Health inspection·July 1, 2022

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 Resident 20's personal request to have a darker window cover/blinds/shades to prevent eye glare, and to have a over bed light cord string were accommodated; and facilty failed to honor Resident 20's food preferences. Residents Affected - Few These failures resulted in Resident 20's discomfort, and feeling stressed and irritated; and had the potential to result in patient not being able to maintain or achieve independent functioning, dignity, and well being to the extent possible in accordance with the resident's own needs and preferences. Findings: A review of Resident 20's facesheet included diagnoses of sleep disorder, seizures, glaucoma (eye disease that can cause vision loss and blindness) and macular degeneration (an eye disease that can blur the person's central vision). Her care plan on Impaired visaul function, dated 1/8/22 included intervention to provide lighting that avoid glare. 1. During an observation and concurrent interview with Resident 20 on 6/27/22 at 1:48 p.m., Resident 20 was awake, lying in bed. She stated the blinds are glary and awful, it gets hot without this blinds. It was observed that Resident 20 and her roommate's pull string/chain connected to the light over her bed were broken and both could not turn their individual lights on when needed. Resident 20 stated the night shift staff had a hard time changing her because if they turn on the ceiling light in the room, it would bother her roommate. Resident also expressed that she did not want to be bothered while sleeping when staff would turn on the ceiling light to provide care for her room mate. During an interview with certified nursing assistant G (CNA G) on 6/27/22 at 1:48 p.m., the staff confirmed the observation and stated that the resident's concerns should be addressed. During a follow up visit with Resident 20 on 6/29/22 at 9:54 a.m., Resident 20 was watching TV with her dark glasses, window blinds were not changed yet. The pull string/cord on both beds were not yet replaced/fixed. During an interview with the maintenance supervisor (MS) on 6/29/22 at 9:57 a.m., the MS stated he would change Resident 20's window blinds. The MS also stated he would fix the pull chain/string so each light could work individually whenever the resident wanted to turn their individual lights on. 2. During lunch observation on 6/28/22 at 12:50 p.m., CNA G provided Resident 20's lunch tray and it was observed that the tray contained cooked vegetables including carrots. Her meal card indicated Page 1 of 26 555712 555712 07/01/2022 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few DISLIKES Carrots. Resident 20 stated,' it's always that way it seems they are not reading the card. Resident 20 claims feeling irritated but had been used to, she then set aside the carrot which was mixed with the other vegetables in her tray. CNA G validated the observation and stated she would inform the kitchen. During an interview and concurrent record review with the registered dietician (RD) and director of nursing (DON) on 6/29/22 at 12:48 p.m., the RD stated that whoever admitted Resident 20 should have indicated resident's likes and dislikes in the Nutrition Assessment done on 5/1/22. The RD and DON reviewed Resident 20's initial admission Assessment section 6 (dietary section) done on 12/29/21 and confirmed it did not indicate Resident 20's food preferences. Both staff admitted the resident's preferences should be respected. Review of the facility's August 2009 revised policy and procedure, Quality of Life- Accommodation of Needs, indicated the resident's individual needs and preferences shall be accommodated to the extent possible . In order to accommodate individual needs and preferences, adaptations may be made to the physical environment, including the resident's bedroom .staff's attitudes and behaviors must be directed towards assisting the residents in maintaining independence, dignity and well being to the extent possible and in accordance with the resident's wishes. 555712 Page 2 of 26 555712 07/01/2022 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on interview and record review, the facility failed to follow their policy and procedure to notify the Office of the State Long-Term Care Ombudsman of Resident 29 being transferred twice to the hospital. This failure had the potential of Resident 29 being incorrectly transferred. Findings: During a review of Resident 29's electronic record (eRecord), Resident 29 had been transferred to the hospital on 7/29/2020 and again on 11/12/21. During an interview on 6/30/22 at 11:52 a.m. with social services staff (SS), SS stated Ombudsman is supposed to be notified of residents being transferred to the hospital. During an interview on 6/30/22 at 1:25 p.m. SS stated she could not find either notice from Resident 29's transfers to the hospital, which should have been sent to Ombudsman. During a review of the facility's policy and procedure titled, Transfer or Discharge Notice, revised 03/21, the policy and procedure indicated, Residents and/or representatives are notified in writing, and in a language and format they understand . a. Transfer refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility when the resident expects to return to the original facility; and b. Discharge refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community, when return to the original facility is not expected. c. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. 555712 Page 3 of 26 555712 07/01/2022 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

