Health inspection·October 31, 2019

F 0656 Review of Resident 9's [NAME] dated 10/29/19, for Treatment/Procedure stated HOB 35-40 [degrees]. Level of Harm - Minimal harm or potential for actual harm Review of Resident #9's LONG TERM CARE PLAN for the area of Altered Nutrition/Hydration indicated an intervention of HOB increased 20-40 degrees during feeding & 30-60 minutes after. Residents Affected - Few During an observation on 10/31/19 at 11:05 a.m., Resident 9 was lying in bed with the tube feeding pumping. Additionally, the HOB bed was flat. During an interview on 10/31/19 at 11:20 a.m., RN D stated Resident 9's HOB should be elevated during tube feedings and proceeded to raise the resident's HOB. During an interview on 10/31/19 at 1:54 p.m., the Director of Quality and Infection Prevention stated the residents beds should be elevated during tube feedings. Review of the facility's undated policy and procedure, Enteral Tube Feeding Intermittent or Bolus, Pediatric, indicated Maintain the child with the head of the bed elevated to at least 30 degrees . Review of the facility's undated policy and procedure, Enteral Feeding, Continuous Drip, Pediatric, indicated under Implementation .position the child supine [lying on the back] with the head of the bed elevated to at least 30 degrees .to help avoid aspiration of gastric contents. 2. Resident 10 was admitted on [DATE] with diagnoses to include Exomphalos (weakness of baby's abdominal wall causing the bowel and liver to protrude in a loose sac) chronic respiratory failure, with tracheostomy (trach). Record review indicated Resident 10 attended an off-site school on Mondays (9:45 a.m. to 12 p.m.), and Tuesday through Fridays he went to school from 10:30 a.m. to 3 p.m On 10/14/19 a Student Accident Report indicated the school nurse did a skin check with the facility nurse at the start of the shift. It indicated Resident 10 had a 1/8 inch scab on his left posterior hand; on his right upper inner arm a 1 inch x 1 inch circular bruise and a scab 1/8 inch on his left lower (inside) leg. During a concurrent interview with Director of Quality and Infection Prevention (DQIP), she stated both the school nurse and the facility nurse would usually do a report at start of shift. She stated the responsible family member was notified. The DQIP stated it was not investigated as Resident 10 was an active child and he would hit and bang his arms/legs. As well as, sometimes when the resident had blood work done it would cause easy bruising. Review of Resident 10's weekly summary also indicated same type of scabs and discoloration on arms and legs. Review of the nursing 24 hour flow sheet dated 10/13/19, indicated similar descriptions of the skin in the same areas (i.e. shin, right arm, antecubital areas, right inner arm). Review of Resident 10's short term and care plan indicated the potential for impaired skin integrity was addressed. However, it did not address the specific behaviors of the resident that would cause skin discoloration. During an interview with the minimum data set coordinator on 10/29/19 at 2 p.m., she confirmed the findings. She stated it should be addressed initially in the short term care plan. However, if the behavior or incident which caused the skin discoloration to continue, then it should be addressed in the long term care plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555734 If continuation sheet Page 2 of 13 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 555734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Hc Org No CA -Pediatric Hospital D/P Snf 3777 South Bascom Avenue Campbell, CA 95008 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm During an observation on 10/30/19 at 10:10 a.m., Resident 10 was in his wheelchair with a lap support. He was dressed for school and had his trach on room air Oxygen saturation at 95%. Resident 10 appeared comfortable and playful, moving upper extremities, and banging his hands on the lap support. The nursing staff aide stated he was doing well. There were no bruises or discoloration noted on upper arms, including right upper inner arm. Residents Affected - Few Review of the facility's undated policy,''Care Plan Management, indicated . Ensure that the interdisciplinary (group of individuals from different disciplines of care who meet to discuss the plan of care for each patient/resident) patient plan of care is based on the patient's assessed needs in conjunction with the patient 's strengths, limitations, values and goals .The registered nurse (RN) review patient's care plan every shift for achievement of goals or the need for new focus areas or problems to be incorporated in the plan of care .Evaluate the patient's progress and revise the care plan as appropriate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555734 If continuation sheet Page 3 of 13 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 555734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Hc Org No CA -Pediatric Hospital D/P Snf 3777 South Bascom Avenue Campbell, CA 95008 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)

