Health inspection·July 13, 2023

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to prevent 13.51% medication error rate when there were five medication pass errors out of 37 medication pass observations. Resident 32's medications were crushed together without an order, including one medication that had enteric coating (EC - designed to pass through the stomach and dissolve in the small intestine, this will protect the stomach lining from irritation). This failure had a potential to affect Resident 32's health due to malabsorption of the medications. Residents Affected - Few Findings: During a concurrent observation and interview on 7/11/23 at 7:35 a.m., with Licensed Vocational Nurse (LVN), LVN 1 stated, they would prepare Resident 32's medications. LVN 1 prepared the following medications: 1. Ecotrin EC (enteric coated - low dose Aspirin may help manage cardiovascular health) 81 milligram (mg) tablet given one tablet. 2. Vitamin D3 (supplement) 50 microgram (mcg) given 1 1/2 tablet, 3. Calcium (supplement) 500 mg given one tablet, 4. Losartan (medication to help manage high blood pressure) 25 mg tablet given 1/2 tablet 5. Farxiga (medication used to manage high blood sugar level) 10 mg tablet given one tablet LVN 1 put all the medications in a small medication bag and crushed the medications, when asked if they crushed all the tablets, LVN 1 stated Yes. During a concurrent interview and record review on 7/12/23 at 7:56 a.m., with Registered Nurse (RN)1, RN 1 reviewed July 2023's physician order for Resident 32's, RN 1 stated, there was no order to crush the medications. RN 1 stated, when crushing the medications they try to do it one medication at a time unless the pharmacy had given them instructions that the medication could be crushed together. RN 1 stated, that there was no instructions from the pharmacy that Resident 32's medications could be crushed together. During a review of the facility's policy and procedure titled Oral Medication Administration Procedure indicated To administer oral medication in an organized and safe manner . Crush medications that are crushable if indicated for this resident, only if there is a current order from MD: May Crush Meds. Any tablet medication formulation that is enteric coated, extended release, sustained release, Page 1 of 5 555843 555843 07/13/2023 Masonic Home 34400 Mission Blvd Union City, CA 94587

F 0759 long-acting should not be crushed. Call the pharmacist to verify if needed. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555843 Page 2 of 5 555843 07/13/2023 Masonic Home 34400 Mission Blvd Union City, CA 94587

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. 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 to provide palatable food when food was served bland (lacking flavor). Residents Affected - Many This failure had the potential to put residents to consume less food resulting in consumption of less calories and nutrients provided by the planned menu. Findings: During a concurrent observation and interview with Resident 11 with her daughter on 7/10/23 at 11:30 AM, Resident 11 was in lying in bed, alert, Resident 11 was asked if she liked her meal, Resident 11 shook her head and stated, no taste. Resident 11's daughter stated, she also tried to taste resident's pureed food and tasted bland. During a food preparation observation with Registered Dietitian 3 (RD3) on 7/12/23 at 9:40 AM, Dietary staff 1 (DS1) was observed preparing Roast beef mechanical/ pureed food. DS 1 was observed chopping the non-measured amount of roast beef into small pieces and put it into a blender to puree the meat, DS1 then proceeded to add a pitcher amount of water in the blender and 4 scoops of thickener in the blender. DS1 then placed the pureed meat in pan. There was no recipe to follow for reference on site during the preparation. During a review of the facility Policy and procedure HC Roast beef, Simply Pureed with revision date on 6/1/2023, indicated Portion .Roast beef . 20 Servings 3 lb. [pounds - a unit for measuring weigh) 12 oz (oza unit of weight) HC Demi-[NAME] [a concentrated, flavorful glaze that is used as a foundation for a number of sauces] 1 qt [a unit of liquid] Shape and Serve Thickener 2 cups. Hot water 2 qt .Step .Placed the beef into a food processor, and process to a fine consistency . Add demi-[NAME] and mix with hot water and Sauce and Serve Thickener to food processor and process until smooth . During an interview with RD3 on 7/12/23 at 10:10 AM, RD3 stated following Recipes and accurate measurements are important to ensure the puree has an acceptable taste, nutrients and texture. During a concurrent observation and interview on 7/12/23 at 12:20 PM, test tray was done with surveyors and RD1, Surveyors and RD1 tasted the tray, Swiss steak did not have tomato gravy but sauce as indicated in the menu, the meat was dry and hard. Mechanical soft chicken was bland (no flavor). RD 1 Verified and acknowledged the observation. During a review of the policy and procedure titled MODIFIED TEXTURE FOODS dated 1/23, the policy indicated, Provide a standardized process for modified texture foods to meet community-approved diet guidelines and to assure palatability, flavor, texture and nutritional value . 555843 Page 3 of 5 555843 07/13/2023 Masonic Home 34400 Mission Blvd Union City, CA 94587