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 interview and record review, the facility failed to develop and update the care plans for three of 12 sampled residents (Residents 14, 20 and 28). For Resident 14, there was no care plan developed for scattered skin rashes on her several body parts. For Resident 20, there was no care plan developed for Cymbalta (antidepressant); and the care plan was not revised/updated or implemented for depression to reflect the change of medications, and ambulation. For Resident 28, there was no care plan developed regarding the presence of left eye conjuntivitis; the care plan for impaired visual function was not implemented. A personalized care plan identifies residents' individualized concerns/needs that outlines the care and services needed to meet their needs. Findings: Resident 14 was in bed with During an observation on 6/27/22 at 11:01 a.m., certified nursing assistant H (CNA H) was present in the room with Resident 14 and observed the resident rubbing her back against the sheets and mattress. CNA H noticed scattered skin rashes on her face, arms and back and resident said it's itchy. CNA H stated the nurses were aware that Resident 14 had this skin rashes the week before and had been scratching them. During a record review and concurrent interview with the minimum data set assistant (MDSA) on 6/29/22 at 11:29 a.m., the MDSA confirmed the resident's primary care physician (PCP) or nurse practitioner (NP) had not been informed of the new onset of skin rashes on her arms, face, and back. The Resident 14's care plan was not updated to include the care and management for the rashes. A review of Resident 20's facesheet included diagnoses of sleep disorder and major depressive disorder ( a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). During a record review and concurrent interview with the MDSA on 6/28/22 at 10:29 a.m., the MDSA reviewed Resident 20's physician's order that indicated Duloxetine HCL {hydrochloride}(Cymbalta, antidepressant) 30 mg. (milligrams, unit of measurement) 1 capsule by mouth daily for depression ordered on 4/29/22 and started 5/7/22. The MDSA did not find any care plan for Duloxetine/Cymbalta. The care plan for mood problem related to diagnosis of depressive disorder indicated administer medications for depression, Wellbutrin (antidepressant), monitor for effectiveness and side effects. The MDSA confirmed the care plan was not updated, and she stated the charge nurse should have updated it. The care plan dated 1/8/22, Impaired ambulation-wheelchair for locomotion- moving around, related to reduced mobility status had a goal to ambulate within the facility 3-5 times per week x 90 days and included intervention to ambulate per required assistance with staff. During an interview and record review with the director of nursing (DON) on 6/30/22 ar 2:47 p.m., the DON confirmed the care plan required revision and needed to be updated. A review of Resident 28's facesheet indicated admission on [DATE]. Her MDS dated [DATE] and 5/5/22 indicated impaired vision and difficulty hearing. 555712 Page 4 of 26 555712 07/01/2022 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 6/27/22 at 10:09 a.m., Resident 28 was in bed awake. Resident 28 claimed she loved reading books and stated, I can't read because of the problem in my eyesight. It was observed that her left eye was red and lower eyelid was swollen. A review of Resident 28's clinical record indicated a physician's order dated 6/23/22 included Gentamicin (antibiotic- treat infection) ointment one drop to left eye twice/day for 7 days for conjunctivitis (highly contagious eye infection and can spread from person to person with symptoms that could last for two weeks after symptoms first appear). There was no care plan developed for conjunctivitis and the use of antibiotics (Gentamicin). A review of Resident 28's Impaired visual function care plan dated 2/6/22 included intervention to arrange consultation for eye care practitioner as required and was not implemented. Optometry/Ophthalmology (optometry deals with the eye and vision care/treatment/ophthalmology is a specialty that deals in eye and vision care) evaluation and treatment as indicated. During an interview and record review with the director of nursing (DON) on 7/1/22 at 8:47 a.m., the DON confirmed that Resident 28's care plan for conjunctivitis and antibiotic use were not developed. 555712 Page 5 of 26 555712 07/01/2022 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

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 interview and record review, the facility failed to provide care and services according to professional standards of practice for two of 12 sampled residents (Residents 19 and 40). When Resident 19's Depakote (medication to treat certain seizures, mania caused by bipolar disorder) level every 6 months and Resident 40's EKG (electrocardiogram, measures the heart's electrical activity) every 6 months while on Nuplazid (indicated for the treatment of hallucinations and delusions associated with Parkinson's disease psychosis) were not done as ordered. These failures could negatively affect the resident's health, safety, and well-being in the facility. Residents Affected - Few Findings: Review of Resident 19's, clinical record, indicated she was admitted with Schizoaffective disorder (a condition that can make you feel detached from reality and can affect your mood), psychotic disorder with hallucinations (mental disorders in which a person's personality is severely confused and that person loses touch with reality), paranoid personality disorder (mental health condition marked by a pattern of distrust and suspicion of others without adequate reason to be suspicious). Review of Resident 19's physician's orders included, order date 6/21/2013, indicated Depakote level every 6 months (Oct./Apr). During a concurrent interview and record review with licensed vocational nurse F (LVN F), on 6/30/2022 at 11:50 a.m., LVN F confirmed that Resident 19's Depakote level was checked on 4/30/2020 and 11/9/21, but no record that it was checked on 10/2020, 4/21 and 4/22. LVN F stated that Depakote level should be checked every 6 months as indicated in the physician's order. Review of Resident 40's clinical record indicated she was admitted with diagnoses including, Parkinson's Disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), psychotic disorder with hallucinations. Review of Resident 40's physician orders, dated 11/16/2020, indicated EKG every 6 months while on Nuplazid (Nov/May). During a concurrent interview and record review with LVN F, on 6/30/2022 at 3:05 p.m., LVN F confirmed that EKG was done on 11/17/2020 and 7/26/21, but no record that it was done after 7/26/21. LVN F stated that EKG was supposed to be checked every 6 months while on Nuplazid. LVN F further stated that Nuplazid can cause abnormal heart rhythm. RN N acknowledged the above findings. 