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 review and revise the care plan (provides direction on the type of nursing care the individual, family may need) for one of 24 residents (Resident 23), when the interventions did not reflect the current tube feeding order, and the positioning of the head of the bed (HOB) did not reflect the current information in the [NAME] (a medical information system used by nursing staff to communicate important information on their patients). This failure could affect outcomes in the residents' care. Findings: During the initial tour on 10/28 /19 at 2:45 p.m., Resident 23 was laying on a pillow flat in bed with oral secretions noted. Resident 23 had a tracheostomy (a tube inserted into the windpipe to allow air into the lungs via a machine (ventilator). He was on intermittent tube feedings (TF) via gastric tube (liquid form of nourishment delivered through a flexible tube inserted into the stomach, GT)). The feeding bag's label indicated Nutren Jr. + 1 Tbsp (tablespoon) protein + water. Review of the Resident 23's clinical record indicated he was admitted on [DATE] with diagnoses to include infantile spinal muscular atrophy (neuromuscular disorder that results in worsening muscle weakness with muscle twitching, affecting respiratory muscles, arm and legs), chronic respiratory failure, tracheostomy and dependence on ventilator. Review of Resident 23's care plan indicated it was reviewed and revised on 9/27/19 (quarterly). The interventions for potential in altered nutrition included TF order, dated 5/22/15, Nutren Jr. Fiber Prosource + lite salt + water via GT. The current order was for 1200 Nutren Jr. + 1 Tbsp protein + H20 (water) = 1830 milliliter (ml. unit of liquid measure). One of the interventions also indicated the HOB (head of bed ) increased to 20-40 degrees during feeding and 30-60 minutes after feeding. Review of the [NAME], under treatment and procedure indicated, the HOB to increase at 20 to 40 degrees at all times. During an interview with the director of quality and infection prevention (DQIP) on 10/30/19 at 10 a.m., she stated the tube feeding orders were written in the [NAME] which was updated each shift. The [NAME] also included information regarding treatment and procedure orders. She stated the nurses used the [NAME] during a shift report. During an interview withe the minimum data set coordinator on 10/31/19 at 9:51 a.m., she stated she was responsible for updating the care plan. She confirmed the findings and stated the care plan should have been revised and updated to reflect the current orders. During another observation on 10/31/19 at 9:30 a.m. Resident 23 was laying on a pillow flat in bed. Tube feeding was off at this time. During a concurrent interview with registered nurse A (RN A), she confirmed the findings based on the [NAME]. She stated the resident's HOB was elevated because the resident had a pillow but acknowledged the HOB was not at 20 to 40 degrees. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555734 If continuation sheet Page 4 of 13 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 555734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Hc Org No CA -Pediatric Hospital D/P Snf 3777 South Bascom Avenue Campbell, CA 95008 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)

F 0657 Level of Harm - Minimal harm or potential for actual harm Review of the facility's undated policy,''Care Plan Management, indicated . Ensure that the interdisciplinary (group of individuals from different disciplines of care who meet to discuss the plan of care for each patient/resident) patient plan of care is based on the patient's assessed needs in conjunction with the patient 's strengths, limitations, values and goals .Evaluate the patient's progress and revise the care plan as appropriate. Residents Affected - Few Review of the facility's undated policy, [NAME], indicated .The [NAME] will be utilized for staff to easily locate information and status determined by the interdisciplinary staff (nursing, rehab, respiratory, MD) . The [NAME] will be updated electronically, dated, and changed PRN (as needed) as patient status changes with assistance form he charge nurse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555734 If continuation sheet Page 5 of 13 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 555734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Hc Org No CA -Pediatric Hospital D/P Snf 3777 South Bascom Avenue Campbell, CA 95008 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)

