Health inspection·July 27, 2023

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. Based on observation, interview, and record review, the facility failed to ensure pharmaceutical products were stored and labeled correctly, when: 1a. One open and expired medication was available for use for Resident 23 in the medication cart, which put residents 23 at risk of receiving expired medication, 1b. One open and expired medication was available for use for Resident 45 in the medication cart, which put residents 45 at risk of receiving expired medication, 1c. Two open and expired medications were available for use for Resident 59 in the medication cart, which put residents 59 at risk of receiving expired medication, 1d. One expired medication was available in the medication cart, which put all residents at risk for receiving expired medications. These deficient practices had the potential for residents to receive medications with reduced potency, had the potential to result in medication errors, or drug diversion. Findings: 1. During an inspection of the Treatment medication Cart number 1 on 7/24/23, at 11:50 a.m., with Licensed Vocational Nurse (LVN 1), four expired, one expired and unlabeled with open date medications were identified in the locked compartment of the treatment medication cart, as follows: a. A Betaxolol (used to relax blood vessels and for slowing heart rate to improve blood flow and decrease blood pressure) eye drop for Resident 23 with an open date of 6/19/23. b. A Brimonidine (is used to lower pressure in the eyes) eye drop for Resident 45 with an open date of 6/25/23. c. A Brimonidine eye drop for Resident 59 with an open date of 6/25/23. d. A Dorzolamide (is used to treat increased pressure in the eye) eye drop for Resident 59 with an open date of 6/25/23. e. An opened multiuse Calmoseptine (multipurpose moisture barrier that protects and helps heal skin (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555611 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morton Bakar Center 494 Blossom Way Hayward, CA 94541 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)