatives not being informed of their payment responsibilities to the facility after Medicare Part A services ended. Findings: Review of Resident 89's medical record indicated she was admitted to the facility under Medicare Part A on 5/26/22. The medical record further indicated Resident 89 came off Medicare Part A on 6/16/22 and continued living in the facility. Review of Resident 89's SNF Beneficiary Protection Notification Review, filled out by the facility on 11/17/22, indicated the facility initiated Resident 89's discharge from Medicare Part A services when benefit days were not exhausted (the resident still had Medicare Part A days remaining). The SNF Beneficiary Protection Notification Review further indicated the facility did not provide a SNF ABN to Resident 89 until 11/17/22. Review of Resident 92's medical record indicated she was admitted to the facility under Medicare Part A on 7/01/22. The medical record further indicated Resident 92 came off Medicare Part A on 7/29/22 and continued living in the facility. Review of Resident 92's SNF Beneficiary Protection Notification Review, filled out by the facility on 11/17/22, indicated the facility initiated Resident 92's discharge from Medicare Part A services when benefit days were not exhausted. The SNF Beneficiary Protection Notification Review further indicated the facility did not provide a SNF ABN to Resident 92 until 11/17/22. During an interview with the director of nursing (DON) on 11/17/22 at 2:00 p.m., she stated the business office manager (BOM) was responsible for the SNF ABN. During an interview with the BOM on 11/18/22 at 10:15 a.m., she confirmed the facility did not provide a SNF ABN to Resident 89 and 92 when they came off Medicare Part A services. The BOM stated the facility should have provided a SNF ABN to Resident 89 and 92 when the residents came off Medicare Part A and stayed in the facility. CMS-20052, dated 10/2022, indicates the facility must provide a SNF ABN when residents are discharged from Medicare Part A services with remaining benefit days and continue to live in the facility. 555444 Page 7 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop, implement and/or update the care plans for five of 23 sampled residents (Residents 28, 107, 164, 31, and 84) when: 1. For Resident 28, there was no care plan developed for urinary retention, and licensed nurse did not follow the doctor's order to notify the doctor when the bladder scan result was greater than 300 ml. (milliliter, unit of measurement). 2. For Resident 107, there was no care plan developed for limitation in the range of motion (ROM), and urinary incontinence to help prevent pressure ulcer (PU, an injury that breaks down the skin and underlying tissue caused when an area of skin is placed under pressure); and did not implement care plan for left ram swelling and left foot edema. 3. For Resident 31, the care plan did not reflect the correct diagnosis on admission. 4. For Resident 84, the care plan of the nutritional risk was not a person-centered care plan. A personalized care plan identifies resident's individualized concerns/needs that outlines the care and services needed to meet their needs and should be implemented and revised accordingly. Findings: 1. A review of Resident 28's facesheet indicated admission on [DATE] with diagnoses of weakness, difficulty in walking, history of falling, urinary tract infection (UTI), surgery of the genitourinary system (genital and urinary systems). Had previous urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) in place and was recently discontinued. During an interview with certified nursing assistant Q (CNA Q) on 11/15/22 at 2:09 p.m., CNA Q claimed Resident 28 had episodes of both urinary continence and incontinence that she had to offer the use of urinal every two hours. During a record review and concurrent interview with RN C and LVN L on 11/18/22 at 8:15 a.m., RN C and LVN L both confirmed Resident 28 had a physician's order dated 11/1/22 for PVR (post void residual, amount of urine left in the bladder after urination) bladder scan (a safe, painless, reliable procedure that allows you to assess the volume of urine retained within the bladder) every shift for three days, and notify MD (doctor of medicine) if greater than 300 ml. (milliliter, unit of measurement). Record review of Resident 28's November 2022 treatment administration record (TAR) indicated resident's bladder scan on 11/3/22 was 876 ml. Other days and shifts indicated bladder scan of 228-288 ml. RN C and LVN L did not find any documented evidence that the MD was notified when the bladder scan was greater than 300 ml. LVN L stated the physician's order was not followed, and confirmed there was no care plan developed for urinary retention. 2. A review of Resident 107's facesheet indicated admission on [DATE] with diagnoses of hemiplegia (paralysis of one side of the body), left side, and muscle wasting and atrophy (wasting away of the 555444 Page 8 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few body or of an organ or part). His care plan for edema/swelling of left arm dated 10/27/22 included intervention of arm sling to left arm; and the care plan for edema on left lower extremity dated 10/27/22 included intervention to elevate foot of bed due to edema/swelling. His Braden Scale (an assessment tool to identify risk for PU development) dated 10/26/22 indicated a score of 13 or moderate risk for PU. During a record review with the minimum data set coordinator (MDSC) on 11/16/22 at 9:51 a.m., the MDSC reviewed resident 107's minimum data set (MDS, an assessment tool) dated 11/2/22 that indicated a modification of the previously submitted MDS was made to reflect Resident 107's functional limitation in ROM. The MDSC confirmed there was no care plan developed for resident's limited ROM and she stated, she would put one right now. During an observation on 11/16/22 at 10:08 a.m., Resident 107 was lying in bed with no arm sling applied on his left arm and the foot part of the bed was not elevated. Certified nursing assistant Q (CNA Q) who came at the resident's bedside validated the observation. During an observation and concurrent interview on 11/16/22 at 10:11 a.m., LVN L confirmed there was no sling applied on resident's left arm and the foot was not elevated. During a record review and concurrent interview on 11/16/22 at 10:21 a.m., LVN L reviewed Resident 107's Skin Evaluation dated 10/26/22 that indicated left foot edema. His LVN L confirmed the care plan was not implemented for left foot edema and there was no care plan developed for resident's incontinence to help prevent PU development. LVN L stated care plan to address risk for skin integrity problems related to bowel and bladder incontinence should have been developed. During an observation on 11/17/22 at 9:12 a.m. CNA Q confirmed Resident 107's left foot was bigger (swollen) than the right foot and the left foot was not elevated. 3. Review of Resident 31's clinical record titled New admission Notification, dated 10/19/21, indicated admitting diagnosis of Dementia ( impaired ability to remember, think, or make decisions ) . During a record review on 11/15/22 at 12:21 p.m. Resident 31's admission record report did not include Dementia. Review of Resident 31's MDS dated [DATE] did not include Dementia. Review of Resident 31's care plan dated 10/22/21, indicated risk for alteration in hydration related to Alzheimer's dementia. Her ADL's (activities of daily living) and pain care plans also mentioned dementia. During a concurrent interview and record review with the MDSC on 11/16/22 at 11:55 a.m., she stated Resident 31 had a diagnosis of Dementia on admission and she missed to include in her diagnosis. MDSC stated she was not sure why Resident 31's care plan indicated Alzheimer's dementia when she confirmed Resident 31's annual MDS assessment did not include the diagnosis of Alzheimer's dementia. 4. Review of Resident 84's clinical record indicated she was admitted on [DATE] and had the diagnoses of hemoperitoneum (a type of internal bleeding in abdomen), dysphagia (difficulty swallowing), and hypertension (high blood pressure). 555444 Page 9 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 84's Minimum Data Set (MDS, an assessment tool) dated 8/17/22, indicated she had a brief interview of mental status (BIMS, a structured cognitive test) scoring 04 (severe impairment). Review of Resident 84's Physician order dated 2/08/22, indicated NPO (nothing by mouth). Review of Resident 84's care plan of Nutritional risk related to Dysphagia initiated on 8/09/22, included Encourage and assist as needed to consume foods and/or supplements and fluids offered. During an interview with registered nurse R (RN R) on 11/15/22 at 10:47 a.m., she confirmed Resident 84 was on NPO and should not be offered foods/fluids. RN R stated staffs were not offering foods/fluids to the resident. During an interview and record review with the director of nursing (DON) on 11/16/22 at 12:20 p.m., she reviewed Resident 84's physician's order and care plan of the nutritional risk. The DON confirmed Resident 84 had the order of NPO and should not be encouraged/assisted to consume foods/fluids. The DON confirmed the care plan was not a person-centered care plan. The DON stated a care plan should be customized to address individual resident concerns. Review of facility's policy Care plan preparation, long-term care reviewed 5/20/22, indicated A care plan is an individualized, written action plan for a resident's care, treatment, and services . The care plan must be person-specific . The care plan should reflect elements of person-centered care . 555444 Page 10 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to update and revise the individualized and comprehensive care plans to meet individual needs for three residents (Residents 27, 45, and 96 ) when : 1. For Resident 27, an oxygen (O2, a colorless and odorless gas that people need to breathe) care plan was not discontinued when no longer in use. 2. For Resident 45, the port (a device used to draw blood and give treatments, including intravenous fluids, blood transfusions, or drugs.The port is placed under the skin, usually in the right side of the chest) site care plan was not updated to include a new diagnosis after a hospitalization, and; 3. For Resident 96, the discharge care plan was not updated when her discharge plan was changed. These failures had the potential to result in not meeting the residents' needs. Findings : 1. During an observation and concurrent interview with licensed vocational nurse D (LVN D) on 11/14/22 at 9:47 a.m., Resident 27's oxygen tubing was on top of the oxygen concentrator without a cover and dated 11/11/22. LVN D stated Resident 27 does not use oxygen lately. Review of Resident 27's physician order dated 3/24/22 indicated oxygen at 2L/m prn (as needed) for SOB (shortness of breath). Resident 27's current November 2022 physician order did not include oxygen . Review of Resident 27's care plan dated 9/27/22, indicated resident has altered respiratory status/ difficulty breathing and provide oxygen as ordered. During a concurrent interview and record review with the assistant director of nursing (ADON) on 11/17/22 at 12:10 p.m., she stated Resident 27 currently did not have oxygen order and the care plan should be updated. 2. Review of Resident 45's progress notes dated 11/1/22, indicated she was sent to acute care hospital for swollen neck and pain on port site. Resident 45 returned the same day to the facility and the progress notes did not include an assessment of Resident 45's port site. During a concurrent interview and record review with Registered Nurse A (RN A) on 11/17/22 at 8:24 a.m, she stated she remembered Resident 45 who came back to the faclility with a diagnosis of hematoma (an injury that causes blood to collect and pool under the skin) on 11/1/22. RN A provided Resident 45's emergency department (ED) After Visit Summary, dated 11/1/22, and it was indicated a diagnosis of hematoma. RN A reviewed Resident 45's care plan and it was not indicated a revision of Resident 45's port site to include hematoma. RN A stated nurses should update Resident 45's care plan. 3. Review of Resident 96's clinical record indicated she was admitted on [DATE] and had the diagnoses of hemiplegia (a symptom that involves the loss of the ability to move on one-side of body) 555444 Page 11 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