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 enteral (delivers liquid nutrition through a catheter inserted directly into the gastrointestinal tract) tube feedings were labeled with the recipe of the contents of the formula for six residents (Residents 6, 8, 9, 15, 22, and 25) out of 12 sampled residents. This failure had the potential for all the residents to receive an inaccurate formula as ordered by the physician. Residents Affected - Few Findings: 1.Record review on 10/28 to 10/31/19 indicated Resident 6 had diagnoses that included myotonic muscular dystrophy (a genetic disorder characterized by both progressive muscle wasting and stiffness, or an inability to relax muscles at will. It can affect the skeletal muscles, muscles in the digestive system and the heart muscles). Additionally, had a gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). Review of the physician orders for Resident 6's diet stated, 900 Nutren Jr + 1 TBSP protein and 1/2 tsp lite salt and 550 ml of water = 1450 ml. Further review of Resident 6's [NAME] (a medical information system used by nursing staff as a way to communicate important information on the residents) dated 10/22/19, stated FEEDINGS 3/28/19 Nutren Jr w.Fiber + protein + lite salt + H2O 220 ml via GT q [every] 4 hr .0800 .). The [NAME] did not identify the measurements of the contents in the enteral tube feeding. During an observation on 10/31/19 at 10:55 a.m., Resident 6's tube feeding was hung on the pump. On the outside of the bag was written the residents name. The enteral tube feeding bag did not have a label on it identifying the measurements of the contents. 2. Record review on 10/28-31/19 indicated Resident 8 had diagnoses that included spastic quadriplegic cerebral palsy (a loss of use of the whole body marked by the inability to control and use the legs, arms, and body) and had a jejunostomy (J-tube, a surgically placed feeding tube into the small intestine to help with nutrition and growth). Review of Resident 8's [NAME] dated 10/29/19, for FEEDINGS 10/23/19 Peptamen Jr. 80ml/hr via J-tube continuously. During an observation on 10/29/19 at 11:18 a.m., Resident 8 was lying in bed. The enteral tube feeding bag was hung and the pump was at 60 ml/hr. The enteral tube feeding bag did not have a label on it identifying the measurements of the contents. 3. Record review on 10/28 to 10/31/19 indicated Resident 9 had diagnoses that included traumatic brain injury (a form of acquired brain injury that occurs when a sudden trauma causes damage to the brain) and persistent vegetative state (condition in which a medical patient is completely unresponsive to psychological and physical stimuli and displays no sign of higher brain function, being kept alive only by medical intervention). Additionally, Resident 9 had a gastrostomy tube for nutrition. Review of Resident 9's [NAME] dated 10/29/19, for FEEDINGS 10/17/19 Nutren Jr. c Fiber + protein + lite salt + H2O . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555734 If continuation sheet Page 6 of 13 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 555734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Hc Org No CA -Pediatric Hospital D/P Snf 3777 South Bascom Avenue Campbell, CA 95008 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)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 10/29/19 at 11:38 a.m. and on 10/30/19 at 10:08 a.m., Resident 9's enteral tube feeding bag was hung. The enteral tube feeding bag had the Resident's name on it and was dated. There was no label on the bag indicating the measurements of the contents of the enteral tube feeding mixture. 4. Record review on 10/28 to 10/31/19 indicated Resident 15 was admitted to the facility with diagnoses that included deformities of brain, and dependence on a respirator/ventilator (a machine that mechanically assists the patient/resident in the exchange of oxygen and carbon dioxide [artificial respiration]). Additionally, Resident 15 had a gastrostomy tube for nutrition. Review of Resident 15's [NAME] dated 10/23/19, for FEEDINGS 8/7/19 Nutren Jr w/ fiber + protein + H2O . During an observation on 10/29/19 at 10:00 a.m., Resident 15's enteral tube feeding bag was not labeled with the measurements of the contents. 5. Record review on 10/28 to 10/31/19 indicated Resident 22 had diagnoses that included congenital central alveolar hypoventilation syndrome (a disorder that affects normal breathing. People with this disorder take shallow breaths (hypoventilate), especially during sleep, resulting in a shortage of oxygen and a buildup of carbon dioxide in the blood). Additionally, Resident 22 had a gastrostomy tube for nutrition. Review of Resident 22's [NAME] dated 10/30/19, for FEEDINGS .9/24/19 Alfamino Jr + water . During an observation on 10/29/19 at 3:51 p.m., Resident 22's enteral tube feeding bag did not specify the measurements of the contents of the tube feeding. 