Health inspection·June 9, 2023

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 observation, interview, and record review, the facility failed to ensure services were provided to meet the professional standard of practice for one of four residents (Resident 6) who had a pacemaker (implanted device for a heart condition, a battery-powered device implanted inside the heart to restore a normal heartbeat) when: Residents Affected - Few 1. The resident's medical record had no pacemaker-paced rate information, 2. The licensed nurse did not develop a care plan to manage pacemaker care. These failures had the potential to compromise Resident 6's health and safety. Findings: A review of Resident 6's clinical records indicated Resident 6 was admitted on [DATE] and had diagnoses including chronic diastolic (congestive) heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), and a pacemaker was implanted on 5/25/2022. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) A on 6/8/2023, at 3:17 p.m., LVN A confirmed Resident 6's medical record had no pacemaker-paced rate information, and no care plan to address the pacemaker care. LVN A stated, the pacemaker paced rate should be documented in the medical record, and nurses should have developed a care plan to monitor the malfunction of the pacemaker. During a concurrent observation and interview with LVN A on 6/8/2023 at 3:20 p.m., in Resident 6's room, LVN A confirmed Resident 6 had a pacemaker in his left upper chest.The LVN stated she did not know the pacemaker-paced rate and should have known the paced rate to monitor pacemaker malfunction. A review of the facility's policy and procedure (P&P), Pacemaker, Care of a Resident with a, revised 12/2015, the P&P indicated, for each resident with a pacemaker, document the following in the medical record and on a pacemaker identification card upon admission .paced rate A review of CMS's RAI Version 3.0 Manual chapter 4.2, Overview of the Resident Assessment Instrument (RAI) and Care Area Assessments (CAAS) indicated the facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs Page 1 of 9 555524 555524 06/09/2023 Health Care Ctr at the Forum at Rancho San Antonio 23600 via Esplendor Cupertino, CA 95014

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of 12 sampled residents (Resident 17) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when Resident 17 received Lorazepam (anxiolytic medication, used to reduce anxity)without a stop date. The failure had the potential to result in inadequate use of psychotropic medications. Findings: A review of Resident 17's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including unspecified dementia (a term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with the patient's daily life), anxiety, and depression. A review of Resident 17's physician's orders dated 5/19/2023 indicated administering Lorazepam 0.5 milligrams (mg, unit of measurement)1 tablet orally every 4 hours as needed (PRN) for anxiety manifested by restlessness. During a concurrent interview and record review with the Director of Nursing (DON) on 6/9/2023 at 1:33 p.m., the DON confirmed that the PRN Lorazepam order for Resident 17 was without stop date, and more than 14 days from the order date. The DON stated that the PRN psychotropic medication order should have a stop date. It should not exceed 14 days for the first time order and should not exceed 90 days for the second-time order. The PRN Lorazepam order for Resident 17 should have a stop date and should be stopped in 90 days. A review of the facility's policy and procedure titled Psychotropic Medication Use, effective date 12/01/07, indicated, PRN psychotropic medications should be ordered for no more than 14 days. Each resident who is taking a PRN psychotropic drug will have his or her prescription reviewed by the physician or prescribing practitioner every 14 days and also by the pharmacist every month .For psychotropic medications, if the attending physician believes a PRN order for longer than 14 days is appropriate, the attending physician can extend the prescription beyond 14 days for residents by documenting their rationale in the resident's medical record .the facility should not extend PRN antipsychotic orders beyond 14 days 555524 Page 2 of 9 555524 06/09/2023 Health Care Ctr at the Forum at Rancho San Antonio 23600 via Esplendor Cupertino, CA 95014

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications and biologicals were stored and labeled appropriately when: 1. Two unlabeled and opened bottles of Di-Dak-Sol diluted Dakin's solution (used to treat or prevent infections caused by cuts or abrasions, skin ulcers, pressure ulcers, diabetic foot ulcers, or surgery), and one unlabeled opened hydrocortisone cream 1% -topical (used to help relieve redness, itching, swelling, or other discomfort caused by skin conditions) were found in the treatment cart; 2. An expired and opened Fluocinolone acetonide Topical solution USP, 0.01% (used to reduce skin inflammation and relieve itching) and an expired opened Normal Saline solution (NSS) 100 milliliters (ml, a unit of measurement for volume) (mixture of sodium chloride in water and applied to the affected area or used to clean wounds) were inside the treatment cart; 3. One opened bottle of Doxazosin Mesylate (used in men to treat the symptoms of an enlarged