F 0657 Level of Harm - Minimal harm or potential for actual harm affecting left nondominant side, depression (a mood disorder that causes a feeling of sadness and loss of interest), diabetes (high blood sugar), muscle weakness, and hypertension (high blood pressure). Review of Resident 96's Minimum Data Set (MDS, an assessment tool) dated 8/30/22, indicated she had a brief interview of mental status (BIMS, a structured cognitive test) scoring 15 (cognitively intact). Residents Affected - Few During an interview with Resident 96 on 11/17/22 at 8:50 a.m., she stated she had planned on being discharged by the end of December and was working on her housing. The resident stated she already expressed her discharge plan to staffs since October. During an interview with the social service coordinator (SSC) on 11/17/22 at 9:08 a.m., she stated she was aware of Resident 96's discharge plan from the middle of October. Review of Resident 96's care plan initiated on 10/17/22, indicated Patient does not show potential for discharge to the community due to lack of housing and care. Patient will remain long term care in the facility. During a concurrent interview and record review with the SSC on 11/17/22 at 9:39 a.m., she confirmed Resident 96 did not have updated discharge care plan. The SSC stated Resident 96's discharge care plan should have been updated because her discharge plan was changed. Review of facility's policy Care plan preparation, long-term care reviewed 5/20/22, indicated Evaluate the resident's progress, and revise the care plan, as appropriate. 555444 Page 12 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 meet professional standards when nurse practitioner (NP) added a diagnosis of Schizophrenia or bipolar disorder for the antipyschotic medication use not previously included as one of the resident's diagnoses for one of two residents (Resident 82). Residents Affected - Few This failure could potentially compromise Resident 82's health and safety. Findings: A review of Resident 82's clinical record indicated he was [AGE] year old male, admitted to the facility with diagnoses of encephalopathy (a disease in which the functioning of the brain is affected by some agents or condition such as viral infection or toxins in the blood), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). His MDS (miminum data set, assessment tool) dated 11/4/22 indicated a brief interview for mental status (BIMS, an assessment for cognition) score of 5 that indicated that Resident 82 had a cognitive impairment. During an interview with the NP on 11/17/22 at 9:38 a.m., he stated Resident 82 had no previous diagnosis or of schizophrenia or any bipolar disorder. The NP also stated a resident did not develop schizophrenia or bipolar in the later part of life. He further stated I was trying to see what's the best option to use because the staff told me not to use dementia as a diagnosis and the nearest one is schizophrenia or bipolar, referring to the use of Olanzapine (used to treat schizophrenia and bipolar disorder). During a review of facility's Policy and Procedures(P&P) title Psychotropic drug use, long-term care dated May 20,2022, indicated, Review the resident's medical record to determine whether there's an underlying medical, physical, functional, psychosocial, emotional, or psychological cause of the resident's behavior. 555444 Page 13 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide nail care for one sampled resident (Resident 31). This failure placed the resident at risk for infection and self-inflicted skin injury. Residents Affected - Few Findings: During an observation on 11/16/22 at 8:08 a.m., Resident 31's fingernails were long, yellowish and has black residue under her fingernails. Resident 31 was observed using her hands to feed herself. During an observation on 11/16/22 at 12:22 p.m., certified nursing assistant G (CNA G) served Resident 31's lunch tray and Resident 31 started to eat using her hand. CNA G did not clean Resident 31 hands. During a concurrent observation and interview on 11/16/22 12:51 p.m., CNA G asked Resident 31 if she wanted to have her fingernails trim and Resident 31 responded yes. CNA G stated she forgot to clean Resident 31 hands prior to eating. CNA G confirmed Resident 31 nails were long and need to be trimmed. During an interview with the director of staff development (DSD) on 11/18/22 at 8:30 a.m., she stated on 11/10/22, CNA G attended Hand Hygiene in service which included checking nails. Review of Resident 31's minimum data set (MDS, an assessment tool), indicated she had a BIMS score of 15, meaning she's cognitively intact, and has one sided upper extremity impairment. Review of Resident 31's care plan, dated 10/29/21, indicated assistance with ADL's (activities of daily living, such as daily hygiene, grooming). Review of the facility's policy, Nail Care, dated 6/17/22, indicated to provide for personal hygiene needs and prevent infection . 555444 Page 14 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

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** 4. Review of Resident 11's physician order, dated 10/28/21, indicated she had an order for oxygen 2 liters (L, a metric unit of volume) per minute as needed for hypoxia (low levels of oxygen in the body tissues) to maintain oxygen saturation (O2sat, the amount of oxygen circulated in the blood) at 92%. Residents Affected - Some During an observation with licensed vocational nurse N (LVN N) on 11/14/22 at 12:15 p.m., Resident 11 was administered oxygen at 4L per minute. During a concurrent interview with LVN N, she reviewed Resident 11's physician order and confirmed Resident 11 should be administered oxygen at 2L per minute as needed and not 4L per minute. LVN N checked Resident 11's O2sat, and it was at 99%. LVN N stated she would stop administering oxygen to Resident 11. 5a. Review of Resident 36's admission Record indicated she was admitted to the facility on [DATE] with respiratory failure diagnosis. Review of Resident 36's physician order, dated 7/4/22, indicated she had an order for oxygen 2L per minute continuously every shift for short of breath. During an observation and interview with LVN N on 11/14/22 at 12:21 p.m., Resident 36 was administering oxygen at 3L per minute. LVN N reviewed Resident 36's physician order and confirmed Resident 36 should have administered oxygen at 2L per minute. LVN N adjusted the oxygen meter from 3L to 2L for Resident 36. 5b. Review of Resident 36's physician orders, dated 11/9/22, indicated she had orders for Norco (used to treat pain) 5-325 milligrams (mg, a metric unit of mass) one tablet every 6 hours as needed for pain level 1-6/10 and Norco two tablets every 6 hours as needed for pain level 7-10/10. Review of Resident 36's 11/2022 Medication Administration Record (MAR) indicated Resident 36 was administered Norco one tablet when she had pain level 8/10 on 11/10/22 at 3:22 a.m., and Norco two tablets when she had pain level lower than 7/10 on 11/12/22 at 5:51 a.m. and 12:40 p.m., on 11/13/22 at 2 p.m., on 11/14/22 at 6:26 a.m. and 1:07 p.m., on 11/15/22 at 1:28 p.m., and on 11/17/22 at 12:40 p.m. During an interview with the director of nursing (DON) on 11/18/22 at 3 p.m., she reviewed Resident 36's clinical record and confirmed Resident 36 was administered Norco one tablet when she had pain level 8/10 on 11/10/22 at 3:22 a.m., and Norco two tablets when she had pain level lower than 7/10 on 11/12/22 at 5:51 a.m. and 12:40 p.m., on 11/13/22 at 2 p.m., on 11/14/22 at 6:26 a.m. and 1:07 p.m., on 11/15/22 at 1:28 p.m., and on 11/17/22 at 12:40 p.m. The DON stated the licensed nurses should follow the physician order, and she would educate them on this. Review of the California Board of Registered Nursing website, California Business and Professions Code, Division 2, Chapter 6, Article 2, Section 2725(b)(2), indicated registered nurses should ensure the safety, protection of residents; administration of medications, and therapeutic agents, necessary to implement a treatment, disease prevention, ordered by and within the scope of the licensure of a physician. 555444 Page 15 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the facility's undated Staff Nurse Position Description, indicated Responsibilities: Resident Care Management. Ensure that treatments are administered and documented in accordance with state regulations and Manor HealthCare policies and procedures. 6. During an observation on 11/14/22 at 11:44 a.m., Resident 43 was lying in bed, and he had three opened skin areas with dry blood above his upper lip, but there was no treatment order found for these opened skin areas. During an observation and interview with licensed vocational nurse O (LVN O) on 11/16/22 at 2:35 p.m., Resident 43 was lying in bed, and he still had skin areas with dry blood above his upper lip. LVN O reviewed Resident 43's clinical record and confirmed there was no treatment order for Resident 43's skin areas with dry blood above his upper lip. LVN O stated she would inform the physician of Resident 43's skin condition. Review of the facility's policy, Change in Condition, dated 11/2016, indicated A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representatives when there is: . A significant change in the resident's physical, mental, or psychosocial status . 2. During an observation on 11/15/22 at 10:03 a.m., Resident 28 was lying on bed awake with O2 inhalation at 2LPM via NC. Review of Resident 28's physician's order dated 11/16/22 indicated to increase O2 inhalation to 4LPM during therapy (Physical and Occupational therapy). Review of Resident 28's nurses progress notes dated 11/14/22 indicated, O2 sat 90% on 2LPM oxygen. The NP (nurse parctitioner) porgress notes dated 11/16/22 indicated, Patient has become more fatigued during therapy where he has begun to require 2-4L NC to maintain SPO2 (pulse oximetry, amount of hemoglobin in the blood at above 92% rather when he is attempting to move or shift body postions, his pain will immense and in turn his SPO2 levels will decrease to 88-89%. During an observation on 11/17/22 at 2:10 p.m., Resident 28 with his DPOA (durable power of attorney, person responsible for making decisions) was at bedside. The DPOA verbalized concern about the delay in completing the blood works for Resident 28. Resident 28 was having his therapy sessions with the physical therapy assistant (PTA) and certified occupational therapy assistant (COTA) and had continuous O2 inhalation at 2LPM via NC. During his therapy session, the COTA staff randomly checked Resident 28's O2 saturation (O2 sat, indicates how much oxygen was carried by the hemoglobin in the blood) which read between 90-91%. There was an episode when the resident's O2 sat went below 90% while therapy was in progress, noted exertional dyspnea (difficulty of breathing on exertion such as activities) as verified by both PTA and COTA. During the concurrent interview with the COTA, she stated the charge nurse was aware of Resident 28's therapy schedule because she administered the pain medication prior to resident's therapy. Both COTA and PTA stated the charge nurse did not increase resident's O2 inhalation to 4LPM before therapy started, or did not instruct them to increase the O2 to 4LPM during therapy. During a record review and concurrent interview with licensed vocational nurse L (LVN L) on 11/17/22 at 2:34 p.m., LVN L verified the physician's order to increase O2 to 4LPM via NC during therapy 555444 Page 16 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and concurred the physician's order was not followed. LVN L stated, the order should have been communicated to the therapy staff. Review of the facility's policy,Oxygen Administration, dated 7/2017, indicated to verify Physician's Order. During the record review, LVN L also verified the physician's orders dated 11/14/22 for laboratory to be done 11/15/22. LVN L confirmed this order was not followed. The blood was collected on 11/16/22 and the results were in on 11/17/22. LVN L stated, if the order for laboratory was 11/15/22, blood should ahve been collected the night before (11/14/22), that's how it works in this facility. Review of the facility's undated policy, Laboratory Guidelines, indicated laboratory tests and, or services are provided when specifically ordered by the attending physicican or physician extender. 3. Review of Resident 107's medical record indicated admission on [DATE] with diagnoses of malignaant neoplasm (cancer) of pancreas, cerebaral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). During an observation on 11/16/22 at 10:11 a.m, Resident 107 was lying on bed without any O2 inhalation. During a record review and concurrent interview and observation done on 11/16/22 at 10:15 a.m., LVN L confirmed Resident 107 should have his O2 inhalation on continuously as ordered. LVN L confirmed Resident 107 had no O2 inhalation when she came at resident's bedside. LVN L stated, if the resident do not need continuous O2 inhalation then the order should have been discontinued or administer O2 as needed (PRN). Based on observation, interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for six of 23 sampled residents (Residents 94, 28, 107, 11, 36, 43, ) when: 1. For Resident 94, a physician order for oxygen (O2, a colorless and odorless gas that people need to breathe ) was not followed and signage was not provided; 2. For Resident 28, license nurse did not follow the physician's order to administer O2 continuously at 2LPM (two liters per minute) via NC (nasal cannula); 3. For Resident 107, license nurse did not ensure the physician's order to increase the O2 to 4LPM via NC during therapy, and did not carry out the physician's order regarding the laboratory orders; 4. For Resident 11, the physician's order for oxygen was not followed; 5. For Resident 36, the physician's orders for oxygen and Norco (medication used to treat pain) were not followed; and 6. For Resident 43, there was no treatment order for his opened skin areas above his upper lip. These failures had the potential to compromise the residents' health and well-being. 555444 Page 17 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