6. Record review on 10/28 to 10/31/19 indicated Resident 25 had diagnoses that included cerebral palsy. Additionally, Resident 25 had a gastrostomy tube for nutrition. Review of Resident 25's [NAME] dated 10/17/19, for FEEDINGS 10/9/19 Alfamino Jr + H2O 63 ml/hr continuous . Review of the physicians orders dated 9/19/19 indicated Alfamino Jr. 1 cup + 14 T, + water = 1600 ml . During an observation on 10/29/19 at 2:00 p.m. and 10/30/19 at 10:35 a.m., Resident 25's enteral tube feeding was pumping at 63 ml/hr. No date was on the enteral tube feeding and there was no label identifying the measurements of the contents of the tube feeding. During an interview on 10/28/19 at 1:40 p.m., Licensed Vocational Nurse B (LVN B) stated the night shift changed the feeding bags and tubing every night. During an interview on 10/29/19 at 7:45 a.m., the Dietary Supervisor (DS) stated the tube feedings are prepared in the kitchen in the evening by the dietary staff. The DS stated the dietary staff had the recipes for the individual residents' formula and prepared them accordingly. Review of the facility's undated policy and procedure, Enteral Feeding, Cntinuous Drip, Pediatric, indicated under Implementation .Compare the label on the enteral feeding to the order in the child's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555734 If continuation sheet Page 7 of 13 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 555734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Hc Org No CA -Pediatric Hospital D/P Snf 3777 South Bascom Avenue Campbell, CA 95008 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)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete medical record .Make sure that the enteral formula container is labeled with the child's identifiers; formula name (and strength if diluted); date and time of formula preparation; date and time that the formula was hung; administration route; rate of administration; administration duration (if cycled or intermittent); initials of who prepared , hung, and checked the enteral formula against the order; expiration date and time. Review of the facility's undated policy and procedure, Storage, Preparation, Delivery and Rotation of Formula, Tube Feedings and Supplements indicated Patient Labels are used to label feeding containers. The label includes: patient's name, room number, date, time, and description of contents. Event ID: Facility ID: 555734 If continuation sheet Page 8 of 13 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 555734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Hc Org No CA -Pediatric Hospital D/P Snf 3777 South Bascom Avenue Campbell, CA 95008 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)

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 observation, interview, and record review, the facility failed to ensure psychotropic medications (medications that are capable of affecting the mind, emotions, and behavior) ordered as PRN (as needed) for one of six residents (Resident 18), was limited to 14 days and if extended would indicate the duration for the PRN order. This failure could potentially create an unnecessary medication for the resident. Findings: 1. During the initial tour on 10/28/19 at 1:47 p.m., Resident 18 was lying in the crib with a tracheostomy (a tube inserted into the windpipe to allow air into the lungs via a machine (ventilator). He also had tube feeding in progress. Resident 18 appeared comfortable and in no distress. Review of Resident 18's clinical record indicated he was admitted on [DATE] with diagnoses to include epilepsy (a neurological condition in which a person has recurrent seizures). Review of the physician's order dated 10/15/19, indicated an order for Lorazepam (anti-anxiety medication) 0.5 milligram (mg., a unit of measure) every four hours as needed for anxiety or seizure. Do not discontinue due to periodic emergency need. During an telephone interview with the registered pharmacist (RPH) on 10/30/19 at 2:30 p.m., he stated he would usually write a note to the physician regarding the 14 day limit on psychotropic medications ordered as PRN. Review of the medication regimen review (MRR) record dated 9/25/19, indicated the RPH recommendation to add do not DC (discontinue) due to periodic emergency need to the PRN Lorazepam order. Review of the physician's progress notes dated 10/30/19, indicated . Resident 18 had rare seizures, controlled with phenobarbital and Keppra (medications for seizures). Review of the monthly Psychotropic Drug Review/Monitoring, dated 9/30/19, indicated there was no PRN medication (Lorazepam) administered for that month. During a concurrent interview with the director of nursing (DON) and the minimum data set coordinator (MDSC) on 10/31/19 at 9:30 a.m., the MDSC stated monitoring for seizure and anxiety was documented separately as indicated in the treatment administration record (TAR). Both the DON and the MDSC stated there was a rationale for the extended use of Lorazepam. During a meeting with the DON, the MDSC, and the medical director (MD) on 10/31/19 at 2 p.m., they acknowledged that in addition to the rationale for the extended 14 day PRN order, the order should indicate the duration of the extended PRN order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555734 If continuation sheet Page 9 of 13 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 555734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Hc Org No CA -Pediatric Hospital D/P Snf 3777 South Bascom Avenue Campbell, CA 95008 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)

