Health inspection·July 8, 2022

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide care and services in accordance with professional standards or practice for one of six residents observed for medication administration (Resident 1) when Resident 1 did not have Systane (lubricant eye gel) overnight therapy. Residents Affected - Few This failure had the potential to compromise the resident's health and well-being to meet the therapeutic needs. Findings: During the concurrent medication pass observation and interview with Registered Nurse E (RN E) on 7/7/22 at 2:08 p.m., RN E prepared the medications for Resident 1. RN E was not able to prepare Resident 1's Systane overnight therapy gel because it was not available. RN E confirmed that they should have available medication for Resident 1. She further stated that they should have ordered the Systane overnight therapy gel before it ran out. Review of Resident 1's admission Record dated 7/6/22, indicated Resident 1 was a two year old male initially admitted with the diagnoses of congenital malformation syndromes (physical defect present in a baby at birth) predominantly affecting facial appearance, dysphagia (difficulty swallowing), dependence on ventilator (machine that helps in breathing), tracheostomy status (provides air passage to help in breathing), gastrostomy status (opening into the stomach made surgically for the introduction of food) and colostomy status (surgical opening in the colon or large intestine). Review of Resident 1's Medication Administration Record (MAR), dated 7/1/22 to 7/31/22, indicated Resident 1 has an order of Systane overnight therapy gel 0.3 percent instill one application in both eyes, three times a day for ocular lubrication (for relief of eye irritation caused by dry eyes). During an interview with the Director of Nursing (DON) on 7/7/22 at 4:00 p.m., she verified Resident 1 should have at least three days supply of medications. The DON further stated that the nurses should make sure that the residents have enough supply of medications. During another interview with RN E on 7/8/22 at 10:05 a.m., she verified that Resident 1's Systane overnight therapy gel just came this morning, and Resident 1 missed two doses of systane overnight therapy gel on 7/7/22. Review of the facility's policy, Ordering and Obtaining Medications, reviewed 1/2019, indicated, Reordering of Medications: Medications should be refilled when a three-day supply of the prescription remains. The nurse was to list the medication on the medication order sheet and notify the pharmacy Page 1 of 6 555734 555734 07/08/2022 Childrens Hc Org No CA -Pediatric Hospital D/P Snf 3777 South Bascom Avenue Campbell, CA 95008

F 0658 by telephone. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555734 Page 2 of 6 555734 07/08/2022 Childrens Hc Org No CA -Pediatric Hospital D/P Snf 3777 South Bascom Avenue Campbell, CA 95008

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure food was stored and prepared in accordance with professional standards for food safety when expired foods and unlabeled food items were found in the refrigerator, freezer, dry storage area and the storage cabinets for plastic containers were unsafe. These failures had the potential to cause the growth of microorganisms which could cause foodborne illness (illness caused by food or water contaminated with bacteria, viruses, parasites or toxins) and cross-contaminated food for the 25 residents residing at the facility. Findings: During the initial kitchen tour observation on 7/5/22 at 9:45 a.m. with the Dietary Supervisor (DS), the following were observed in the freezer, refrigerator, dry storage and storage cabinets: 1. seven boxes of pedialyte freezer pops and expired on 1/1/22; 2. one box deep dish singles pizza and expired on 6/30/22; 3. six expired kids' meals and one unlabeled kid meal; 4. one almost empty cheetos puffs pack left in the rack of the dry storage room; 5. one can of [NAME] snacks crunches and expired 6/1/22; 6. 30 pieces of unlabeled candies; 7. 3 pieces of unlabeled cookies; 8. two unlabeled plastic containers with kids' snacks and; 9. two uncleaned storage cabinets for plastic containers. During the interview with DS on 7/5/22 at 10:15 a.m., she verified the above findings was expired. DS further stated that expired food items should have been discarded, food items or their storage containers should have been labeled, and storage cabinets should have been cleaned. During an interview with Director of Nursing (DON) on 7/8/22 at 1:59 p.m., she confirmed that expired food items should have been discarded immediately. DON further stated that food stuffs should have been labeled with open dates and kitchen cabinets should be cleaned. Review of facility's inservice titled, Expiration Dates, Labeling and Dating, dated 7/5/22, indicated, Dietary aides will understand labeling and dating for food/formula items. Foods must be labeled with open dates. Ready to eat foods will remain properly stored until expiration date noted on the label or product. Dietary aides would check the beginning and end of shifts for any expired food products or damaged food products. 555734 Page 3 of 6 555734 07/08/2022 Childrens Hc Org No CA -Pediatric Hospital D/P Snf 3777 South Bascom Avenue Campbell, CA 95008