F 0684 Findings: Level of Harm - Minimal harm or potential for actual harm 1. Review of Resident 94's physician order dated 10/28/22 , indicated oxygen at 2 liters/minute (l/m) via nasal cannula (NC) every shift for shortness of breath (SOB) related to pulmonary metastatic disease. Residents Affected - Some During a concurrent observation and interview with Licensed Vocational Nurse D (LVN D on 11/14/22 at 10:30 a.m., Resident 94 was observed with a nasal cannula connected to an oxygen concentrator at 3.5 l/min . There was no oxygen signage prior to entering Resident 94. LVN D stated oxygen signage should be posted . During a concurrent observation and interview with LVN D on 11/15/ 22 at 11:35 a.m., Resident 94 was observed with a nasal cannula connected to an oxygen concentrator at 1.5 l/min. LVN D stated Resident 94 's oxygen order should be on 2l/min. Review of the facility's policy,Oxygen Administration, dated 7/2017, indicated place No Smoking Oxygen in Use sign on the doorway. Verify Physician's Order. 555444 Page 18 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 interview with Resident 45 on 11/15/22 at 10:18 a.m., she stated she smoked three times a day and kept her cigarettes and lighter with her. During an interview with licensed vocational nurse D (LVN D) on 11/15/22 at 10:22 a.m., she stated Resident 45 has her own smoking supplies and she kept them with her. During an observation and concurrent interview with LVN D on 11/15/22 at 11:35 a.m., Resident 45 has an oxygen concentrator and tubing in her room. There was no oxygen signage prior to entering Resident 45's room. LVN D stated Resident 45 uses oxygen as needed. Review of Resident 45 physician order dated 11/7/22, indicated oxygen at 2L/m (liter per minute) via nasal cannula (NC) prn (as needed) for shortness of breath (SOB) . Review of Resident 45's smoking assessment dated [DATE], indicated Resident 45 was a safe smoker and understand smoking accessories must be returned and kept under control of staff when not in used. Review of Resident 45's care plan dated 12/13/21, indicated Resident 45 was an independent smoker and prefers to keep her smoking materials. During an interview with the director of nursing (DON) on 11/18/22 at 12:29 p.m., she stated Resident 45 should not keep her smoking materials with her as per facility's policy. Review of the facility's policy, Smoking Guidelines, dated 10/2019, indicated Safe Smokers must still follow smoking guidelines including , but not limited to , keeping smoking accessories in control of center staff. Retention , storage , and distribution of smoking accessories are to be kept under the control of center staff when not in use. This includes cigarettes, pipes , matches , lighter fluid, electronic cigarettes , etc. Review of the facility's policy,Oxygen Administration, dated 7/2017, indicated place No Smoking Oxygen in Use sign on the doorway. Smoking materials should have been removed from patients receiving respiratory therapy. 3. Review of Resident 74's clinical record indicated he was admitted to the facility with a diagnosis of malignant (spread to other sites) neoplasm of rectum. Review of Resident 74's minimum data set (MDS, an assessment tool) dated 9/26/22, indicated he has brief interview of mental status (BIMS) score of 1 (scores of 0-7 indicated severe mental impairment). His locomotion on and off unit indicated he needed one person supervision . Review of Resident 74's admission behavioral symptom assessment dated [DATE], indicated he was wandering without intent or purpose. During a concurrent observation and interview on 11/18/22 at 11:30 a.m., in the entrance lobby, Resident 74 was alone in the facility's parking lot. The receptionist staff (RS) confirmed it was Resident 74 and escorted Resident 74 back to the entrance lobby. RS stated she was talking to a visitor 555444 Page 19 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and did not notice Resident 74 went out. RS stated Resident 74 would walk around and loves to sit by the entrance lobby. RS stated on same day earlier, Resident 74 attempted to get out of the facility and she did not inform Resident 74's nurse about about his attempt to get out of facility. During an interview with the DON on 11/18/22 at 2:12 p.m., she stated this was Resident 74 first attempt to elope and wandering around the facility was not an indication to put put him on alarm system and watch process list (the facility's process to identify unsafe wanderers). Review of Resident 74's progress notes , dated 11/18/22 , indicated the nurse was made aware of three elopement attempts, Resident 74 successfully escaped from front door main entrance. Review of the facility's policy, Behavior wandering Guidelines, dated 3/2022, indicated Wandering and exit seeking are behavioral symptoms of special concern in the elderly , patients are evaluated and interventions to consider include personal security bracelet, safety, wandering interventions. 4. Review of Resident 410's fall change of condition, dated 11/16/22 at 1:52 p.m., indicated on 11/8/22, Resident 410 was found on the floor next to his bed . Review of Resident 410's Interdisciplinary Team (IDT, team members from different departments involved in a resident's care) dated 11/8/22, indicated explained benefits of low bed position and Resident 410 understood but may not comply. Review of Resident 410's nurses' notes from 11/9/22 to 11/10/22 did not include his post fall assessments. Further review also indicated on 11/8/22, there was no notification of Resident 410's physician regarding the fall. During an observation on 11/16/22 at 8:18 a.m., Resident 410's bed was high and has a trapeze bar. During a concurrent observation and interview with certified nursing assistant Z (CNA Z) on 11/16/22 at 8:20 a.m., she stated Resident 410's bed was not in lowest position and she would follow Resident 410's request if he wanted his bed up. During a concurrent interview and record review with registered nurse C (RN C) on 11/16/22 at 10:07 a.m., he stated licensed nurses should document on their notes about Resident 410's refusal to let his bed in lowest position. RN C was not able to provide evidence licensed nurses were documenting Resident 410's refusal. RN C reviewed his care plan and stated he would make an update to include Resident 410's noncomplaint with his bed in lowest position. During a follow-up interview with RN C on 11/16/22 at 2:00 p.m., he stated Resident 410 should have a post fall assessment documentation for 72 hours . RN C confirmed licensed nurses did not document his post fall assessment for two days . He stated he would look for the physician notification about the fall but RN C was not able to provide evidence of physician notification. Based on observation, interview, and record review, the facility failed to ensure residents were free of accidents for four of 23 sampled residents (Residents 15, 45, 74, and 410) when: 1. Resident 15 was transferred using a Hoyer lift (equipment used to transfer residents using a sling) with only one staff; 555444 Page 20 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

