Health 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). Page 1 of 6 555841 555841 12/05/2022 Baywood Post Acute 238 Virginia Avenue Campbell, CA 95008

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, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions when: Residents Affected - Some 1. The kitchen microwave was not clean; 2. Employee's food was inside the kitchen refrigerator; and 3. The test strip to check the red bucket (sanitizer bucket) was expired. These failures had the potential to cause food borne illnesses to the residents in the facility. 1. During the initial kitchen observation on 4/5/2022, at 8:28 a.m., there were brown, black, and white substances at the top of the inside of the microwave and food buildup. During a follow up observation and concurrent interview with the dietary aide (DA) on 4/5/2022, at 1:40 p.m., DA confirmed the above observation. DA stated the microwave was used to warm residents' food. DA tried to clean them but DA could not remove the debris. DA further stated it should have been replaced. During an interview with the Registered Dietitian (RD) 4/8/2022 at 3:30 p.m., RD stated all kitchen equipment should have been kept clean. RD further stated microwave ovens should have been cleaned weekly or as needed. Review of the facility's undated policy, Kitchen Sanitation, indicated, All utensils, counters, shelves and equipment should have been kept clean and maintained in good repair. 2. During a kitchen observation and concurrent interview with DA and [NAME] E on 4/5/2022, at 8:38 a.m., there was a plastic bag inside the kitchen refrigerator labeled 12/5/2022. DA stated it was his food for lunch. During an interview with the RD on 4/8/2022, at 3:35 p.m., RD was made aware of the above observation. RD stated employee's food should have been separated from the resident's food. RD further stated the employee's food should have been kept inside the employee's refrigerator in the break room. 3. During a kitchen observation and concurrent interview with the DA on 12/8/2022, at 8:40 a.m., after checking the red bucket sanitizer concentration. The surveyor noted the test strip was expired. The test strip label indicated, Expired: March 2022. During an observation and concurrent interview with the RD and [NAME] F, on 12/8/2022, at 8:43 a.m., RD acknowledged the test strip was expired. [NAME] F called Auto-Chlor (the test-strip manufacturer) and stated that the test strip should have not used when expired. Review of the facility's undated policy, titled, Quaternary Ammonium Policy, indicated, Check for test strip expiration date. 555841 Page 2 of 6 555841 12/05/2022 Baywood Post Acute 238 Virginia Avenue Campbell, CA 95008