prostate) in the medication cart had no change of direction label; and 4. One opened suture removal kit was found inside medication Cart A together with multiple house supply medication bottles. These failures could result in the accidental administration of expired or contaminated medications or biologicals to the residents. Findings: 1. During a concurrent observation and interview on [DATE] at 9:03 a.m., with licensed vocational nurse C (LVN C), the treatment cart had two opened bottles of Di-Dak-Sol diluted Dakin's solution with no expiration date, no resident's name and room number, and the label was ripped off. LVN C confirmed this observation and stated medications should have expiration date, label for instructions, resident's name, and room number. LVN C further stated these bottles should have been discarded. During a concurrent observation and interview on [DATE] at 8:57 a.m., with LVN C, the treatment cart had one unlabeled opened hydrocortisone cream 1%. LVN C confirmed this observation and stated the hydrocortisone cream should have been labeled. A review of the facility's policy and procedure, revised date 11/2020 titled Storage of Medication, indicated the nursing staff is responsible for maintaining medication storage and preparation areas in a safe, clean and sanitary manner. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 2. During a concurrent observation and interview on [DATE] at 9:02 a.m., with LVN C, one opened and expired bottle of NSS 100 ml was found inside the treatment cart. LVN C confirmed the observation and stated the NSS expired on [DATE] and should have been discarded. 555524 Page 3 of 9 555524 06/09/2023 Health Care Ctr at the Forum at Rancho San Antonio 23600 via Esplendor Cupertino, CA 95014

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the facility's policy, revised date [DATE] titled 8.2 Disposal /Destruction of Expired or discontinued Medication Manual title California LTC Facility's Services and Procedures Manual, indicated the facility should place all discontinued or outdated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medications discontinued and subject to destruction Facility should dispose of outdated medications, discontinued medication in a timely fashion or no more than 90 days of the date the medication was discontinued by physician/prescriber. 3. During medication pass observation on [DATE] at 8:07 a.m., with LVN A, she gave Doxazosin Mesylate to Resident 15. The label on the bottle indicated, Doxazosin Mesylate tablet 4 milligrams (mg, a unit of measurement) one tablet at bedtime. During a concurrent observation of medication cart A and interview with LVN A on [DATE] at 10:28 a.m., LVN A confirmed that the label on Resident 15's medication bottle of Doxazosin Mesylate tablet 4 mg indicated to take one tablet at bedtime. LVN A also confirmed the medication had been given in the morning ever since it was ordered on [DATE]. LVN A further stated that the medication came from an outside pharmacy and a direction change sticker should have been put on the outside of the bottle to prevent confusion. During an interview on [DATE] at 10:33 a.m., with the Director of Nursing (DON), the DON stated that medications coming from outside pharmacies should be checked by licensed nurses. The DON stated if the directions on the bottles do not match the physician's orders, a sticker for change in direction should be put in place. Review of the facility's policy, revised date [DATE] titled California LTC Center's Services and Procedures Manual Policy , indicated . 4.5 Reordering, Changing, and Discontinuing orders, indicated if an order has been changed and there is adequate supply on hand, the facility should notify the pharmacy to send a sticker or label indicating the change in directions. The policy further indicated the change in directions sticker should be applied to the existing supply of medications. 4. During a concurrent observation of medication cart A and interview with LVN A on [DATE] at 10:23 a.m., one opened suture removal kit tray was found inside medication cart A together with multiple house supplies (bulk medication shared by several residents)medication bottles. LVN A confirmed the observation and stated the removal kit tray should be stored inside the treatment cart, not mixed with the bottles of house supply medications. A review of the facility's policy and procedure, revised date 11/2020 titled Storage of Medication, indicated the nursing staff is responsible for maintaining medication storage and preparation areas in a safe, clean and sanitary manner. 555524 Page 4 of 9 555524 06/09/2023 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when: 1. A scoop was inside the dry legume container in the dry storage area; 2. There were opened, undated, unlabeled, and outdated food items in the food preparation and dry storage areas; 3. There were opened, undated, and unlabeled food items in the walk-in refrigerator; 4. There were undated, and unlabeled food items in the walk-in freezer. These failures had the potential to cause food contamination and food-borne illness to 22 of 22 residents who received their food from the kitchen. Findings: During an initial kitchen tour on 6/5/23 at 8:25 a.m., accompanied by the director of dining services (DDS), the following observations were made in the facility's kitchen: 1. Inside the kitchen's dry storage area there was a plastic bin containing dry legumes with a scoop inside the bin. The scoop was touching the legumes. The DDS confirmed the scoop was inside the bin on top of the dry legumes. The DDS stated there was a scoop holder inside the bin that could be used to store the scoop but he confirmed the scoop was laying in the dry legumes, not inside the scoop holder. Review of the facility's policy titled Food and Supply Storage, revised 1/23, indicated Dry Storage: Scoops may be stored in bins on a scoop holder. The food level must be no closer than one inch below the handle of the scoop. 