F 0689 2. Staff did not keep Resident 45 's smoking materials, and oxgen signage was not posted; Level of Harm - Minimal harm or potential for actual harm 3. Staff did not provide adequate supervision to prevent Resident 74 going out of facility unattended; Residents Affected - Some 4. Licensed nurses did not monitor Resident 410 post fall, inform the physician about the fall , and update the fall care plan . These failures had the potential to result in serious injury to the residents in the facility. Findings: 1. Review of Resident 15's clinical record indicated he was admitted on [DATE] and had the diagnoses of transient ischemic attack (TIA, temporary stroke), muscle atrophy (decrease in size of muscle), fall, and fracture of left femoral neck (broken hip bone). Review of Resident 15's Minimum Data Set (MDS, an assessment tool) dated 8/12/22, indicated he had a brief interview of mental status (BIMS, a structured cognitive test) scoring 13 (cognitively intact) and required extensive assistance (staff provide weight-bearing support) from two or more people for transfers. Review of Resident 15's care plan of Requires assistance for transferring revised on 8/08/22, indicated he required mechanical lift transfers. During an observation on 11/17/22 at 11:30 a.m., Resident 15 was lying on the bed and certified nursing assistant H (CNA H) was in his room with a hoyer lift. CNA H closed the room door. During an observation on 11/17/22 at 11:42 a.m., Resident 15 was sitting up in a wheelchair when CNA H opened the room door and CNA H came out from the room with the hoyer lift. During an interview with CNA H on 11/17/22 at 11:42 a.m., she stated she transferred Resident 15 using the hoyer lift by herself. CNA H stated hoyer lift transfers should have performed by two staff members for the safety. During an interview with Resident 15 on 11/17/22 at 11:51 a.m., he confirmed CNA H transferred him using the hoyer lift by herself. A Staff development program dated 7/28/22, indicated the facility conducted an in-service on transferring patient with lift. The in-service included, How many person to operate a hoyer lift? It should be operated by two or more people for the patient's safety and yours. The staff development program attendance record dated 7/28/22, indicated CNA H attended this in-service. During an interview with the director of nursing (DON) on 11/17/22 at 2:10 p.m., she acknowledged hoyer lift transfers should have performed by two people. The DON stated a hoyer lift transfer should have not performed by one person. Review of facility's policy Transfer with a mechanical lift revised 5/20/22, indicated for mechanical lift, ensure that two staff members are present during the transfer to stabilize and support the resident. 555444 Page 21 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure appropriate treatment was rendered for one sampled resident (Resident 84) to prevent complications of enteral (refers to the delivery of a nutritionally complete feed, containing protein, carbohydrate, fat, water, minerals, and vitamins, directly into the stomach, duodenum or jejunum) feeding. This failure could result in health complications. Findings: Review of Resident 84's clinical record indicated she was admitted on [DATE] and had the diagnoses of hemoperitoneum (a type of internal bleeding in abdomen), dysphagia (difficulty swallowing), and hypertension (high blood pressure). Review of Resident 84's care plan of Need for feeding tube included Elevate head 30-45 degrees. During an observation on 11/15/22 at 10:32 a.m., Resident 84 was seen lying in bed and head of the bed was elevated less than 30 degrees during enteral feeding. During a concurrent interview and observation with the director of staff development (DSD) on 11/15/22 at 10:40 am., she confirmed the observation and stated Resident 84's head of the bed should be elevated to at least 45 degrees during enteral feedings to prevent complications. During a concurrent interview and observation with certified nursing assistant X (CNA X) on 11/15/22 at 10:49 am., she confirmed the observation and stated Resident 84's head of the bed should have been elevated to 45 degrees during enteral feedings. CNA X raised the resident's head of the bed to 45 degrees. A Staff development program dated 11/10/22, indicated the facility conducted an in-service on hygiene and grooming. The in-service included, Gastrostomy tube (GT, a surgically placed device for enteral feeding) patient - after changing, put patient up (45 degrees) then turn on GT. The staff development program attendance record dated 11/10/22, indicated CNA X attended this in-service. Review of facility's policy Enteral tube feeding, gastric revised 11/19/21, indicated Position the patient with the head of the bed elevated to at least 30 degrees to prevent aspiration. 555444 Page 22 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards of practice for one sampled resident (Resident 45) with a central venous line (a catheter placed into large vein commonly placed in veins of neck, chest, groin, or through veins in the arms to administer medications or prolonged intravenous therapies such as parenteral nutrition ) and receiving parenteral nutrition (TPN, to infuse specialized form of food through an IV) when the central venous dressing was not done properly, there was no flushing order, the physician order did not indicate the correct site , care plan was not revise to reflect the correct site and implement intervention, and intake and output was not initiated .These failures had the potential to affect the residents' health conditions. Residents Affected - Few Findings : During a concurrent observation and interview with the director of nursing (DON) on 11/16/22 at 11:00 a.m., Resident 45's left chest central venous line has a transparent dressing secured with a white adhesive in the ends .The central venous line tip position was closed to the white adhesive and made it less visual of the surrounding site. The DON stated the dressing should have more window to look and be able to assess the entry site (tip) .The DON stated the dressing needed to be change. Review of Resident 45's clinical record indicated she was readmitted to the facility with bacteremia ( an infection that enters the bloodstream) and on vancomycin ( a type of antibiotic ) . Resident 45 was also receiving parenteral nutrition ( TPN, to infuse specialized form of food through an IV [intravenous , through a [NAME]] ) Review of Resident 45' admission/ readmission evaluation dated 11/7/22, indicated Left upper chest with double lumen (line) central line and 2 surgical incisions . Review of Resident 45's physician order dated 11/7/22, indicated Right upper chest central line : Measure external catheter length with each dressing change prn ( as needed) for Right upper chest central line care .The order on 11/7/22 also indicated TPN Therapy per physician order at bedtime and on 11/8/22,Vancomycin HCL IV solution 750 milligram /150 millimeter (mg/ml) two times a day for bacteremia until 12/3/22 . The physician order did not include flushing the central line and measuring intake and output. Review of Resident 45's medication administration record (MAR) for November 2022, indicated the flushing order every 8 hours was discontinued on 11/7/22. Review of Resident 45's care plan dated 11/8/22, potential for complications at IV insertion site : Right chest central line . Interventions included to flush IV line per physician orders. During a concurrent interview and record review with registered nurse C (RN C) on 11/16/22 at 9:57 a.m., he stated registered nurses were flushing the central venous line and confirmed Resident 45 did not have an order to flush the central venous line .RN C verified a missing physican order to flush the central line since 11/7/22. The care plan was reviewed and he stated it needed to be revised to reflect the correct site which was on the left chest and the intervention was not implemented to flush the central line as ordered. 555444 Page 23 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with the assistant director of nursing (ADON) on 11/17/22 at 12:09 p.m., she stated for Resident 45 receiving IV antibiotic and TPN, there was no need to record the intake and output , and it depends on the physician order . During a concurrent interview and record review with the DON on 11/18/22 at 12:00 p.m., the facility's intake / output policy was reviewed. The DON stated intake and output should have been initiated for Resident 45. Review of the facility's policy, IV Dressing Change, dated 8/19/22 , indicated Placed a sterile, transparent semipermeable dressing over the insertion site, and catheter hub to prevent contamination of the insertion site. Review of the facility's policy Intake and Output measurement, dated 2/18/22, indicated monitoring of fluid intake and output is essential in patients who receive IV therapy or parenteral or enteral feedings. Fluid intakes includes IV fluids . Record intake and output measurement in millimeters on a 24 -hour intake and output record. 555444 Page 24 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

