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 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 6 Event ID: 555734 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 07/08/2022 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)