2. There was an opened gallon container of barbeque liquid smoke on a shelf in the food preparation area. The label on the liquid smoke indicated it had a discard date of 5/1/23. The DDS confirmed the liquid smoke was beyond the discard date and he stated the liquid smoke must be discarded. Inside the kitchen's dry storage area, there was a plastic bag of uncooked bowtie pasta labeled with an open date of 12/15/22. There was a discard date of 5/1/23 on the pasta label. The DDS confirmed the pasta was beyond the discard date and he stated the pasta must be discarded. There was a plastic bag containing 12 hot dog buns on a shelf in the food preparation area. There was no label on the hot dog buns. The DDS confirmed the hot dog buns had no label. He stated all food items should be labeled with an open date and a discard date. The DDS stated the hot dog buns must be discarded. 3. In the walk-in refrigerator there was a metal container with three pieces of red meat inside covered with plastic wrap. There was no label and no date on the container. The DDS stated the red meat 555524 Page 5 of 9 555524 06/09/2023 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 was filet [NAME] and he confirmed there was no label and no date on the container of red meat. The DDS stated the red meat must be discarded. In the walk-in refrigerator there was an open 16-ounce container of whipped topping. There was no label and no date on the container. The DDS confirmed the whipped topping had no label and no date. He stated the whipped topping must be discarded. During a kitchen tour on 6/6/23 at 8:15 a.m., accompanied by the DDS, the following observations were made in the facility's walk-in freezer: 4. There was a package with 12 frozen pizza flatbreads that was unlabeled and undated. There was a package of 12 frozen tortilla rounds that was unlabeled and undated. There were 12 frozen turkey patties that were unlabeled and undated. There were 4 loaves of frozen rye bread that were unlabeled and undated. There were ice particles on the rye bread loaves and ice crystals at the bottom of the four rye bread bags. The DDS confirmed the presence of the ice particles in the bags of frozen rye bread. The DDS confirmed the pizza flatbread, the tortilla rounds, the turkey patties, and the rye bread loaves had no label and were undated. He stated all food items should be labeled with an open date and a discard date. The DDS stated the pizza flatbread, the tortilla rounds, the turkey patties and the rye bread must all be discarded. Review of the facility's policy titled Food and Supply Storage, revised 1/23, indicated Cover, label and date unused portions and open packages. Products are good through the close of business on the date noted on the label. Commercially produced foods may be held frozen until the manufacturer's expiration date, or for 3 months if no expiration date on the package. 555524 Page 6 of 9 555524 06/09/2023 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During the medication pass observation on [DATE] at 9:55 a.m., RN D touched the bedside table, gave the oral medication to Resident 3 without performing hand hygiene then went to the medication cart to get the drinking straw, opened the drinking straw and put it inside the cup of juice and gave to the Resident 3 without performing hand hygiene. Residents Affected - Some During an interview on [DATE] at 10:16 a.m., with RN D, she confirmed the above observation and stated that she should have performed hand hygiene in between procedure to prevent contamination. Review of the facility policy dated 8/2019, titled Handwashing/ Hand Hygiene, indicated this facility considers hand hygiene the primary means to prevent the spread of infections All personnel shall follow the handwashing/ hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non- antimicrobial) and water for the following situations: before and after direct contact with residents; before preparing or handling medications; after contact with objects in the immediate vicinity of the resident. 3. During an initial tour of the facility on [DATE] at 9:10 a.m., Resident 127's spirometer mouthpiece was touching the side table. During a concurrent observation and interview on [DATE] at 9:14 a.m., Licensed vocation nurse C (LVN C) confirmed the above observation. LVN C stated that the spirometer apparatus mouthpiece should not be touching the bedside table surface and it should be put inside the plastic bag. 4. During an initial tour of the facility on [DATE] at 9:06 a.m., trash can attach to the medication cart B has one used facial mask and one N-95 that were exposed. During a concurrent observation and interview on [DATE] at 9:07 a.m., with RN D, she confirmed the above observation. She stated that she just throws the N-95 inside the trash can that was attached to the medication cart and changed to facial mask and vice versa when passing medications to the different residents. She further stated that N-95 and facial mask should not be disposed inside the trash can attach to the medication cart B to prevent contamination and spread of infection. 