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 ensure resident receiving dialysis (removal of waste and excess fluid from the body) treatment received care consistent with professional standards for one sampled resident (Resident 85) when his Hemodialysis Communication Forms (HCF) were incomplete and missing. This deficient practice had the potential for Resident 85's dialysis care not being properly communicated and could put Resident 85 at risk for complications. Residents Affected - Few Findings: Review of Resident 85'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 85 received dialysis on Tuesday, Thursday, and Saturday. Review of Resident 85's HCFs indicated the HCF was not completed consistently. Resident 85's HCF dated 8/09/22, indicated the Section 1: completed by Manorcare staff was incomplete. HCFs on 7/21/22, 8/13/22, 8/25/22, and 9/17/22 were missing. The dialysis center staff used a blank paper to document Section 2: completed by dialysis center on 7/21/22. During a concurrent interview and record review with the director of nursing (DON) on 11/16/22 at 10:10 a.m., she reviewed Resident 85's HCF dated 8/09/22 and stated the HCF were incomplete. The DON further acknowledged there was no HCF on 7/21/22, 8/13/22, 8/25/22, and 9/17/22. The DON stated the HCF should have been completed by a nurse and sent with the resident to communicate with the dialysis center. Review of the facility's Dialysis Communication Form dated 4/2022, indicated Completed by nurse and sent with patient every time the patient goes to dialysis outside of the center. Review of the facility's policy, Dialysis Guidelines dated 11/2017, indicated Both the center and the dialysis facility are responsible for shared communication regarding patients receiving dialysis services. The Hemodialysis Communication Form was to be used. 555444 Page 25 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe disposal of a used fentanyl patch (a potent narcotic medication applied to the skin for pain) for one of one resident (Resident 18); and controlled substance (drugs with high potential for abuse or addiction) medications were fully accounted for three out of seven residents (Residents 83, 96, and 107), when medications were signed out of the Control Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented as given to the resident on the medication administration record (MAR). The failure had the potential for accidental exposure and/or diversion of controlled medications. Findings: 1. During a medication administration observation on [DATE], at 9:14 a.m., in Resident 18's room, Registered Nurse B (RN B) removed the used fentanyl patch and placed a new patch on the resident's right shoulder. During an interview with RN B, on [DATE], at 9:29 a.m., she stated she threw the used fentanyl patch in the resident's trash can by the resident's bed. RN B then picked up the used fentanyl patch and put it in the open trash bin on the side of the medication cart (which was accessible to staff, residents, and visitors). She stated she would normally dispose of the used fentanyl patch in the medication cart's trash bin. During an interview with Licensed Vocational Nurse O (LVN O),on [DATE] at 9:44 a.m., she stated she had disposed of the used fentanyl patch by putting it in the gloves and threw in the open trash bin attached to the side of medication cart. During an interview with the unit manager (RN C), on [DATE] at 11:27 a.m., he stated for the disposal of used fentanyl patch to drop in the drug buster [a disposal system that contains a solution to dissolve medications] and do not leave in the patient's room trash bin because it's a narcotic. During an interview with the Director of Nursing (DON), on [DATE] at 2:40 p.m., she stated they should put the patch in the drug buster. She stated, They can't put it in the trash can. During a review of facility's Policy and Procedures title Disposal /Destruction of Expired or Discontinued Medication, dated 04/2022, the P& P indicated, Facility staff should destroy and dispose of medications in accordance with facility policy and Applicable Law, and applicable environmental regulations. A review of Lexi-comp, a nationally recognized drug information, indicated, Accidental exposure of even one dose of fentanyl . can result in a fatal overdose of fentanyl .Deaths due to a fatal overdose of fentanyl have occurred when children and adults were accidentally exposed to fentanyl transdermal patch. Strict adherence to the recommended handling and disposal instructions is of the utmost importance to prevent accidental exposure. 2. The Controlled Drug Records (CDRs) for seven (7) random residents receiving PRN (meaning as needed) controlled medications were requested for review during the survey. 555444 Page 26 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with the Assistant Director of Nursing (ADON) on [DATE] at 11:02 a.m., she stated when nurses removed a controlled medication for administration, they needed to document the administration on the MAR to indicate it was given to the resident. a. Resident 107 had a physician's order, dated [DATE], for oxycodone-acetaminophen 5/325 mg 1 tablet every 3 hours as needed for cancer-related pain. On [DATE] at 11:02 a.m., a review of Resident 107's CDR for oxycodone-acetaminophen 5/325 mg and the [DATE] MAR with the RN C indicated a nursing staff signed out one (1) tablet on [DATE] at 0000 a.m., but did not document the administration on the MAR. The RN C verified this finding. b. Resident 83 had a physician's order, dated [DATE], for oxycodone (a potent controlled medication for moderate to severe pain) 10 milligrams (mg, unit of measurement), 1 tablet by mouth every 4 hours as needed for severe breakthrough pain. During a concurrent interview and record review with the ADON on [DATE] at 11:26 a.m., a review of Resident 83's CDR for oxycodone and the 5/2022 MAR reflected the nursing staff signed out of the CDR but did not document the respective administration on the MAR on [DATE] at 2:00 a.m. The ADON verified this finding and acknowledged one (1) oxycodone tablets were not accounted. c. Resident 96 had a physician's order, dated [DATE], for hydrocodone-acetaminophen (a controlled medication for pain) 5/325 mg, 1 tablet every 6 hours as needed for moderate pain. On [DATE] at 11:44 a.m., a review of Resident 96's CDR for hydrocodone-acetaminophen and the [DATE] MAR with the ADON indicated, on [DATE] at 5:45 a.m., the nursing staff removed a tablet of hydrocodone-acetaminophen without documenting the administration on the MAR. She verified one hydrocodone-acetaminophen tablet was unaccounted. During a review of facility's Policy and Procedures(P&P) title General Dose Preparation and Medication administration. dated 08/2018, it indicated, Document the administration of controlled substance in accordance with Applicable Law. 555444 Page 27 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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** 5. Review of Resident 2's physician order indicated he had an order for clonazepam 0.75 mg every day for anxiety (intense, excessive, and persistent worry and fear about everyday situation) manifested by verbalizing of feeling anxious like having panic attacks, started on 1/13/22. Review of Resident 3's physician order indicated she had orders for duloxetine 20 mg at bedtime for depression (a persistent feeling of sadness and loss of interest) manifested by angry outbursts, started on 12/30/20, and olanzapine 5 mg at bedtime for schizoaffective disorder (a mental disorder characterized by abnormal thought processes and an unstable mood) manifested by hearing voices, started on 3/22/22. Review of Resident 7's physician order indicated she had an order for Lexapro 10 mg every day for depression manifested by verbalization of sadness, and it was started on 8/14/20. Review of Resident 11's physician order indicated she had an order for Paxil 30 mg every day for angry outburst, screaming, verbally aggressive to staffs, and it was started on 5/10/22. Review of Resident 36's physician order indicated she had an order for Lexapro 10 mg every day for depression manifested by verbalization of sadness, and it was started on 11/15/22. Review of Resident 52's physician order indicated she had orders for clonazepam 0.5 mg two times a day for anxiety manifested by crying and yelling, started on 1/17/22, Lexapro 10 mg every morning for depression manifested by crying, started on 2/23/22, and Seroquel 25 mg at bedtime for psychosis (a mental disorder characterized by a disconnection from reality) manifested by seeing things not present, started on 3/25/22. Review of the clinical records of Residents 2, 3, 7, 11, 36, and 52 indicated there were no monitoring the number of episodes of manifested behaviors for Residents 2, 3, 7, 11, 36, and 52. During an interview with the director of nursing (DON) on 11/18/22 at 3 p.m., she acknowledged that the number of episodes of manifested behaviors should have been monitored and recorded for Residents 2, 3, 7, 11, 36, and 52. Review of the facility's policy, Psychotropic Drug Use, Long-Term Care, dated 5/20/22, indicated Implementation: . Use a behavior monitoring tool to identify the frequency, intensity, duration, and impact of the resident's behavior. Based on observation, interview and record review, the facility failed to ensure 12 of 23 sampled residents (Resident 102, 162, 10, 82, 2, 3, 7, 11, 36, 52, 22 and Resident 45) were free from unnecessary psychotropic (any drug that affects brain activities associated with mental processes and behavior) medications when the psychotropic medications ordered did not include monitoring of the targeted behaviors every shift, and the monitoring of side effects were not specific to each type/classification of psychotropic medications. These failures had the potential to result in staff not monitoring the intended target behaviors, 555444 Page 28 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the side effects of the medication and not properly evaluating the effectiveness of the psychotropic medications. Findings: 1. Review of Resident 102's clinical record indicated she was admitted on [DATE] with diagnosis that included depression (behavior that affects the person's ability to work, sleep, study, eat, and enjoy once-pleasurable activities). Her physician's order dated 10/4/22 included Cymbalta (antidepressant) DR (delayed release) 30 milligrams (mg, unit of measurement) one capsule twice per day for depression manifested by feeling down/depressed, and monitor side effects related to use of psychotropic medications. Review of Resident 102's medication administration record (MAR) for October and November 2022, indicated behaviors were monitored twice at 9:00 a.m. and 5:00 p.m. by indicating yes or no if the behavior was observed and did not indicate the number of behavior episodes observed. The behavior was not monitored during the night shift. The monitoring of the side effects monitoring done every shift was not specific to Cymbalta. 2. Review of Resident 162's clinical record indicated admission on [DATE] with diagnoses of insomnia, malignant neoplasm (cancerous tumor that develops when abnormal cells grow, multiply and spread to other parts of your body) of the lungs. A review of Resident 162's physician's order dated 11/11/22 included Sertraline (antidepressant) 25 mg. one tablet by mouth at bedtime. A review of Resident 162's medication administration record (MAR) for November 2022, indicated the behavior was monitored and documented once at 9:00 p.m. (bedtime) when the medication was ordered to be administered. The documentation of behavior was either yes or no if the behavior was observed and did not indicate the number of behavior episodes observed, and was not monitored every shift. The monitoring of the side effects monitoring done every shift was not specific to Seroquel. During a record review and concurrent interview with registered nurse S (RN S) and licensed vocational nurse T (LVN T) on 11/17/22 at 4:03 p.m., RN S and LVN T reviewed Resident 102 and 162 physician's orders and their respective MAR and verified licensed nurses did not monitor and document every shift the target behaviors specific to the ordered medications, and did not also indicate the number of behaviors episodes observed. Both RN S and LVN T confirmed they could not identify the side effects of each of the psychotropic medications. During an interview with registered nurse C (RN C), Unit Manager, on 11/17/22 at 4:21 p.m., RN C stated, no way to know the number of episodes. He confirmed and concurred the number of behavior episodes could not be quantified if the documentation required was asking if the resident exhibited the behavior or not. RN C also verified the side effects specific to each psychotropic medication were not monitored. During an interview with the pharmacy consultant (PC) on 11/18/22 at 12:22 p.m., she stated having done medication regimen review (MRR) for all the facility residents on a monthly basis. The PC upon review of Resident 102 and 104's records confirmed that the behavior were not consistently monitored every shift and could not be quantified. The PC stated, the facility can do better in quantifying the behavior episodes. The PC also confirmed the side effects monitoring done by staff were not 555444 Page 29 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