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 and prepare food in accordance with professional standards for safety when: Residents Affected - Many 1. Dietary Staff 2 (DS2) scooped ice without gloves and touched the ice. 2. Multiple spices containers with residue on the lids stored on the kitchen shelves were unlabeled. 3. Multiple trays of uncooked meat and multiple pies placed in a speed rack, unlabeled and undated in refrigerator 1. 4. A tray of cooked meat with used by date of 7/8/23 was left in refrigerator 1. 5. Portable kitchen counter tops were dirty with food particles on the shelves. 6. Open deep fryer at the portable kitchen was dirty wit built up brown rustic looked like sticky residue particles surrounding it and on its the walls. 7. Dietary Staff 1 (DS1) did not change gloves and wash hands in between task during food preparation. These failures had the potential for contamination of food resulting in food borne illness for 60 residents who received food from the kitchen. Findings: 1. 555843 Page 4 of 5 555843 07/13/2023 Masonic Home 34400 Mission Blvd Union City, CA 94587

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a concurrent observation and interview in the kitchen with DS 2 on 7/10/23 at 10 AM, DS 2 was observed scooping ice from the ice machine with no gloves on. DS 2 was observed touching the ice several times while scooping the ice. DS 2 acknowledged that he should have worn gloves to prevent contamination. During a review of the facility's P&P titled Sanitation and infection prevention/control with revised date 1/21, the P&P indicated, ICE HANDLING .Ice must be protected from splash, drip and hand contamination during storage and service . 2. During a concurrent observation iand interview with the Director of Dining Services (DSS) on 7/10/23 at 10:10 AM, there were multiple opened spices containers with residue on the lids, unlabeled and undated at the kitchen shelves. The DSS verified and acknowledged that they should have been dated and cleaned their lids when opened. 3-4. During the same observation and interview in the kitchen with the DSS, multiple trays of uncooked bacon and multiple trays of pies uncovered, undated and placed in a speed rack and a tray of cooked meat in a deep-dish tray pan with a sticker indicated used by date 7/8/23 in refrigerator 1 was observed. The DSS verified and acknowledged the findings. The DSS removed the bacon, pies and cooked meat in a tray and stated those should have been thrown out and not stored in the refrigerator. 5- 6. During the kitchen initial tour observation and interview with the DSS on 7/10/23, at 10:30 AM, the portable kitchen countertops were observed dirty, filled with sticky mushy particles. The opened deep fryer was dirty with blackened colored oil with built up sticky brown rustic looked like residue particles surrounding it and on its walls. The DSS verified and acknowledged the findings. The DSS stated they normally dump the oil and clean it supposedly. During a review of the facility's policy and procedure (P&P) titled SANITATION AND INFECTION PREVENTION /CONTROL with revised date of 1/23, the P&P indicated, . Sanitize food contact surfaces after they have been thoroughly washed and rinsed . 8. During the food preparation observation on 7/12/23, at 9:30 AM, DS 1 was observed preparing mechanical/ pureed food. DS1 was observed cutting the meat on a chopping board and placing the meat in a blender/processor with gloves on, DS 1 was observed opening a door in the kitchen, touching the doorknob, went to touch a clip board hanging on the wall and went back to cut the meat and placed in the blender without changing gloves and washing his hands. During a review of the facility P&P titled PRODUCTION, PURCHASING STORAGE with revised date 1/23, the P&P indicated, FOOD HANDLING GUIDELINES . Foods shall be protected against crosscontamination .Gloves are changed between task or if punctured or ripped. Hands are wash after gloves are removed . 555843 Page 5 of 5