555712 Page 6 of 26 555712 07/01/2022 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A review of Resident 28's facesheet indicated admission on [DATE]. Her MDS dated [DATE] and 5/5/22 indicated impaired vision and difficulty hearing. Residents Affected - Few During an observation on 6/27/22 at 10:09 a.m., Resident 28 was in bed awake, watching TV without any sounds. Resident 28 claimed she had no hearing aid and had difficulty with hearing but could not turn the TV loud enough to hear because the facility would not allow it. Resident claimed she could not reach for her headphones which were hung near the TV set and staff did not offer it to her. Resident 28 also indicated she loved reading books, and she stated, I can't read because of the problem in my eyesight. Resident 28 stated she and her daughter were concerned about her eye and wanted to see the eye specialist. During the concurrent interview with certified nursing assistant G (CNA G) who was at bedside, CNA G validated Resident 28 was not wearing her hearing aid and offered the headphones but she could not make it work. During a record review and concurrent interview with licensed vocational nurse F (LVN F) on 6/30/22 at 10:41 a.m., LVN F stated Resident 28 needed eye referral, and the social worker should have sent the eye consult referral since the physician's order was in place since 1/25/22. LVN G also confirmed the care plan dated 2/5/22 for impaired visual function . included consultation with eyecare practitioner was not done. During an interview and concurrent record review with the social services staff (SS) on 6/30/22 at 10:41 a.m., the SS admitted having missed to include Resident 28 in the list for residents to be seen by the eye doctor during the visit on 1/28/22. The SS also confirmed from Resident 28's family that resident had her hearing aid in the facility and should wear them at all times. 555712 Page 7 of 26 555712 07/01/2022 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to consistently provide a restorative nurse assistant (RNA) program (nursing intervention to assist or promote resident's ability to attain their maximum functional potential) for two residents (20, 28). These failures had the potential to compromise the residents' ability to attain their maximum functional potential and result in a decline of resident's health. Findings: Review of Resident 20's clinical record indicated she was admitted with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body), and muscle weakness. Her admission minimum data set (MDS, an assessment tool) dated 1/6/22 indicated she had functional limitation in range of motion with impairment on both sides of upper and lower extremities, and resident and direct care staff believed she was capable of increased independence in at least some ADLs (activities of daily living, i.e bed mobility, transfer, dressing, toilet use, personal hygiene. etc.). A review of Resident 20's care plan, The resident has hemiplegia/hemiparesis . dated 1/8/22 included a goal to maintain optimal status and quality of life within limitations imposed by hemiplegia/hemiparesis, and the intervention included range of motion (ROM), active or passive with am/p.m. care daily. A review of Resident 20's care plan, The resident has an ADL self-care performance deficit . and the resident has impaired physical mobility . dated 1/8/22 both included intervention such as RNA, PT, OT referrals as indicated and ordered . During an observation and concurrent interview with 6/29/22 12:09 p.m., Resident 20 was in bed awake and she stated she stayed in bed most of the time. The resident also stated, I would love to be able to get out of bed at least or have someone help me with bed exercises, that would be great, in this facility no one had done that. During an interview with certified nursing assistant I (CNA I ) and certified nursing assistant J (CNA J) on 6/29/22 at 4:06 p.m., both staff claimed they worked evening shift and had been regularly assigned to Resident 20 and stated never done any exercises to her because she never asked for it. 2. A review of Resident 28's clinical record indicated she had the diagnoses of disorder of the autonomic nervous system ( system that regulates involuntary physiologic processes including heart rate, blood pressure, respiration, digestion, and sexual arousal ), muscle weakness, abnormality of gait (manner of walking) and mobility, low back pain, osteoarthritis (degenerative joint disease that can affect the many tissues of the joint). A review or Resident 28's admission MDS dated [DATE] , indicated she had functional limitation in range of motion with impairment on both sides of upper and lower extremities, and resident and direct care staff believed she was capable of increased independence in at least some ADLs. During a record review and concurrent interview with the MDS Coordinator (MDSC) on 6/30/22 at 12:08 555712 Page 8 of 26 555712 07/01/2022 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few p.m., the MDSC confirmed Resident 20 and 28 had been assessed to have the potential and would require RNA program to help prevent their decline. The MDSC confirmed that there was no RNA or therapy initiated. The MDSC also stated, I think I've missed it. During an interview with the director of nursing (DON) on 6/30/22 at 2:47 p.m. , the DON confirmed the RNA program should have been done for Residents 20 and 28. Review of the facility's July 2017 revised policy and procedure, Resident Mobility and Range of Motion, indicated residents will not experience an avoidable reduction in ROM. Residents with limited ROM will receive treatment and services to increase and/or prevent a further decrease in ROM. As part of the comprehensive assessment, the nurse will identify the resident's . opportunities for improvement and develop care plan and interventions, exercises, therapies to prevent decline and improve mobility and ROM Restorative Nursing Services help promote resident's optimal safety and independence, and may be started upon admission, during the course