F 0759 Ensure medication error rates are not 5 percent or greater. 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 had a medication error rate of 11.54% when the facility failed to ensure the enteral feeding tube was flushed as ordered by the physician prior to administration of medications for three out of nine residents (Residents 3, 14, and 21) observed during a medication pass. This failure had the potential to compromise the residents' medical health. Residents Affected - Few Findings: 1. Record review on 10/28 to 10/31/19 indicated Resident 14 had diagnoses that included chondrodysplasia punctata (a condition that impairs the normal development of many parts of the body. The major features of this disorder include skeletal abnormalities, distinctive facial features, intellectual disability, and respiratory problems) and had a gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition directly to the stomach). Further review of Resident 14's [NAME] (a medical information system used by nursing staff as a way to communicate important information on the residents), dated 10/26/19, indicated 12/27/18 Flush with 5 ml water before passing first med to verify placement of enteral tube [GT]. Flush with additional 5 ml water after passing last med. During an observation of a medication pass on 10/30/19 at 11:30 a.m., Licensed Vocational Nurse B (LVN B) mixed 10.2 grams (15 ml) of polyethylene glycol (a laxative) with 30 ml of water for Resident #14. RN B then went to Resident 14's room and opened the Resident's enteral tube. Without flushing, LVN B gave the polyethylene glycol via the enteral tube. After the medication was administered, LVN B flushed the enteral tube with 5 ml of water. During an interview on 10/30/19 at 11:45 a.m., LVN B stated the procedure was to flush the tube with 5 ml after medications were administered. RN B stated it was not required to flush prior to administering the medication. 2. Record review on 10/28 to 10/31/19 indicated Resident 21 had diagnosis that included chronic respiratory failure (is a condition in which not enough oxygen passes from your lungs into your blood) and had a gastrostomy tube. Further review of Resident 21's [NAME] dated 9/19/19, indicated 2/11/18 Flush GT with 5ml water before passing first medication . During an observation of a medication pass on 10/30/19 at 12:05 p.m., LVN B administered the following medications to Resident 21, via the GT: Levetiracetam solution, 200 mg (an anti-seizure mediation); Clonazepam, 0.1 mg (a muscle relaxant); and Topiramate, 72 mg (an anti-seizure medication). During the observation, LVN B did not flush the GT prior to administering the medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555734 If continuation sheet Page 10 of 13 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 555734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Hc Org No CA -Pediatric Hospital D/P Snf 3777 South Bascom Avenue Campbell, CA 95008 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)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 10/30/19 at 4:28 p.m., Registered Nurse C (RN C) stated the facility did not flush the enteral tubes between the medications. RN C stated the facility flushed before and after medication administration unless specified differently for a resident. 3. Record review on 10/28 to 10/31/19 indicated Resident 3 had diagnoses that included chronic respiratory failure and had a GT. During an observation of a medication pass on 10/31/19 at 12:40 p.m., LVN B administered the following medications to Resident 3, via the GT: Famotidine 8.8 mg (for GERD - gastroesophageal reflux disease); Furosemide 10 mg (a diuretic); Polyethylene glycol 4.25 grams; and Sodium chloride 30 mEq (milliequivalent), a dietary supplement. During the observation, LVN B did not flush the GT prior to administering the medications. During an interview on 10/31/19 at 12:55 p.m., LVN B stated .not required that you flush prior to the medication given. During an interview on 10/31/19 at 7:30 a.m., the director of quality and infection prevention (DQIP) stated the enteral tube should be flushed before and after medication administration with 5 ml of water. Record review of the facility's standing, Physician admission Orders last revised 2/9/18, indicated a standing order Flush with 5 ml water before passing first med to verify placement of enteral tube . The facility's policy and procedure, Enteral Tube Feeding, Intermittent or Bolus, Pediatric printed on 10/30/19, indicated .Flush the tube with water using the lowest volume needed to clear the tube (typically 2 to 5 ml in children .), as ordered . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555734 If continuation sheet Page 11 of 13 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 555734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Hc Org No CA -Pediatric Hospital D/P Snf 3777 South Bascom Avenue Campbell, CA 95008 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)