F 0758 specific to the medication. Level of Harm - Minimal harm or potential for actual harm During an interview with the administrator (ADM) and director of nursing (DON) on 11/21/22 at 12:33 p.m., both the DON and ADM confirmed there was a problem in the behavior and antipsychotic medications side effects monitoring. Both staff stated these issues would be discussed during their QAPI (Quality Assurance and Performance Improvement) meeting. Residents Affected - Some A review of the May 20,2022 revised facility's policy, Psychotropic Drug Use in Long Term Care, indicated facility to use a behavior monitoring tool to identify the frequency, intensity, duration, and impact of the resident's behavior. Ensure that the targeted behavior is identified, diagnosed as appropriate for treatment with psychotropic drugs, and monitored routinely. Monitor the resident closely for adverse reactions to the psychotropic drug. 6. Review of Resident 22's clinical record indicated he was admitted on [DATE] with diagnoses including Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), dementia (decline in mental capacity affecting daily function), and anxiety (chronic condition characterized by excessive and persistent worry and fear without cause). Review of Resident 22's physician's order, dated 10/31/22, indicated Lorazepam 0.5 mg by mouth two times a day for anxiety/agitation manifested by inability to relax. Review of Resident 22's October and November medication administration record (MAR) indicated Lorazepam was administered at 9 a.m. and 5.p.m. every day. There was an entry on the MAR labeled behavior where licensed nurses were indicating yes or no to behavior when they administered the Lorazepam at the designated times. During an interview with licensed vocational nurse I (LVN I) on 11/17/22 at 4:20 p.m., she stated Resident 22 receives Lorazepam every evening. She further stated Resident 22 gets agitated and on occasion swings his cane at staff. LVN I stated she does not record Resident 22's number of agitation episodes on the MAR during her shift, but only documents Yes or No if behavior occurred at the time of the 5p.m. Lorazepam administration. During a record review of Resident 22's MAR and concurrent interview with licensed vocational nurse supervisor J (LVNS J) on 11/17/22 at 4:30 p.m., he stated licensed nurses document yes or no if behavior was present at 9 a.m. and 5 p.m. when Lorazepam is administered to Resident 22. When asked if behaviors occur for Resident 22 on the night shift, do the licensed nurses record the behavior yes or No on the MAR. LVNS J stated there was no documentation of behaviors by the night shift nurses, he added the behaviors would be documented in Resident 22's progress notes. LVNS J confirmed there was no documentation on the MAR to indicate the frequency of episodes of behavior manifested by Resident 22. LVNS J stated the frequency of episodes should be documented by all shifts to identify if the use of Lorazepam is effective for the target behavior. During an interview with the pharmacy consultant (PC) on 11/18/22 at 12:30 p.m., she stated there should be quantified, measurable behavior monitoring done by licensed nurses on all shifts when a resident receives Lorazepam. She further stated when licensed nurses indicate yes or no for behaviors, it only indicates there is behavior but does not indicate if there were multiple episodes of the behavior. 7. Review of Resident 45's physician order dated 11/7/22 , indicated Buspirone HCL 10 mg , give one 555444 Page 30 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

F 0758 tablet by mouth three times a day for anxiety m/b angry outburst r/t life events and medical condition . Level of Harm - Minimal harm or potential for actual harm Review of Resident 45's MAR indicated Buspirone was scheduled at 9:00 a.m.,1:00 pm., and 5:00 p.m. The documentation of behavior was either yes or no and side- effects monitoring every shift was not specified. Residents Affected - Some During an interview with RN B on 11/18/22 at 10:14 a.m., she was asked the side -effects of Buspirone and stated she was not sure . RN B stated she would need to look at the internet . RN B stated she would monitor the episodes by entering yes or no in the MAR . 3. For Resident 10, there was no specific behavior for the use of Seroquel (an antipsychotic medication) for bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic [extremely elevated and excitable mood associated with bipolar disorder] high). During review of Resident 10's physician's order, dated 03/04/22, indicated, Seroquel 150 mg tablet by mouth in the afternoon for bipolar disorder type manifested by paranoid (characterized by, or suffering from the mental condition pf paranoia), ideation, auditory hallucination such as hearing voices r/t physical and verbal aggression. GIVE Seroquel IN THE AFTERNOON WITH FAMILY PRESENT. IF NO FAMILY PRESENT MAY GIVE AT 7:00PM. During an interview with LVN N on 11/17/22 at 11:38 a.m., showed there was no behavioral monitoring for room to room wandering for Resident 10 During an interview with the Assistant Director of Nursing (ADON) on 11/17/22 at 2:27 p.m., she stated for behavior monitoring the staff document in progress notes. During a review of Resident 10's electronic health record and eMARs (electronic medication administration record), no specific behavior monitoring since February 2022 to November 2022. Review of facility's policy and procedure (P &P) titled Psychotropic drug use, long-term care dated May 20,2022, indicated Use a behavior monitoring tool to identify the frequency, intensity, duration, and impact of the president's behavior. Include the location, surrounding, or situation in which the behavior occurred to help the multidisciplinary team identify individualized interventions or approaches necessary to prevent or address the behavior. 4. The facility increased Resident 82's Zyprexa (Olanzapine-to treat mental disorders, including schizophrenia, [a disorder that affect a person's ability to think, feel, and behave clearly], and bipolar disorder) bipolar disorder and there was no documentation for behavior monitoring. A review of Resident 82's clinical record indicated he was admitted to the facility with diagnoses of ENCEPHALOPATHY(a disease in which the functioning of the brain is affected by some agents or condition such as viral infection or toxins in the blood), DEMENTIA (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) IN OTHER DISEASES CLASSIFIED ELSEWHERE, UNSPECIFIED SEVERITY, WITH OTHER BEHAVIORAL DISTURBANCE, SCHIZOAFFECTIVE (a mental health condition including schizophrenia and mood disorder symptoms) DISORDER, UNSPECIFIED, BIPOLAR DIORDER. During an interview with licensed vocational nurse N (LVN N) on 11/17/22 at 11:31 a.m., stated nobody show to them the behavior monitoring of medication sheet. She's not sure if they entered in the 555444 Page 31 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

F 0758 computer showed behavioral monitoring for room to room wandering in a paper form, Level of Harm - Minimal harm or potential for actual harm During an interview with the Assistant Director of Nursing (ADON) on 11/17/22 at 2:04 p.m., she stated nurses should undergo training, cause the way they understood the behavior observe like checking Yes or No. She acknowledges they need to educate the staff. Residents Affected - Some A review of Lexi-comp, a nationally recognized drug information resource, it indicated antipsychotic medications have the ability to cause metabolic changes including increase in blood sugar and lipids (such as cholesterol and triglycerides). Lexi-comp indicated to monitor lipid panel 12 weeks after initiation and dose change, then annually for Seroquel and olanzapine use. Review of facility's P&P titled Psychotropic drug use, long-term care dated May 20, 2022, indicated identify the date, time, and location of the resident's specific behavior that's causing concern as well as any identified trigger. Gather information from staff members who have witnessed the behavior., Use a behavior monitoring tool to identify the frequency, intensity, duration, and impact of the resident's behavior. Include the location, surrounding, or situation in which the behavior occurred to help the multidisciplinary team identify individualized interventions or approaches necessary to prevent or address the behavior., Monitor the resident's behavior to evaluate the effectiveness of therapy. 555444 Page 32 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

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 medication error rate of 11.11 %, when three medication error out of 27 opportunities during a medication administration for three of 13 sampled residents (Residents 82, 107, and 97) as follows: Residents Affected - Few 1.Resident 82 was given crushed divalproex sodium (brand name: Depakote; medication to treat seizure) ER (extended release, a long-acting form of medication) 2.Resident 107 was given Creon (medication used to treat for people who cannot digest food normally because their pancreas does not make enough enzyme) medication without a meal. 3.Resident 97 been given insulin (medication to lower blood sugar) without priming the needle. These failures had the potential to compromise the residents' medical health and the residents not receiving the full therapeutic effect of the medications. Findings: 1.During an observation of medication administration on 11/14/22 at 9:50 a.m., licensed vocational nurse N (LVN N) was observed preparing four medications for Resident 82. Using a crushing device, she crushed each medication including a tablet of Depakote ER and mixed them in applesauce before administering to Resident 82. A review of the pharmacy label on the Depakote bubble pack for Resident 82 indicated, Do NOT CHEW or CRUSH before swallowing. During an interview with LVN N on 11/14/22 at 10:23 a.m., LVN N stated, I have been crushing the Depakote ER every time I give to the resident. LVN stated she knew the Depakote ER was not supposed to be crushed but the resident could not swallow whole tablets. During an interview with the director of nursing (DON) on 11/15/22, at 2:32 p.m., the DON stated Depakote ER should not be crushed; the nurse should have contacted the physician to change to Depakote liquid. During resident 82's clinical record review for physician orders indicated, Divalproex sodium ER oral tablet extended release 24-hour 250 mg [milligram- unit of mass or weight] give 1 tablet by mouth every 8 hours for seizures, dated 8/31/22. A review of Lexi-comp, a nationally recognized drug information resource, indicated to not crush or chew extended-release tablets. 2.During an observation of the medication administration on 11/15 /22 at 11:45 a.m., LVN O was observed administering 2 medications to Resident 107 including 2 capsule of Creon. A review of the pharmacy label on the Creon bubble pack indicated to take it with meals. There was no lunch being provided at this time, at 11:45 a.m. During an interview with LVN O on 11/15/22, at 11:48 a.m., the LVN O acknowledged it should be 555444 Page 33 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