of stay or when discharged from rehabilitative care. 555712 Page 9 of 26 555712 07/01/2022 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on interview and record review, the facility failed to ensure the proper functioning of a wander guard (a device worn on a resident or their mobility equipment to warn staff of resident possibly leaving the facility) for one resident (Resident 32). This failure has the potential of a resident eloping (leaving the facility without staff's knowledge), and potentially being harmed or killed. Findings: During a review of Resident 32's electronic record (eRecord) on 6/27/22 4:15 p.m., Resident 32's eRecord indicated that he had eloped on 4/26/22, and was found by sign board by staff. Resident 32 was at high risk for elopement. During an interview on 6/29/22 at 4:01 p.m. with the director of nursing (DON), DON stated, Resident 32 eloped. Afterward, he started using a wander guard. The wander guard should be checked weekly. DON stated, she did not see a schedule for checking the wander guard in the physicians orders. During an interview on 6/30/22 at 11:35 a.m., DON stated, physicians orders were started after you pointed them out to me. DON stated, checks for wanderguard, functioning of the wanderguard, and attempts to wander have not been monitored and documented. During a review of the Wanderguard undated User Guide, the User Guide indicated, .Note: Transmitters in use must be tested at least weekly.4. Your facility must keep records of test and transmitter inspection completions, as well as transmitter warranty expiration dates. 555712 Page 10 of 26 555712 07/01/2022 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review, the facility failed to ensure four controlled medications ( medications included in the Drug Enforcement Administration) which are subject to special handling, storage, disposal and record keeping in the facility) had been accurately accounted for in the two of two medication carts checked when the amount of medications counted from the blister cards (a pharmacy-prepared paperboard with medications in individual doses that can be punched out of the card when administered) were not consistent with the narcotic count sheet for three controlled medications, and one controlled medications was signed out before dispensing and administering the medication to resident. These failures had the potential to create problems related to accounting of controlled medications. Findings: During an inspection of medication cart # 1 (Men's side) with licensed vocational nurse C (LVN C) on 6/27/22 at 9:18 a.m., LVN C stated at the start of each shift, two nurses (incoming and outgoing nurses) should count the controlled drugs and affix their signatures in the Controlled Drugs-Count Record to confirm the count was completed and accurate. LVN C upon checking the Controlled Drugs-Count Record confirmed that there were several missing nurses' signatures/or initials in the May and June 2022 Controlled Drugs-Count Record. During the concurrent accounting of controlled drugs with LVN C, the following were found: 1. Resident 26's Hydrocodone/APAP (narcotic pain medication)10/325 mg.(milligrams, unit of measurement) count sheet indicated 12 but the actual amount found in the blister card was 13 tablets. 2. Resident 26's Hydrocodone/APAP 5/325 mg. count sheet indicated 20 but the blister card contained 21 tablets. LVN C verified the mismatch between the count and documented amount. LVN C stated I don't' know, the count should match. 3. Resident 33's Lacosama (antiseizure) 200 mg. count sheet indicated 46 but the blister card has 47 tablets. LVN C stated he had signed out the medication early which was due at 12 noon. LVN C also stated, nurses should not sign ahead and should only sign out controlled drugs when they are due to be administered. During an inspection of medication cart #2 (Women's side) with licensed vocational nurse E (LVN E) on 6/27/22 at 11:25 a.m., LVN E after checking the medication bottle multiple times had confirmed that Resident 34's Controlled Drugs-Count Record for Morphine Sulfate (MSO4-narcotic pain medication), indicated the count sheet was 29 ml. (milliliter, unit of measurement). The record also indicated Resident 34 had received three doses of 0.25 ml. (0.75ml total) MSO4, but the actual amount in the bottle was 30 ml (full bottle). During the concurrent interview, LVN E stated the pharmacy may have overfilled the bottle. LVN E also reviewed the Medication Cart #2 Women's side June 2022 Narcotic-Controlled Drugs-Count Record sheet and confirmed there were several missing signatures/initials noted. 555712 Page 11 of 26 555712 07/01/2022 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the facility's Controlled Drugs-Count Record form, indicated that signing below acknowledges that you have counted the controlled drugs on hand and have found that the quantity of each medication counted is in agreement with the quantity stated on the Controlled Drug Administration Record. A review of the facility's 2007 policy and procedure, Controlled Medication Storage, indicated at each shift change or when keys are surrendered, a physical inventory of all Schedule II, is conducted by two licensed nurses or per state regulation and is documented in on the controlled substance accountability record or verification of controlled substances count report. 555712 Page 12 of 26 555712 07/01/2022 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interview and record review, the facility failed to ensure a licensed pharmacist performed a monthly Medication Regimen Review (MRR) for one of four residents (Resident 29) when Resident 29 was missing some monthly MRRs. This failure had the potential of residents being administered incorrect medications. Findings: During an interview on 6/30/22 at 2:36 p.m., with the director of nursing (DON), DON stated, in 12/2020 we were in a full COVID outbreak, so no, the pharmacist did not do a MRR. DON stated, the facility had a temporary pharmacist, but we were not introduced to them. During a review of Resident 29's eRecord and the binder for the facility's MRR, both records indicated, Resident 29 did not have a MRR for: 12/2020, 5/2021, 10/2021, 11/2021, 4/12/22, 5/13/22. The facility was not able to provide a copy of a MRR for those months. During an interview on 7/01/22 at 11:17 a.m., with the consultant pharmacist, (CP), CP stated, she performed a MRR on 12/2020, 4/2022, and 5/2022. 555712 Page 13 of 26 555712 07/01/2022 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

