Health inspection·May 3, 2019

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure residents administer medications correctly to themselves for one of two residents receiving eye drops. For Resident 19, the facility failed to ensure she was taught and monitored how she administered her own eye drops. This failure had the potential of Resident 19 contracting an eye infection. Residents Affected - Few Findings: During a medication administration observation on 5/1/19 at 8:16 a.m., licensed vocational nurse A (LVN A) handed Resident 19 a bottle of eye drops. While Resident 19 was administering her own eye drops, she touched the dropper tip to her eye. LVN A did not offer Resident 19 any education or instruction on how to use the eye dropper. During an interview with LVN A on 5/1/19 at 8:36 a.m., he stated he encouraged the residents to administer their own eye drops and inhalers in order to prepare them when they returned home. During an interview with Resident 19 on 5/3/19 at 2:43 p.m., she stated she might have touched the dropper tip to her eye. During an interview with LVN A on 5/3/19 at 2:55 p.m., he stated he had not taught Resident 19 any instruction or proper administration technique on use of the eye dropper. He just watched her. The facility's policy and procedure, 6.0 General Dose Preparation and Medication Administration revised on 1/1/13, indicated .5.7 Provide the resident with any necessary instructions (e.g., using an inhaler). Page 1 of 3 555524 555524 05/03/2019 Health Care Ctr at the Forum at Rancho San Antonio 23600 via Esplendor Cupertino, CA 95014

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation,interview and record review the facility failed to ensure food was stored, prepared, and served under sanitary conditions when foods were not labeled and dated. The kitchen staff did not demonstrate changing gloves in between tasks. These failures had the potential to affect safety in food consumption as well as cross contamination of food. Findings: During an initial kitchen tour observation on 5/1/19 at 8:17 a.m., with the dietary manager an open bag of vegetables had no opening date, two bags of noodles had an expiration date of 3/17/17. One bag of black garlic had no use by or expiration date. An open tartar (a cold sauce, typically eaten with fish, consisting of mayonnaise mixed with chopped pickles, capers) sauce had no open date. An open bag of thyme was unlabelled/undated and had a brown discoloration. The dietary aid B (DA B) changed the trash bin liners and went to the dish rack turned on the faucet and did not change gloves or wash hands. During a concurrent interview with the dietary manager, she confirmed the above observation. During an observation on 5/2/19 at 11:02 a.m., DA C was observed chopping broccoli with gloved hands. He then went to the sink and turned on the faucet to wash the broccoli without changing gloves. Concurrent he dietary manager stated the kitchen staff should have changed their gloves after chopping the broccoli and also when touching trash bin liners. The facility's 1/2019 policy, Food and Supply Storage, indicated all food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Procedures: Cover, label and dated unused portion and open package. All associates handling foods shall wash hands before handling food or clean utensils/dishes/equipment. 555524 Page 2 of 3 555524 05/03/2019 Health Care Ctr at the Forum at Rancho San Antonio 23600 via Esplendor Cupertino, CA 95014

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure residents stay free from infection for one of two residents receiving eye drops. For Resident 19, the facility failed to educate and monitor her use of eye dropper which had the potential of Resident 19 contracting an eye infection. Residents Affected - Few Findings: During a medication administration observation on 5/1/19 at 8:16 a.m., licensed vocational nurse A (LVN A) handed Resident 19 a bottle of eye drops. While Resident 19 was administering her own eye drops, she touched the dropper tip to her eye. LVN A did not offer Resident 19 any education or instruction on use of the eye dropper, nor offer her hand hygiene prior to administering the eye drops. During an interview with LVN A on 5/1/19 at 8:36 a.m., he stated he encouraged the residents to take their own eye drops & inhalers for when they go home. During an interview with LVN A on 5/3/19 at 8:03 a.m., he stated touching the tip of the eye dropper to Resident 19's eye could be an infection control issue. During an interview with the director of nursing (DON) on 5/3/19 at 2:35 p.m., she stated if Resident 19 touched the dropper to her eye, it needed to be thrown away and reordered right away. During an interview with Resident 19 on 5/3/19 at 2:43 p.m., she stated she might have touched the dropper tip to her eye. During an interview with LVN A on 5/3/19 at 2:55 p.m., he stated he had not taught Resident 19 any instruction or proper administration technique on use of the eye dropper. He just watched her. The facility's policy and procedure, 6.0 General Dose Preparation and Medication Administration revised on 1/1/13, indicated .3.5 If a medication which is not in a protective container is dropped, Facility staff should discard it according to Facility policy. 555524 Page 3 of 3