F 0759 given with a meal. Level of Harm - Minimal harm or potential for actual harm On 11/15/22 at 12:17 p.m., the lunch carts were observed being brought to the hallways. Residents Affected - Few During record review for resident 107's physician orders, dated 10/27/22, indicated, Creon Oral Capsule Delayed Release . give 2 capsules by mouth with meals. During an interview with the DON on 11/15/22, at 2:32 p.m., the DON stated medications with meals meant during meals or when resident had a bite of food. During a review of facility's Policy and Procedures (P&P) title Oral Drug Administration, dated 05/20/2022, it indicated, Verify that you're administering the medication at the proper time, in the prescribed dose, and by the correct route to reduce the risk of medication error. 3. During medication administration observation on 11/15/22 at 11:53 a.m., LVN O was observed preparing 3 units of insulin lispro (brand name: Humalog, a short-acting insulin) to Resident 97. She removed the insulin lispro pen from the medication cart, removed the cap, wiped the tip of the pen, placed the pen needle on the tip of the pen, dialed to 3 units, and proceeded to administering the insulin to the resident without first priming the pen needle. During an interview with LVN O on 11/15/22, at 11:56 a.m., LVN O stated she did not prime the insulin pen and did not know she was supposed to prime the pen needle. During an interview with DON on11/15/22, at 2:47 p.m., the DON stated the insulin pen should be primed at every injection to remove the air. Every nurse should know that, or it will be a med error. During record review of Resident 97's physician order, dated 8/31/22, indicated, Humalog Kwikpen Subcutaneous Solution Pen Injector 100 unit/ml (Insulin Lispro) Inject as per sliding scale (a set of instructions for administering insulin dosages based on specific blood glucose readings) for diabetes. During a review of facility's Policy and Procedures (P&P) title, Insulin pen use, home care, dated 05/2/2022, it indicated, Confirm that the patient holds the pen vertically with the needle pointing up, dials1 or 2 units on the dosage knob, and presses the injection button several times until a drop of insulin appears at the tip of the needle to prime the pen. A review of Lexi-comp, indicated the following for Humalog prefilled pen devices, Prime the needle before each injection with 2 units of insulin. 555444 Page 34 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 ensure proper medication storage and labeling of medication for two out of three medication storage rooms and three out of five medication carts, when: 1.Seven insulin (medication to treat high blood sugar) pens (devise to use to give preloaded insulin) had the pharmacy label on the caps instead of the body of the pens. 2.Two opened bottles of lorazepam ( medication used to treat anxiety disorder) were found in the medication refrigerator with no open date . 3.One inhaler (handheld portable device that delivered medication into the lungs) was found in the medication cart without open date. 4. An expired Humulin N (an intermediate acting insulin) insulin vial (a small glass or plastic bottles used to store liquids, or powder medication) was found in a medication cart These deficient practices had a potential for residents to receive medications with reduced potency from expired medications, and /or medication error due to medications not being labeled. Findings: 1. During a concurrent observation and interview with registered nurse R (RN R) on 11/14/22 at 11:05 a.m., in medication storage room V, an inspection of the medication refrigerator identified 2 insulin pens with pharmacy label on the caps instead of the body of the pens. She verified and stated there was a potential for medication error if not labeled properly. During a concurrent observation and interview with RN C on 11/14/22 at 11:33 a.m., in medication storage room W, an inspection of the medication refrigerator identified 2 insulin pens with pharmacy label on the caps instead of the body of the pens. RN C acknowledge it has a potential for wrong pen to be injected to resident in case of mix up. During a concurrent observation and interview with RN C on 11/15/22 at 9:44 a.m., in medication cart X, an inspection of the medication cart X identified 3 insulin pens with pharmacy label on the caps instead of the body of the pens. RN C stated and verified it has a potential for wrong pen to be injected to resident in case of mix up. During an interview with director of nursing (DON) on 11/15 /22, at 2:43 p.m., the DON stated the label should not be in the caps and will communicate with the pharmacist. 2. During a concurrent observation and interview with RN C on 11/14/22 at 11:33 a.m., in medication storage room X , two opened bottles of lorazepam was found with no open date. RN C verified the above observation. Review of the medication label indicated to discard medication lorazepam after 90 days once opened per manufacturer's recommendation. 555444 Page 35 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview with director of nursing (DON) on 11/15 /22, at 2:46 p.m., the DON stated that licensed nurses should date the medication once opened 3. During a concurrent observation and interview with LVN O and LVN U on 11/15/22 at 9:44 a.m., one incruse ellipta (medication to treat chronic lung diseases) inhaler open date on the label in medication cart Y. LVN O and LVN U both verified no open date for incruse ellipta inhaler. Review of the medication label indicated to discard incruse inhaler after 6 weeks once opened per manufacturer's recommendation. During an interview with director of nursing (DON) on 11/15 /22, at 2:46 p.m., the DON stated that licensed nurses should date the medication once opened . 4. During a concurrent observation and interview with LVN U on 11/15/22 at 10:01 a.m.,Resident 104 Humulin N vial was found in medication cart X . The label indicated was opned on for 10/15/22 and expiration date of 11/13/22. RN C verified the medication was expired. During a review of facility's Policy and Procedures (P&P) title Storge and Expiration Dating of Medication s, Biologicals, Syringes, and Needles, dated 04/2022, the P& P indicated, Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. 555444 Page 36 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

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 and interview, the facility failed to ensure food was stored in accordance with professional standards for food safety when Residents Affected - Some 1. Undated food, food past their best-by or use-by date, and expired food were found in the refrigerator and on the shelves in the kitchen; and 2. The ice machines did not have air gap. These failures had the potential to cause the growth of micro-organisms which could cause foodborne illness and cross-contaminated food for the 109 residents eating at the facility. Findings: 1. On 11/14/22 at 8:55 a.m., during an observation of the refrigerator and the storage shelves in the kitchen, with the Food Service Director (FSD), the following were observed: a. Two boxes of apple juice base were undated b. Six bags of frozen spinach were undated c. Two coconut cream pies were undated d. Two boxes of croissants were undated e. Four boxes of vanilla wafers best by 12/6/21 f. Four bags of angel food cake mix used by 9/30/22 g. 100 bags of one ounce of crackers used by 6/25/22 h. One bottle of banana extract expired on 9/2022 i. One bag of 25 pounds powdered non fat dry milk expired on 11/25/21 j. Two bags of 25 pounds powdered non fat dry milk expired on 11/2/22 k. Ten loads of texas toast dated 5/23/22. The FSD stated the loads were good for 3-5 months, and they were expired. l. Twelve bags of 24 ounces of gelatin mix dated 5/24/21 and 7 bags dated 10/11/21. The FSD stated the gelatin mix were good for one year, and they were expired. m. Three boxes of wild rice dated 6/21/21. The FSD stated the wild rice were good for one year, and they were expired. n. 24 bags of 24 ounces of lemonade mix dated 7/29/19. The FSD stated the lemonade mix were good 555444 Page 37 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

F 0812 for two years, and they were expired. Level of Harm - Minimal harm or potential for actual harm o. One box of 500 bags of saltine crackers dated 3/8/21. The FSD stated the crackers were good for one year, and they were expired. Residents Affected - Some During a concurrent interview with the FSD, he stated he would discard these food items. Review of the facility's policy, Labeling Food and Date Marking, dated 11/2020, indicated Foods are labeled following delivery, preparation or opening to identify the item and to provide date, time and, or temperature information. Review of the facility's policy, Storage of Food, dated 11/2020, indicated Guidelines: . 15. Discard food that has exceeded the expiration date or when use-by date was unclear. 2. During an observation and interview with the director of maintenance (DM) on 11/16/22 at 1:30 p.m., the ice machine in the dining room by the kitchen did not have an air gap. The DM stated he would fix it. During an observation and interview with the DM on 11/16/22 at 1:45 p.m., the ice machine at the nurse station Cambridge I did not have an air gap. The DM stated he would fix it. According to the 2017 Food and Drug Administration (FDA) Food Code, Section 5-402.11 Backflow Prevention, a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed. Review of the facility's icemaker instruction manual indicated G. Water Supply and Drain Connections: . Drain lines should not be piped directly to the sewer system. An air gap of a minimum of 2 vertical inches (5 centimeters) should be between the end of the drain pipes from the icemaker, the condensation drain, the storage bin, and the water-cooled condenser (if applicable) and the floor drain. 555444 Page 38 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 2's physician order indicated he had an order for oxygen 4 liters (L, a metric unit of volume) per minute every shift for short of breath, started on 1/10/22. Resident 2 also had an order for ipratropium-albuterol solution (used to relax and open the air passages to the lungs to make breathing easier) 0.5-2.5 (3) milligrams (mg, a metric unit of mass) per 3 milliliters (ml, a metric unit of volume) inhale orally four times a day for short of breath, started on 1/12/22. Residents Affected - Some During an observation with licensed vocational nurse N (LVN N) on 11/14/22 at 1:09 p.m., Resident 2 was on oxygen. The oxygen tubing was undated, and the filter of the oxygen concentrator was dusty. Resident 2's nebulizer (a device that turns the liquid medicine into a mist so it can be inhaled into the lungs) mask and tubing were also undated. During a concurrent interview with LVN N, she confirmed the filter of Resident 2's oxygen concentrator was dusty. LVN N stated the filter of the oxygen concentrator should have been cleaned, and she would inform the maintenance of the dusty filter. LVN N also stated Resident 2's oxygen tubing and his nebulizer mask and tubing should have been dated and changed every week. During an interview with the infection preventionist (IP) on 11/18/22 at 2:23 p.m., she stated oxygen tubing, nebulizer mask and tubing should be dated, and the filter of the oxygen concentrator should be clean. Review of the facility's policy, Oxygen Administration, dated 7/2017, indicated Preparation of Equipment: . 3. For oxygen concentrator, . Ensure that exhaust filters are clean and unblocked . Application of Nasal Cannula: . Ensure that tubing and cannula or mask is labeled with date and time. 3. Review of Resident 20's admission Record indicated she was admitted to the facility on [DATE]. During a dining observation on 11/14/22 at 12:37 p.m., certified nursing assistant P (CNA P) walked into Resident 20's room, pulled on a chair, and started feeding Resident 20 without cleansing her hands. During a concurrent interview with CNA P, she stated she should cleansing her hands before feeding Resident 20 her lunch. During an interview with the infection preventionist (IP) on 11/18/22 at 2:23 p.m., she stated the facility staff should cleanse their hands before feeding the residents. Review of the facility's policy, Feeding, Long-Term Care, dated 11/19/21, indicated Implementation: . Perform hand hygiene . 4. Review of Resident 36's admission Record indicated she was admitted to the facility on [DATE] with respiratory failure diagnosis. Review of Resident 36's physician order, dated 7/4/22, indicated she had an order for oxygen 2L per minute continuously every shift for short of breath. During an observation and interview with licensed vocational nurse N (LVN N) on 11/14/22 at 12:21 555444 Page 39 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