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** 3. During a review of Resident 29's electronic record (eRecord) on 6/29/22 at 1:48 p.m., the eRecord indicated, there was an informed consent for Seroquel (used to treat certain mental/mood disorders) 50mg (mg, a dosage amount), dated 11/18/21, but there was not an informed consent for the increase to 75mg per day. During an interview on 7/01/22 at 11:17 a.m., with the consultant pharmacist (CP), CP stated, The facility needed an updated informed consent for an increase in Seroquel. The facility did not supply written documentation of an informed consent for an increase in Resident 29's Seroquel. Based on interview and record review, the facility failed to ensure three of 12 sampled residents (Residents 20, 25 and 29) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors, example is antipsychotics) when: 1. Resident 20 had no informed consent signed prior to the administration of Duloxetine (Cymbalta, antidepressant). 2. Resident 25 did not have a documented clinical rationale or justification for the continued use of Olanzapine (antipsychotic- medication used to manage psychosis including delusion or hallucinations)when the recommended GDR was declined by her primary care physician (PCP). 3. Resident 29, did not have an informed consent signed for the dose increase of Seroquel (used to treat certain mental/mood disorders) from 50mg. ( milligrams, unit of measurement) to 75mg. per day. These failures resulted in the unnecessary use of psychotropic medications. Findings: 1. A review of Resident 20's clinical record indicated she was admitted on [DATE], self-responsible and included a diagnosis of major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). During a record review and concurrent interview with the MDSA on 6/28/22 at 10:29 a.m., the MDSA reviewed Resident 20's physician's order that indicated Duloxetine HCL {hydrochloride}(Cymbalta, antidepressant) 30 mg. (milligrams, unit of measurement) 1 capsule by mouth daily for depression ordered on 4/29/22 and started 5/7/22. The MDSA did not find any informed consent signed by Resident 20 during the record review. There is no documented evidence that staff had verified from the attending physician had obtained an informed consent. 2. During a record review and concurrent interview with the MDSA on 6/29/22 at 10:30 a.m., the MDSA confirmed Resident 25 received Olanzapine antipsychotic medication) 7.5 mg daily and 2.5 mg. twice a day since 5/4/21. The Pharmacist recommendation to consider a gradual dose reduction (GDR, a tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if 555712 Page 14 of 26 555712 07/01/2022 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the dose or medication can be discontinued) was declined on 3/22/22. The MDSA confirmed there was no documented clinical rationale by the physician for why an attempted GDR was not indicated. During an interview with the consultant pharmacist (CP) on 7/1/22 at 11:07 a.m., the CP stated an informed consent should be taken prior to administration of any psychotropic medications, and doctor's documentation if a prior verbal consent was taken. The CP also stated there should be a documented rationale regarding the risks and benefits if GDR was not clinically indicated. A review of the facility's 12/14/17 revised policy and procedure, Informed Consent-Psychotherapeutic Medications , indicated obtain informed consent from the resident or surrogate decision maker prior to use of chemical restraint (psychotropic medication). 555712 Page 15 of 26 555712 07/01/2022 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

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 7.14% (percent) error rate when two medication errors out of 28 opportunities were observed during a medication pass. Residents Affected - Few These failures resulted in the medications not being administered according to the physician orders and the manufacturer's specifications. Findings: A review of Resident 8's physician order dated 4/25/22 indicated Insulin Aspart Solution 100 units/ml. (milliliter, units of measurement), inject 8 units subcutaneously (under the skin) before meals for type 2 diabetis mellitus( a disorder in which the body does not produce enough or respond normally to insulin, causing blood sugar levels to be abnormally high). During the medication pass observation on 6/28/22, at 4:54 p.m., licensed vocational nurse A (LVN A) prepared Resident 8's medication of Aspart insulin (medication to lower blood sugar) and was about to administer to Resident 8. When LVN A rechecked the insulin syringe, LVN A verified the syringe contained 7 units and she had to add one more unit to complete the correct dose of 8 units. During the interview with LVN A on 6/28/22 at 5:42 p.m., LVN A stated she should follow the doctor's order to inject 8 units of Aspart. A review of Resident 39's physician's order dated 4/7/21 indicated Lipitor (medication to help lower cholesterol in the blood) 20 mg. (milligrams, units of measurement) give one tablet by mouth to be given with dinner. During a medication pass observation with licensed vocational nurse B (LVN B) on 6/28/22 at 4:46 p.m., she administered one tablet of Lipitor 20 mg. to Resident 39. During an observation on 6/28/22 at 5:50 p.m., certified nursing assistant D (CNA D) delivered Resident 39's dinner tray to her room and resident started to eat at 5:53 p.m. During an interview and concurrent record review with LVN B on 6/28/22 at 5:57 p.m., LVN B confirmed that the Lipitor should be given with dinner. LVN B stated she failed to read the instruction related to this medication. Review of the facility's 2007 policy and procedure, Medication Administration, indicated medications are administered in accordance with written orders of the prescriber. Medication to be given with meals are to be scheduled for administration at the resident's meal times. 