Health inspection·October 11, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview, observation, and record review, the facility failed to remove discontinued controlled substances from the Med-Cart for Resident 30. Residents Affected - Some The failure to ensure the proper disposition of discontinued controlled substances had the potential for administration to the resident or drug diversion. Findings: During a concurrent observation and interview on 10/8/24 at 10:55 with LVN1 the Med Cart A had multiple controlled medication in the locked bin that had been discontinued for Resident 30. LVN1 stated they are unaware of how long the medication had been there. The controlled discontinued medications included: 1 bottle of Morphine (Schedule II narcotic under the Controlled Substance Act) 100 mg/ml, with 9.25 ml remaining in bottle, 32 tablets of 1 mg Lorazepam (Schedule IV Controlled Substance), 69 tablets of .5 mg Lorazepam. During an interview on 10/8/24 at 12:00 p.m. with Charge Nurse (CN), the CN stated that the discontinued controlled medications should have been given to Charge Nurse or Director of Nursing (DON) for destruction and the medications should not be left in the med cart. During a review of Resident's 30 Face sheet the information indicated Resident 30 was admitted to facility on 11/29/22 with multifactorial encephalopathy (damage or disease that affects the brain), and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). During a review of Resident's 30 medical record and physician's orders, Resident 30 is in Hospice care (a program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions). The Physicians orders noted Morphine 100 mg/5 injection was discontinued on 10/4/24; Lorazepam 0.5 mg was discontinued 9/14/24; and Lorazepam 1 mg was discontinued on 10/3/24. During a review of the facility's policy and procedure (P&P) titled, Medication Storage, Controlled Medication Storage dated 9/08, indicated Medications included in the state and federal Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and record keeping in the nursing care center in accordance with federal state and other applicable laws and regulations. Controlled medications remaining in the nursing care center after the order has been discontinued are retained in the nursing care center in a securely double locked area with restricted access until destroyed as outlined by state regulation. Page 1 of 4 555855 555855 10/11/2024 Baywood Court Health Center 21966 Dolores Street Castro Valley, CA 94546

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. During Observation, Interview and record review the facility failed to label multidose eye drops designed for multiple administrations for 4 out of 5 Residents. This failure had the potential for cross-contamination. Findings: During an observation on 10/8/24 at 10:55 a.m. with LVN 1, Med-Cart A contained 5 multidose eye drops for Resident 2, 7, 9, 20, and 23. (Artificial Tears, Liquid Gel Refresh, and Refresh Tears) with 4 of the 5 boxes labelled with room number only and not the Resident's name, for Residents 7, 9, 20, and 23. During an interview on 10/8/24 at 12:00 p.m. with Charge Nurse stated that multidose eye drops should have resident's full name on the box and not just the Resident's room number. Charge nurse stated this is done to prevent cross-contamination. During a review of Resident 2's Physician's Orders, dated 12/1/23, the physician ordered Carboxymethylcellulose sodium Refresh Tears (eye drops used to relieve dry, burning, irritated eyes), 1 drop to both eyes, PRN (as needed) for dry eyes. During a review of Resident 7's Physician's Orders, dated 7/3/23, the physician ordered Refresh Tears (Refresh Celluvisc, Carboxymethylcellulose sodium), one drop to each eye, twice a day, for dry eyes. During a review of Resident 9's Physician's Orders, dated 6/10/24, the physician ordered Artificial Tears (drops, gels, or ointments that can help relieve dry, irritated eyes), one drop, three times a day, PRN for dry eyes. During a review of Resident 20's Physician's Orders, dated 12/8/22, the physician ordered Artificial Tears to both eyes, twice a day, to prevent dry eyes During a review of Resident 23's Physician's Orders, dated 4/7/22, the physician ordered Artificial Tears two drops to each eye, once a day, to prevent dry eyes. During a review of the facility's policy and procedure (P&P) titled, Medications and Medication labels dated 1/23, Consultant Pharmacist Services Provider Requirements, the P&P indicated each prescription medication will be labeled to include Resident's name, Specific directions for use, including route of administration. 555855 Page 2 of 4 555855 10/11/2024 Baywood Court Health Center 21966 Dolores Street Castro Valley, CA 94546

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 ready to eat food under sanitary conditions to prevent contamination from dust. Residents Affected - Some This improper food safety practice had the potential for food contamination resulting in food-borne illnesses. Findings: On 10/8/24 at 9:25 A.M. during an initial tour of the facility kitchen with the Executive Chef (EC), there were undated, open plastic bags of various breads: 6 pieces of english muffin, 5 slices of raisin bread, 3 pieces of bagel, 10 pieces of square bread, and 7 pieces of hamburger buns. These food items were exposed to dust and possible splash contamination as they were stored on a corner counter top with binders and small kitchen appliances. During an interview with the EC, she stated the plastics bags had to be closed and the binders and small appliances should have been in a separate area. 2022 Food Code, U.S Food and Drug Administration : 3-305 Preventing contamination from premises 3-305.11 Food Storage indicated food shall be protected from contamination by storing the food: (1) In a clean, dry location (2) Where it is not exposed to splash, dust, or other contamination 555855 Page 3 of 4 555855 10/11/2024 Baywood Court Health Center 21966 Dolores Street Castro Valley, CA 94546

F 0880 Provide and implement an infection prevention and control program. 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 implement infection control practices for an already compromised resident (Resident 12) when oxygen and suction tubing were undated and of unknown age. Residents Affected - Few This failure put Resident 12 at risk for healthcare-associated infections. Findings: During a review of Resident 12's admission record, Resident 12 was readmitted to the facility on [DATE] with a terminal diagnosis, and required suctioning and the provision of oxygen as needed. During observations on 10/8/24 at 11:05 A.M., 10/9/24 at 9:25 A.M. and 10/11/24 at 8:05 A.M., the suction tubing with a yankauer tip (a tool used to suction secretions in the mouth and throat) attached to it, and oxygen tubing at the bedside of Resident 12 did not have any dates on them. During an interview on 10/10/24 at 10:05 A.M. with Infection Preventionist (IP), IP stated the tubings needed to be dated. During a review of the facility's policy titled, Suctioning and revised August 2014, it indicated: #13. Change and date the suction and tubing every 14 days, or as needed. A review of the facility's policy titled Department (Respiratory Therapy) - Prevention of Infection dated 2001, #7 stated: Change and date the oxygen cannulae and tubing every 14 days, or as needed. 555855 Page 4 of 4