F 0812 Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy and procedure, Storage, Preparation, Delivery and Rotation of Formula, Tube Feedings and Supplements, reviewed January, 2019, indicated, Dietary would check the expiration date and ensure that the product is acceptable. The nursing unit was responsible for double checking the expiration date and whether the product was damaged or otherwise unusable. Outdated formula/supplements would have been disposed. Residents Affected - Some Review of the facility's policy and procedure, General Sanitation in the Kitchen, reviewed January 2019 indicated, Kitchen personnel should have washed all work areas of kitchen area with soapy water followed by sanitizing agent before preparing formula. Review of the facility's policy, Food Storage, reviewed January 2019 indicated, Food storage areas should have been clean at all times. 555734 Page 4 of 6 555734 07/08/2022 Childrens Hc Org No CA -Pediatric Hospital D/P Snf 3777 South Bascom Avenue Campbell, CA 95008

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to implement their infection control practices and precautions when: Residents Affected - Some 1. Staff did not wear N95 (a type of respirator mask) while caring for Coronavirus 2019 (COVID-19, an infectious disease caused by the SARS-CoV-2 virus) exposed residents; 2. A nurse did not change gloves after touching a contaminated object; 3. A nurse did not perform hand hygiene after removing gloves and before donning new gloves. These failures have the potential to spread infection in the facility. Findings: 1. During an observation on 7/5/22 at 9:59 a.m., therapist A (TA) was in Resident 2's room. TA did not have an N95 on. During an observation on 7/5/22 at 10:16 a.m., TA was in Resident 16's room. TA did not wear an N95 mask. During an observation on 7/5/22 at 10:32 a.m., licensed vocational nurse B (LVN B) was in Resident 12's room. LVN B did not wear N95 mask. During an concurrent interview with the registered nurse C (RN C) confirmed the residents were exposed to COVID-19 and staff were not wearing N95. During an interview on 7/5/22 at 11:20 a.m., RN C stated the staff should have been wearing N95. During an interview on 7/8/22 at 11:15 a.m., the infection preventionist (IP) stated staff should have been wearing N95s in the rooms of COVID-19 exposed residents. Review of Resident 2's physician orders indicated she had an order for contact droplet precaution, dated 6/26/22. Review of Resident 12's physician orders indicated he had an order for contact droplet precaution, dated 6/26/22. Review of Resident 16's physician orders indicated he had an order for contact droplet precaution, dated 6/26/22. Review of the facility's 8/4/21 policy, COVID-19 Infection Control, indicated for residents with suspected COVID-19 infection, the residents would have been placed on contact/droplet precautions and staff providing care for suspected COVID-19 residents would wear full personal protective equipment which includes N95 mask, face shield, disposable gown, and disposable gloves. 2. During a concurrent medication pass observation and interview with registered nurse E (RN E) on 7/7/22 at 12:17 p.m., RN E was preparing the prune juice and feeding for Resident 24. RN E saw 555734 Page 5 of 6 555734 07/08/2022 Childrens Hc Org No CA -Pediatric Hospital D/P Snf 3777 South Bascom Avenue Campbell, CA 95008

F 0880 Level of Harm - Minimal harm or potential for actual harm gloves fall on the floor. RN E picked up the gloves on the floor with her gloved hand. RN E did not change her gloves, wash her hands, or put on new gloves. She then proceeded to give the prune juice and the feeding with the contaminated gloves. RN E also proceeded to apply Amlactin (skin moisturizer) daily lotion with the contaminated gloves. RN E verified that she should have removed her gloves after she picked up the gloves that fell on the floor, washed her hands, and put on a new pair of gloves. Residents Affected - Some During an interview on 7/8/22 at 1:59 p.m., with the director of nursing (DON), she verified that RN E should have removed her gloves after picking up the gloves that fell on the floor, washed her hands, and she should have put on a new pair of gloves. 3. During an observation of tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow direct access to the breathing tube) care on 7/7/22 at 4:15 p.m., registered nurse D (RN D) removed Resident 9's tracheostomy tie (bands around the neck which holds tracheostomy in place). After cleaning Resident 9's neck and applying A+D ointment (moisturizer) and RN D removed her gloves. RN D put on new gloves without performing hand hygiene. During an interview on 7/7/22 at 4:34 p.m., RN D stated she should have used hand sanitizer after removing her gloves. During an interview on 7/7/22 at 4:34 p.m., the IP stated before putting on new gloves, staff should wash hands or hand sanitize. Review of the facility's Hand Hygiene Policy and Procedure, created 1/2018, indicated, Perform hand hygiene: Before patient contact . After removing gloves or other personal protective equipment . After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient . After personal contact that may contaminate hands . 555734 Page 6 of 6