555712 Page 16 of 26 555712 07/01/2022 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review, the facility failed to ensure the licensed nurses stored, disposed/discard medications per manufacturer's recommendations when: 1. One multi-dose vial of tuberculin solution (drug use to help diagnose tuberculosis)was dated when opened. 2. One pack of Tylenol (analgesic and antipyretic-for fever) suppository (inserted via rectum) was not stored together with Refresh eye drops (drug used to lubricate dry eyes). 3. One bottle of Fluticasone nasal spray (drug used to relieve symptoms of rhinitis such as sneezing and a runny, stuffy nose) opened on 5/18/22 was disposed/discarded from the medication cart. 4. One container of Breo Ellipta (drug used for asthma) 100-25 mcg. (micrograms, unit of measurement) inhaler opened on 4/10/22 , marked by pharmacy discard after 42 days from opened date was disposed beyond the discard date. 5. The medication refrigerator's temperature was not checked and recorded twice per day per facility's guidelines when storing testing solution (i.e. tuberculin solution). These failures had the potential of administering expired medications or medications stored beyond the acceptable storage temperature (between 46-76 degrees Fahrenheit), and potential contamination of internal medication with external medications. Findings: During an inspection of Nurses Station medication storage room with licensed vocational nurse F (LVN F) on 6/27/22 at 8:55 a.m., LVN F confirmed that the Tuberculin solution was not dated when opened, and Fluticasone nasal spray bottle and Breo Ellipta inhaler were not disposed beyond the discard date. LVN F validated the inhaler was already 77 days since it was opened and LVN F stated it should have been discarded. LVN F also confirmed upon review of the April, May and June 2022 Temperature Log for Refrigerator that there were several times and days that the temperature were not taken and documented. During the concurrent interview and record review with LVN F, LVN F also confirmed upon review of the April, May and June 2022 Temperature Log for Refrigerator that there were several times and days that the temperature were not taken and documented. LVN F stated, licensed nurses should take the temperature twice daily and document them in the temperature log. LVN F also stated, nurses should date the tuberculin solution when opened, and should discard or dispose medications beyond the discard date. Review of the facility's 2007 policy and procedure, Medication Storage, indicated internally administered medications are stored separately from medicationsused externally such as lotions, creams, ointments and suppositories. The temperature of any refrigerator that stores vaccines should be monitored and recorded twice daily. Outdated, deteriorated . medications are immediately removed from 555712 Page 17 of 26 555712 07/01/2022 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0761 stock, disposed of according to procedures for medication disposal. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555712 Page 18 of 26 555712 07/01/2022 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and record review the facility did not ensure the proper sanitization levels of the dishwasher and 2-compartment sink, when kitchen staff did not properly check the sanitizer strength in the dishwasher nor in the 2-compartment sink. This failure had the potential of causing a facility-wide food borne illness. Findings: During an observation and concurrent interview on 6/28/22 at 8:39 a.m., with a cook (Cook I), [NAME] I stated, the cook in the morning needs to checks washer sanitizer. Water temp should be 140F degrees , it is 119F degrees. [NAME] I ran the dishwasher twice, the temperature was at 120F degrees. [NAME] I tested the dishwasher sanitizer by holding test paper in the sanitizer water for 10 seconds, which she confirmed, then read the results. During an observation and concurrent interview on 6/28/22 at 10:53 a.m. with [NAME] I, [NAME] I stated, we don't check the sanitizer for the compartment sink. The sanitizer is added one Tbs of sanitizer per gallon of water, which she pointed to a cup, indicated a small amount. [NAME] I was not sure how much water was in the sink. During a review of the instructions on the bottle of chorine test papers, the instructions indicated, dip and remove quickly, blot immediately with paper towel, compare to color chart at once. During a review of the facility's undated policy and procedure (P&P), titled, Policy and Procedure for the Use of Chlorine Bleach as a Sanitizer for Two Compartment Sink, the P&P indicated, 1. Fill sink 3/4 full (20 gallons) 2. Chlorine: add 1/14 cup chlorine bleach (concentration will be 200 ppm hypochlorite in this wash water. 3. Use test strip to check the amount of chlorine in the water-chlorine concentration. 555712 Page 19 of 26 555712 07/01/2022 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interviews and record review, the facility failed to ensure the Resident' 20s food allergy was considered, and dislikes were followed. This failure could compromise and affect Resident 20's clinical condition and could potentially result in complications. Findings: A review of Resident 20's Order Summary Report included allergies such as fish, bean, pineapple .etc. Her dietary indicated she was allergic to beans and dislikes carrots. During a lunch observation on 6/28/22 at 12:50 p.m., certified nursing assistant G (CNA G) provided Resident 20's lunch tray with some beans mixed in the food served. It also included cooked vegetables and carrots. This observation was validated by CNA G. During the concurrent interview, Resident 20 stated she was allergic to beans and would not eat carrots at all. Resident 20 claimed staff continued to provide her with food that included beans and carrots and she would just set them aside. Resident also claimed the staff were aware she does not want carrots. During the interview and concurrent record review with the registered dietician and the director of nursing (DON) on 6/29/22 at 12:48 p.m., the RD reviewed Resident 20's Nutrition Screening