5. During a medication room observation on [DATE] at 8:28 a.m., 8:41a.m., with LVN C, three medication containers inside the medication room refrigerator have grayish substance and the disposal container cover for discontinued/ refused medication had multiple red spots of liquid substance on top of the cover. LVN C acknowledge the observation and stated that the refrigerator's three medication containers and disposal container cover need to be clean to prevent contamination. 6. During an observation of treatment cart on [DATE] at 8:55 a.m., with LVN C, Inside the first drawer has grayish powder substance together with multiple treatment supplies that was stored. LVN C confirmed the observation and stated the treatment cart need to be clean to prevent contamination. 7. During an observation of medication cart A on [DATE] at 10:28 and 10:29 a.m., with LVN A, MOM liquid has dried whitish substance outside the bottle cover and the natural Dentist Healthy gums liquid/oral rinse( mouth wash) has greenish substance around the outside cup cover stored inside the medication cart A. LVN A acknowledge the observation and stated that it should have been clean and wipe 555524 Page 7 of 9 555524 06/09/2023 Health Care Ctr at the Forum at Rancho San Antonio 23600 via Esplendor Cupertino, CA 95014

F 0880 after used to prevent contamination. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure, revised date 11/2020 titled Storage of Medication, indicated the nursing staff is responsible for maintaining medication storage and preparation areas in a safe, clean and sanitary manner. Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure staff implemented proper infection control practices when: 1. The licensed nurse did not change gloves between tasks; 2. Registered Nurse D (RN D) did not perform hand hygiene in between procedures; 3. Resident 127's spirometer (an apparatus for measuring the volume of air inspired and expired by the lungs- measures ventilation, the movement of air into and out of the lungs) mouthpiece was touching the side table; 4. Trash can attached to the Medication Cart B has used facial mask and N-95; 5. Three medication containers inside the medication room refrigerator has grayish substance, and disposal container for discontinued and refused medication had red spots of liquid substance inside the medication room; 6. There was a grayish powder seen in the first drawer of the treatment cart. 7. The Medication Cart A had a bottle of Milk of Magnesia oral- MOM (a laxative to relieve occasional constipation and used as an antacid to relieve indigestion, sour stomach, and heartburn) liquid with dried whitish substance outside the bottle cover, and the oral hygiene solution (The natural Dentist Healthy gums liquid/oral rinse- mouth wash) has greenish substance outside the cup cover. These failures had the potential to result in cross-contamination and the spread of infection among residents and staff. Findings: 1. A review of Resident 6's clinical records indicated he was admitted on [DATE] and had diagnoses including bacteremia (viable bacteria in the blood) and lobar pneumonia (acute exudative inflammation of the entire lobe of a lung). A review of Resident 6's physician order dated [DATE] indicated to infuse Ceftriaxone(medication used to treat certain infections caused by bacteria) 2-gram solution /50 ml. (milliliter, unit of volume in the metric system) at 100 ml/hr (milliliter/ hour) over 30 minutes for pneumonia IV (intravenous therapy, uses a type of tiny plastic tubing that goes into the vein, a needle, and plastic tubing that connects the set-up to a bag of fluid) for 37 Days. During a concurrent observation and interview with Registered Nurse B (RN B) on [DATE] at 3:05 p.m., in Resident 6's room, Resident 6 had a peripherally inserted central catheter (PICC, a long, thin tube that's inserted through a vein in patients' arm and passed through to the larger veins near patients' heart) on his right upper arm. RN B disinfected the PICC line port with an alcohol swab, 555524 Page 8 of 9 555524 06/09/2023 Health Care Ctr at the Forum at Rancho San Antonio 23600 via Esplendor Cupertino, CA 95014

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some flushed the port with 10 ml. (milliliter, unit of measurement) prefilled normal saline, set up the IV pump machine and connected the IV line to the PICC line port with the same pair of gloves. RN B acknowledged that she should have changed gloves between tasks. RN B stated that using one pair of gloves to perform multiple tasks might cause cross-contamination. A review of the facility's policy and procedure(P&P) titled Standard Precautions Revised [DATE], the (P&P) indicated Gloves are changed as necessary, during the care of a resident to prevent cross-contamination . (When moving from a dirty site a clean one) . Gloves are not to be reused . Gloves are removed promptly after use, before touching non-contaminated items . 555524 Page 9 of 9