F 0880 Level of Harm - Minimal harm or potential for actual harm p.m., Resident 36 was on oxygen, and her oxygen tubing was undated. LVN N stated the oxygen tubing should be dated and changed every week. During an interview with the infection preventionist (IP) on 11/18/22 at 2:23 p.m., she stated the oxygen tubing should be dated. Residents Affected - Some Review of the facility's policy, Oxygen Administration, dated 7/2017, indicated Application of Nasal Cannula: . 7. Ensure that tubing and cannula or mask was labeled with date and time. 5. Review of Resident 43's admission Record indicated he was admitted to the facility on [DATE] with dysphagia (difficulty swallowing) diagnosis. Review of Resident 43's physician order indicated he had an order for 1300 milliliters (ml, a metric unit of volume) of enteral feeding (a way of delivering liquid nutrition directly to the stomach or small intestine) to be infused into him every day and water flush of 80 ml per hour during infusion, started on 11/10/22. During an observation and interview with licensed vocational nurse O (LVN O) on 11/16/22 at 2:30 p.m., Resident 43's water flush bag and syringe were undated. LVN O stated the water flush bag and the syringe should be dated and changed every day. During an interview with the infection preventionist (IP) on 11/18/22 at 2:23 p.m., she stated the water flush bag and the syringe should be dated. Review of the facility's policy, Enteral Tube Feeding, Gastric, dated 11/19/21, indicated Label the enteral administration set with the date and time that it was first hung. 6. During an observation and concurrent interview with licensed vocational nurse E (LVN E) on 11/16/22 at 1:28 p.m., LVN E was seen coming out of resident's room and noted her nails were colored light pink about three inches long. During the concurrent interview with LVN E she stated these are my own nails, I like it like that. During the concurrent interview with licensed vocational nurse V (LVN V), nurse supervisor, she stated LVN E was responsible in passing medications and responding to resident's call lights. During an interview with the director of staff development (DSD) and director of nursing (DON) on 11/16/22 at 1:31 p.m., the DON confirmed LVN E worked in the facility and from an agency. The DON stated, long nails were not allowed when working in the facility. The DSD stated, it's not safe and difficult to pass medications with long nails. The DSD also confirmed having long nails was considered infection control concern because long nails could harbor microorganisms. A review of the facility's June 2016 revised policy on Professional Appearance and Dress Code Guidelines for Employees, indicated fingernails must be kept clean and neatly trimmed so as not to interfere with work performance. Employees providing direct care must keep fingernails short (1/4 inch). Based on observation, interview and record review, the facility failed to ensure infection control practices were implemented when: 555444 Page 40 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

F 0880 Level of Harm - Minimal harm or potential for actual harm 1. Staff did not perform hand hygiene in between tasks and practiced triple gloving (wearing of multiple inner and outer gloves) during wound care; 2. Resident 2's oxygen tubing, nebulizer (a device that turns the liquid medicine into a mist so it can be inhaled into the lungs) mask and tubing were undated, and the filter of the oxygen concentrator was dusty; Residents Affected - Some 3. Certified Nursing Assistant P (CNA P) did not cleanse her hands before feeding Resident 20 her lunch; 4. Resident 36's oxygen tubing was undated; 5. Resident 43's water flush bag and syringe were undated; 6. Licensed vocational nurse had long nails when working with residents in the facility; 7. Staffs did not perform hand hygiene in between tasks and prior to applying hand gloves; 8. For Resident 27 and 45 , oxygen tubings were left uncovered and undated; and 9. For Resident 8, facility staff did not keep a urinary drainage bag connected to Foley catheter (a flexible tube placed in the bladder to drain urine) below the level of the bladder. These failures had the potential to result in the transmission and spread of infection throughout the facility. Findings: 1. During an observation of wound care performed by the treatment nurse (TN) on 11/16/22 at 10:45 a.m., the TN performed hand hygiene and then proceeded to apply three pairs of gloves on each hand. The TN removed the old dressings from the wound and removed the outermost set of gloves from both of her hands. The TN then applied a new dressing to the wound without performing hand hygiene or removing any of her remaining gloves. The TN stated she wears three sets of gloves to reduce the number of times I need to wash my hands During an interview with the TN on 11/17/22 at 8:35 a.m., she was asked if she followed standard practices for glove wearing when she wore triple gloves. The TN stated I need to wear one pair of gloves at a time and do hand washing or hand sanitizer in between each glove change. I should change my gloves in between the dressing change when I remove the old dressing and put on new gloves to put on the new dressing. During an interview with the infection preventionist (IP, professional who ensures healthcare workers and residents are practicing infection prevention) on 11/17/22 at 4:00 p.m., she stated staff should never wear double or triple sets of gloves at any time. She further stated hand washing or hand sanitizing should be done in between glove changes and gloves should be changed in between the dirty and clean tasks when performing a wound dressing change. Review of facility's Infection Control Manual - Practice Guidelines dated 7/21, indicated Gloves: wear only one pair of gloves at a time and change gloves between tasks and proceedures on the same 555444 Page 41 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

F 0880 patient or after contact with material that may contain a high concentration of microorganisms. Level of Harm - Minimal harm or potential for actual harm 7. During a concurrent observation and interview on 11/14/22 at 9:30 a.m., Resident 31 was lying in bed and her call light button was on the floor. Registered Nurse A (RN A) placed Resident 31's call light within her reach. RN A did not clean the call light prior to handing to Resident 31 and she stated she should have clean the call light light. Residents Affected - Some During an observation on 11/14/22 at 12:45 p.m., CNA F entered Room A and B respectively with a lunch tray and did not perform hand hygiene in between tasks. During an interview on 11/14/22 at 12:55 p.m., CNA F stated she forgot to perform hand hygiene. During a concurrent observation and interview on 11/16/22 at 12:22 pm., CNA G entered Room B with a lunch tray, fixed the wheel chair footrest, and applied hand gloves. CNA G did not perform hand hygiene prior to entering room and applying hand gloves. CNA G acknowledged she did not perform hand hygiene. 8. During an observation and concurrent interview with LVN D on 11/14/22 at 9:47 a.m., Resident 27's oxygen tubing was on top of the oxygen concentrator without a cover and dated 11/11/22. LVN D stated oxygen tubing should have a plastic cover. Review of Resident 27's physician order dated 3/24/22 indicated oxygen at 2L/m prn (as needed) for SOB (shortness of breath) During an observation and concurrent interview with LVN D on 11/15/22 at 11:35 a.m., Resident 45's oxygen concentrator has a tubing on the floor without a cover and undated. LVN D stated oxygen tubing should have been covered and dated. Review of Resident 45 physician order dated 11/7/22, indicated oxygen at 2l/m via nasal cannula (NC) prn for SOB. During an interview with the IP on 11/18/22 at 8:22 a.m., she stated staffs should perform hand hygiene before entering and exiting residents' room, and before applying hand gloves. IP also stated oxygen tubing should be secured in a bag when not in use. 9. Review of Resident 8's clinical record indicated, he was admitted on [DATE] and had diagnoses of sepsis (a life-threatening infection), obstructive and reflux uropathy (a blockage in the urinary track), urinary retention (a condition which you cannot empty all the urine from the bladder), and benign prostatic hyperplasia (BPH, a condition in men in which prostate gland is enlarged). During an observation on 11/14/22 at 9:39 a.m., Resident 8 was lying in bed and his urinary drainage bag with connecting tube was on the bed. During an observation and interview with certified nursing assistant K (CNA K) on 11/14/22 at 9:51 a.m., she confirmed the observation. CNA K stated the urinary drainage bag should be placed below the level of the bladder because urine from the bag could go back to his bladder and cause an infection. During an interview with the director of nursing (DON) on 11/15/22 at 1:34 p.m., she stated a 555444 Page 42 of 43 555444 11/18/2022 Sunnyvale Gardens Post Acute 1150 Tilton Drive Sunnyvale, CA 94087

F 0880 urinary drainage bag connected to a foley catheter should be kept below the level of the bladder. Level of Harm - Minimal harm or potential for actual harm Review of facility's policy Catheter care: indwelling catheter updated 4/2019, indicated Check that tubing is not kinked, looped, clamped, or positioned above the level of the bladder and off the floor. Residents Affected - Some The Centers for Disease Control and Prevention (CDC) guideline for prevention of catheter-associated urinary tract infections (2009) indicated, 3. Proper techniques for urinary catheter maintenance - 3.B.2. keep the collecting bag below the level of the bladder at all times. 555444 Page 43 of 43