and Assessment, dated 1/5/22 and confirmed the assessment indicated allergies to fish, bean, pineapple, etc. The RD did not find any documented evidence that the Nutrition Assessment included the resident's likes and dislikes. The RD stated, whoever had done the Nutrition admission Assessment should have included the food preferences. The RD also confirmed Resident 20's meal card/diet card indicated she was allergic to beans and dislikes carrots. Resident 20's updated meal card after dietary interview with resident indicated she was allergic to beans and disliked carrots, legumes and green beans. The DON and RD stated the importance of honoring and respecting Resident 20's food preferences and allergies. A review of the October 2017 revised policy and procedure, Food and Nutrition Services, indicated the multidisciplinary team, the attending physician and the dietician will assess each resident's nutritional needs, foods likes and dislikes, That affect eating and nutritional intake and utilization. A resident-centered diet and nutrition plan will be based on the assessment. Reasonable efforts should be made to accommodate resident's choices and preferences. A review of the facility's October 2017 revised policy and procedure, Nutritional Assessment, indicated as part of the comprehensive assessment, the nutritional assessment will be systematic . and using data to help define meaningful interventions for the resident . Food preferences, food restrictions, including food allergies . affecting food choices should be identified. 555712 Page 20 of 26 555712 07/01/2022 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to prepare the puree meals to meet the nutritive value needed for 9 of 9 residents who receive a puree diet, when: Residents Affected - Some 1. the cook added water and thickener to the pureed vegetables, 2. the bread and cake, which were on the menu, were not pureed nor served to the residents who are on a puree diet. These failures had the potential of the residents who received a puree diet to not receive the appropriate nutrients/calories. Findings: During an observation on 6/28/22 at 11 a.m. of kitchen cook (Cook H), after cooking the Italian blend vegetables, [NAME] H drained the vegetables using a colander. He then added less than one cup of water to five scoops of the vegetables and blended it. [NAME] H then placed five scoops of vegetables into robot coupe, added 2 cups water, and blended it. It was runny. He then added 4 scoops of vegetables to robot coupe, blended them, did not added any water. This came out thick thick, used spatula to scoop into container with other pureed veggies, whisked to blend, added thickener, about one tsp. During an interview on 6/28/22 at 11:16 a.m., [NAME] H stated that was typically how he made pureed veggies; add water, then veggies, then thickener. During on observation and concurrent interview on 6/28/22 at 12:28 p.m., [NAME] H stated puree diets do not get a roll or cake. During a review of the facility's policy and procedure titled, Nutrient Retention of Foods, Revised 04/2007, indicated, This facility will endeavor to prepare and serve food in such a manner as to conserve the nutritive value of foods. Supervisors will instruct cooks to prepare food in accordance with guidelines to minimize nutrient loss. 555712 Page 21 of 26 555712 07/01/2022 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

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 1. properly label the arrival and/or open date of foods in the kitchen and 2. to keep MedPass formula at proper temperature, when Residents Affected - Some - onions were in a clear bin unlabeled, - three clear containers of pastas were unlabeled, - four open boxes of breakfast cereal were unlabeled, - packets of hot chocolate mix and low calorie instant lemon drink were unlabeled, and - containers of MedPass formula were on medication carts for extended periods without proper refrigeration. These failures had the potential of causing food-borne illness. Findings: 1. During an observation and subsequent interview on 6/28/22 at 8:31 a.m., with the dietary supervisor (DS). It was observed that a clear plastic container containing onions did not have a delivery date on it. DS stated, the clear container of onions needed a date on the outside. During an observation and subsequent interview on 6/28/22 at 9:03 a.m., with DS, there were three containers with pastas without any date on them, four opened boxes of cereal without a date on them, a container containing hot chocolate packets without a date on it, and a clear container with instant lemon drink packets inside without a date on it. DS stated, The three clear containers with pasta should have been dated, same with the four boxes of cereal that were opened. DS did not comment on the hot chocolate packets and instant lemon drink packets which were undated and did not have an expiration date, DS just threw them away. During a review of the facility's policy and procedure (P&P), titled, Refrigerators and Freezers, revised 12/2014, the P&P indicated, all food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage.Expiration dates on unopened food will be observed and use by dates indicated once food is opened. 2. A review of the manufacturer's storage instructions for the formula written in its box indicated, once formula was opened the product can be consumed within four days if properly refrigerated, consume within four hours if not refrigerated. During the medication cart check with licensed vocational nurse C (LVN C) on 6/27/22 at 9:38 a.m., LVN C verified the Medication Cart #1 (Men's side) had a box of Med Pass 2.0 Fortified Nutritional Shake Vanilla opened and not dated. The box of the formula was placed in a small plastic container with one ice pack on the side. LVN C stated she received the Med pass box already opened from the night nurse. LVN C started his shift at 7:00 a.m. Surveyor had regularly checked the cart and the formula was not refrigerated in between medication pass ( morning and noon). 