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 failed to ensure the kitchen staff were safely performing their functions when the dishwasher's temperature was below the manufacturer's specifications for the water temperature. This failure could cause unsanitary cleaning of the feeding bottles and could cause illnesses in the residents. Findings: During an observation of the kitchen with dietary supervisor (DS) on 10/29/19 at 7:42 a.m., he stated they only have one small dishwasher for the feeding bottles, since meals were not prepared in the kitchen. He stated the feeding bottles were washed around 3 p.m. He proceeded to run the dishwasher for the chlorine sanitizer test. The temperature gauge read 110 F. During a concurrent interview with the DS, he stated he was not sure of the dishwasher's manufacturer. He also stated there was no maintenance or sanitation schedule as he called maintenance only when needed. During an interview with the director of maintenance (DOM) on 10/29/19 at 2:20 p.m., he confirmed the temperature reading at 110 F. He stated he obtained the manufacturer's manual online and the specification for the water temperature was 120 F. He stated he had increased the water temperature of the heater tank that supplied the kitchen. He also stated there was a procedure for cleaning and maintenance of the dishwasher in the manual but did not specify how often it should be done. Review of the manufacturer's owner manual (MODEL EAH/EC) Revision 1.02, under Specifications, Water Requirements indicated the minimum requirement was 120 degrees F and the recommended water temperature was 140 degrees F. The specification for the cycle temperatures was 120 F. Review of the facility's undated policy, Dishwasher Procedure, indicated . 5. When the door is completely closed, begin cycle by first holding down white button with tape (on right side of the machine) until temperature on temperature gauge reaches 120 degrees. Review of the facility's undated policy, Job Description, Dietary Service Supervisor, indicated one of the responsibilities of the DS is to oversee cleaning of the kitchen and dining areas, and washing of kitchen utensils and equipment according to sanitary methods. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555734 If continuation sheet Page 12 of 13 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 555734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Hc Org No CA -Pediatric Hospital D/P Snf 3777 South Bascom Avenue Campbell, CA 95008 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)

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain one of one dishwasher when the dishwasher temperature was below the manufacturer's water requirements of 120 to 140 degrees Fahrenheit (F, temperature scale that bases the boiling point of water at 212 and the freezing point at 32). This failure could cause improper sanitation of the feeding bottles and potentially cause illness in the residents. Residents Affected - Some Findings: During an observation of the kitchen with the dietary supervisor (DS) on 10/29/19 at 7:42 a.m., he stated they only have one small dishwasher for the feeding bottles, since meals are not prepared in the kitchen. He stated the feeding bottles were washed around 3 p.m. He proceeded to run the dishwasher for the chlorine sanitizer test. The temperature gauge read 110 F. He stated it should be at 120 F. During a concurrent interview with the DS, he stated he was not sure of the dishwasher's manufacturer. He also stated there was no maintenance schedule as he called maintenance only on as needed basis. During an interview with the director of maintenance (DOM) on 10/29/19 at 2:20 p.m., he confirmed the temperature reading at 110 F. He stated he obtained the manufacturer's manual online and the specification for the water temperature was 120 F. He stated he had increased the water temperature of the heater tank that supplied the kitchen. During another dishwasher run observation with the DS on 10/29 at 3 p.m., the dishwasher temperature reading was initially at 120 F but after a few minutes, the temperature began to fluctuate down to 117 degrees F. The DS notified the DOM. During an interview with the administrator(ADM) on 10/30/19 at 10 a.m., he stated the corrective action plan was immediately in place. Review of the facility's current daily dishwasher temperature log including the last two months (August and September) indicated the temperature was at 120 degrees F. Review of the manufacturer's owner manual (MODEL EAH/EC) Revision 1.02, under Specifications, Water Requirements , indicated the minimum requirement was 120 degrees F and the recommended water temperature was 140 degrees F. The specification for the cycle temperatures was 120 F. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555734 If continuation sheet Page 13 of 13