F 0851 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on interview and record review, the facility failed to electronically submit staffing information based The deficient practice prevented the provision of complete and accurate direct care staffing information to the public. Findings: A review of facility's Payroll - Based Journal (PBJ - nurse staffing and non-nurse staffing datasets) submission, facility did not submit the third fiscal quarter of 2022 (April 1 - June 30) staffing information to CMS. During an interview with the business office manager (BOM) on 12/8/22 at 10:59 a.m., he stated the previous BOM failed to submit the staffing information from April 1 to June 30, 2022. During an interview with the director of nursing (DON) on 12/8/22 at 11:15 a.m., the DON acknowledged the previous BOM failed to report direct care staffing and census information electronically. A review of the facility's policy titled, Reporting Direct - Care Staffing Information (Payroll - Based Journal) dated October 2017, it indicated Census data was reported each fiscal quarter and includes resident census on the last day of each month of the quarter. A review of CMS's PBJ Policy Manual Version 2.6, dated June 2022, indicated, Submission schedule. The facility must submit direct care staffing information on the schedule specified by CMS, but no less frequently than quarterly. [ .] Direct care staffing and census data will be collected quarterly, and it was required to be timely and accurate. 555841 Page 3 of 6 555841 12/05/2022 Baywood Post Acute 238 Virginia 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 3. During an observation of gastrostomy tube (G-tube - a tube inserted through the belly that brings nutrition directly to the stomach) bolus feeding (a type of feeding where a syringe is used to send formula through the G-tube) on 12/6/22, at 11:49 a.m., with LVN D, observed him donning gloves after entering Resident 16's room. LVN D repositioned resident's leg and elevated resident's head of bed. LVN D also reconnected resident's call light cord to the wall. Then he started with the tube feeding without performing hand hygiene and did not change the gloves. Residents Affected - Few During an interview on 12/7/22, at 9:22 a.m., with LVN D, he confirmed above observation, and stated he should have performed hand hygiene before starting the tube feeding, he further stated hand hygiene should be done between tasks. During an interview on 12/7/22, at 11:11 a.m., with IP, she stated staffs should perform hand hygiene between tasks. A review of facility's P&P, titled Handwashing/Hand Hygiene, dated April 2012, indicated, Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: [ .] Upon and after coming in contact with a resident's intact skin, (e.g., when taking pulse or blood pressure, and lifting a resident); [ .] After handling soiled or used linens; After handling soiled equipment. [ .] and after removing gloves. Based on observation, interview and record review, the facility failed to ensure effective infection process when: 1. Foley catheter (FC, a tube inserted in the bladder to drain urine) and drainage bag were in direct contact with Resident's wheelchair wheel. 2. Staff did not perform hand hygiene in between tasks. 3. One licensed nurse did not perform hand hygiene between tasks during tube feeding. These failures had the potential to result in transmission of infection in the facility. Findings: 1. During an observation on 12/5/22 at 8:43 a.m., inside Resident 24's room, Resident 24's FC tubing and drainage bag were in direct contact with Resident 24's wheelchair wheel. During an interview with licensed vocational nurse (LVN) B on 12/5/22 at 8:43 a.m. inside Resident 24's room, LVN B acknowledged the above observation and stated the FC tubing and drainage bag should have not touched the dirty surfaces such as wheelchair wheel. During an interview with infection preventionist (IP) on 12/7/22 at 10:07 a.m., the IP stated urinary tubing and drainage bags should have not direct contact with dirty surfaces. She further stated urinary drainage bag should have been placed inside a cover bag to prevent contamination Review of the facility's Policy and Procedure (P&P), titled, Catheter Care, Urinary, dated October 2010, it indicated Be sure the catheter tubing and drainage bag are kept off the floor and place 555841 Page 4 of 6 555841 12/05/2022 Baywood Post Acute 238 Virginia Avenue Campbell, CA 95008

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few drainage catheter bag inside the cover bag. Cover bag protects catheter bag from damage, contamination, and contains spills or leaks, if a leak in the catheter bag will occur. 2. During an observation on 12/5/22 at 8:21 a.m., certified nursing assistant (CNA) A stepped out of Resident 22's room wearing gloves and carrying a plastic bag of trash. CNA A went to the dirty utility room and disposed trash and gloves, CNA A did not wash or sanitize hands and took clean linens from the clean linen room and went back to the Resident 22's room. During an interview with CNA A on 12/5/22 at 8:23 a.m., CNA acknowledged the above observation and stated he should have washed his hands after disposing trash bags and before touching clean linens. During an interview with the IP on 12/7/22 at 10:02 a.m., she stated hand hygiene should have been performed by all staff after touching dirty items and gloves should have not worn in the hallway to prevent cross contamination. During an interview with the director of nursing (DON) on 12/8/22 at 10:19 a.m., the DON stated all staff should have perform hand hygiene after touching disposing trash and gloves should have never be worn in the hallway. 555841 Page 5 of 6 555841 12/05/2022 Baywood Post Acute 238 Virginia Avenue Campbell, CA 95008

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the following resident rooms provided less than 80 square feet per resident. Findings: 1. room [ROOM NUMBER], a four-person room, measured 73.4 square feet per resident. 2. room [ROOM NUMBER], a four-person room, measured 73.4 square feet per resident. 3. room [ROOM NUMBER], a four-person room, measured 73.4 square feet per resident. During the survey, none of the rooms were observed to inhibit the staff from providing care or services, or the residents from receiving adequate care and services. The staff and residents moved freely in the rooms unhampered by the lack of space. Wheelchairs were easily accommodated. The residents had no concerns regarding the space or privacy in their room. Recommend waiver remain in effect. 555841 Page 6 of 6