555712 Page 22 of 26 555712 07/01/2022 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The Medication cart # 2 was checked. with licensed vocational nurse F (LVN F) on 6/27/22 at 11:25 a.m., the Med pass 2.0 formula was dated 6/27/22 , an ice pack at the bottom and another pack on the side of the box, was not refrigerated after the nurse completed her morning medication pass. The surveyor marked the box of formula with a marking pen at 11:22 a.m. without informing the nurse. During an observation and concurrent interview with registered nurse K (RN K) on 6/27/22 at 4:02 p.m, the same box of Med pass formula was still not refrigerated and kept in the cart. Surveyor requested to the check the formula's temperature. RN K poured a half cup full of formula in a paper cup and checked the temperature, the reading indicated 66.4 F (Farenheit). RN K validated the formula was not refrigerated, and the mark the surveyor wrote at the side of the box of the formula and was not refrigerated. RN K was not aware the formula should be refrigerated once opened but kept an ice pack at the bottom and side of the box to keep it cold. During an observation and concurrent interview with licensed vocational nurse B (LVN B) on 6/27/22 at 4:07 p.m., the box of Fortified Nutritional shake was kept in the same container seen that morning with an ice pack on one side of the box, and checked the temperature with a reading of 77.3 F. During an interview with the director of nursing on 6/29/22 at 2:10 p.m., the DON confirmed that the staff had started storing the Med pass 2.0 formula in the refrigerator after they were done with their medication pass. 555712 Page 23 of 26 555712 07/01/2022 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 2. During an observation on 6/27/22 at 8:35 a.m., upon entering the facility, the staff let surveyors enter the facility, but did not give directions on screening, nor ask COVID symptom, travel, or exposure questions. Residents Affected - Many During an observation on 06/28/22 at 9:34 a.m., a visitor entered the facility, and was asked for their vaccination status, but was not asked any COVID questions related to symptoms, travel, or exposure. Not able to view if their temperature was taken. During multiple observations during the first two days of the survey, there were no observations of anyone cleaning/disinfecting the thermometer after using it upon entry. It was observed that four staff members used the thermometer without cleaning/disinfecting it afterward. During an interview on 7/01/22 at 10:43 a.m. with the director of nursing (DON), DON stated, she had initialed the surveyor sign-in sheets after she had later asked surveyors about symptoms, which was not at time of entry. 3. During a dining observation on 6/28/22 at 12:32 p.m., certified nursing assitant L (CNA L) did not wash her hands or perform hand hygiene before putting on gloves to assist Resident 30 with her lunch, after touching her uniform and other possibly contaminated surfaces. CNA L confirmed the observation and admitted she should have washed her hands. During an interview with the infection preventionist (IP) on 6/29/22 at 2:21 p.m., the IP stated the staff should wash hands before putting on their gloves. Based on observation, interview and record review, the facility failed to implement their infection control practices and precautions when: 1. Facility staff did not ensure visitors were thoroughly screened for signs and symptoms of Covid-19 (an acute respiratory illness in humans caused by a coronavirus, capable of producing severe symptoms and in some cases death, especially in older people and those with underlying health conditions) and did not give directions on screening; 2. Facility staff did not clean and disinfect the thermometer in the screening area after each use; and 3. One facility staff did not perform hand hygiene before glove use. These failures have the potential to spread infection and to compromise the health and well-being of the residents in the facility. Findings: 1. During an observation on 6/27/2022 at 8:37 a.m., surveyors were in the main entrance lobby. Licensed vocational nurse F (LVN F) asked for surveyors' vaccination status but did not screen surveyors for signs and symptoms of Covid-19, no instructions on screening and did not take surveyor's temperature. Surveyors were allowed entry into the facility. 555712 Page 24 of 26 555712 07/01/2022 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During another observation on 6/28/2022 at 8:07 a.m., while in the main entrance front lobby. LVN C did not screen surveyors for signs and symptoms of Covid-19, did not ask for any recent exposures or history of travel. LVN also did not provide directions regarding screening and checked surveyor's temperature. During an interview with IP on 6/29/2022 at 2:21 p.m., IP was informed of the above observations. IP stated surveyors are considered visitors and should have been screened for signs and symptoms of Covid-19 and checked their temperatures upon entering. IP stated that screening questions regarding potential exposures and history of travel were very important to ask and should be included in the screening form. IP also stated that thermometer should be cleaned after each use by screener. Review of the facility's policy, Coronavirus Disease (Covid-19) - Visitors, revised 11/2021, indicated, Core principles of Covid-19 prevention and best practices to reduce Covid-19 transmission are adheredto all times, including: a)screening of all who enter the facility for signs and symptoms of Covid-19. 555712 Page 25 of 26 555712 07/01/2022 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation, interview and record review, the facility failed to ensure multiple rooms had at least 80 square feet per resident. Having less than 80 square feet per resident had the potential to compromise the care and services the residents receive. Findings: During the initial pool observation on 6/27/2022 at 9:35 a.m., the following was observed: Room Beds Sq ft./Room Sq. ft./Resident 1 3 224.28 74.76 2 3 194.67 64.89 6 3 194.67 64.89 12 3 189.03 63.01 14 2 140.52 70.26 15 2 146.46 73.23 During observations and staff and resident interviews during survey, there were no care issues identified regarding the size of the rooms. Recommended continuance of the room waiver. 555712 Page 26 of 26