Inspection·December 5, 2022

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one opened multi-dose eye medication was dated with an open and discard date, to make sure it was not used beyond the discard date. The deficient practice had the potential for unsafe and ineffective use of medication being used past the expiration date. Finding: During an inspection of the medication cart on [DATE], at 9:54 a.m., with Licensed Vocational Nurse (LVN) C, one opened lubricant eye drop bottle for Resident 19 was identified without an open date, LVN C stated, the bottle was newly opened, and confirmed it should have been labeled with an open date upon opening. During an interview with the Director of Nursing (DON) on [DATE], at 1:28 p.m., he stated for multi-dose medications, the licensed nurses should have verify expiration date before opening and administering the medication, and they should have label the bottle with an open date upon opening. The DON further stated lubricant eye drops were good for 60 days after opening. A review of facility's policy and procedure (P&P), titled Medication Administration - General Guidelines, dated 01/2021, indicated, Certain products or package types such as multi-dose vials and ophthalmic drops have specified shortened end-of-use dating, once opened, to ensure medication purity and potency. When date open expiration dating was not available from the manufacturer, the following may be considered in determining facility policy: Position statements from American Society of Ophthalmic Registered Nurses and American Society of Cataract & Refractive Surgery (ASCRS) state that the multi-use eye drops and ointments should have been disposed of 28 days after initial use. [ .] All other ophthalmic drops are to be considered expired after 60 days from the date opened. A review of facility's P&P, titled Medication and Medication Labels, dated 2007, indicated the Multi-dose vials should have labeled to assure product integrity, and considering the manufacturer's specifications. (Example: Modified expiration dates upon opening the multi-dose vial). 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: 555841 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 555841 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywood Post Acute 238 Virginia 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)