Health inspection·February 18, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure staff upheld a resident's right to be treated with dignity for three of 13 sampled residents (Residents 53, 168, and 24) when: 1. Staff did not answer Resident 53's request for assistance in a timely manner and when staff did not assist Resident 53 with incontinence care. (Refer to F600) 2. Staff did not provide pain management intervention(s) to Resident 168 in a timely manner when requested by a family member and staff did not provide incontinence care in a timely manner. (refer to

F600) 3. Staff did not to assist Resident 24 with incontinent care in a timely manner. Failing to treat each residents with dignity had the potential to make them feel unwanted, depressed, and not respected. Findings: A thorough review of staff response to request for assistance was initiated during this survey due to two factors: i. There were three prior complaints alleging delay in staff response and/or substandard response to requests for assistance. ii. Review of resident council meeting minutes for the last three months (November 2021 to January 2022) indicated slow response to requests for assistance may be a systemic issue. The meeting minutes indicated that 10 out of 15 feedbacks (66.7%) identified slow call light response time as a problem within the facility. 1. Review of Resident 53's records titled Clinical Admission notes, dated 1/20/22, indicated he was admitted to the facility on [DATE] with multiple diagnoses including: a recent fall resulting in a left hip fracture and a right upper arm bone fracture. His Clinical Admission notes indicated he had .complaints of pain upon assessment 4/10 to left hip while moving, 4/10 right humerus (upper arm) while moving hand or arm patient has lots of discomfort. Review of Resident 53's MDS (Minimum Data Set, a standardized clinical assessment), dated 1/23/22, indicated his had no problems with his cognition (brain-based skills) or his memory. According to Page 1 of 29 555856 555856 02/18/2022 Peninsula Post-Acute 1609 Trousdale Drive Burlingame, CA 94010

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some his MDS, he required extensive assistance of one staff with bed mobility, dressing, toilet use, and personal hygiene. He was totally dependent on staff for bathing and was frequently incontinent of urine. During an interview on 2/16/22 at 11:47 AM, Resident 53 was asked about call light response. Resident 53 said requests for assistance can take a long time. Resident 53 stated On Sunday the thirteenth (2/13/22) around 9 PM, I had to wait about an hour trying to get back to bed from my wheelchair. I had been up for seven hours. I already pushed the call light. I knew it was around 9 PM because my wife just flew in from Orange county and she called to check in on me. After I told her what happened, she had to call the facility to get someone to come in to help me. I was pissed that night. What's going on they can't help. I was just mad. This wasn't the first time something like this happened. About two and a half weeks (after admission) I had to wait 45 minutes for help to change my (adult brief). When the CNA (Certified Nursing Assistant) finally came, she made me feel like I was just a burden. The CNA looked like she was pissed off when she came in. She threw the clean (adult brief) on the bed and said someone else will be in later to help. I was so angry. I was sitting in my wet (adult brief). Even though I was in pain when I move my arm and legs. I had to reach with my other good leg and grab the (adult brief) with my toes bring it up to my good arm. Then I have to take off my wet (adult brief) to put on the clean one. 2. Review of Resident 168's records titled Resident Face Sheet dated 12/2/21, indicated she was admitted to the facility on [DATE] with multiple diagnoses including: history of falls resulting in fractures of the left thigh bone, left forearm bone, left upper arm bone, arthritis of the bones of the right hip, depressed mood, glaucoma, age related bone loss resulting in fragile and brittle bones. Review of Resident 168's MDS, dated [DATE], indicated her BIM (Brief Interview for Mental Status test used to determine cognition and memory condition) was 13/15 (a score of 13-15 indicated the subject was cognitively intact). According to her MDS, she required extensive assistance of two staff for bed mobility and transfers. She required extensive assistance of one staff for dressing, toilet use and personal hygiene. Resident 168 was assessed as being frequently incontinent of bowel and bladder. The MDS also indicated, she experienced pain almost constantly, making it hard for her to sleep at night and to do her day-to-day activities. Her pain level was assessed as 8 out of 10 (this is a 10-point pain scale, with 7 to 9 = very severe pain and 10 = worst possible pain) Review of Resident 168's Medication Administration records, dated 12/2/21 to 12/9/21, indicated she was experiencing severe pain almost on a daily and/or more frequent basis. Staff documented Resident 168 reported very severe pain levels (7-9 out of 10) at least 14 times during her stay. On 12/8/21 at 8:00 PM, staff documented Resident 168 had pain level 10 out of 10 (worst possible pain). During an interview, on 2/16/22 at 12:20 PM, Resident 168's daughter stated when family visited, they witnessed numerous occasions when staff were slow in responding to call lights/request for assistance. Resident 168's daughter stated You would buzz and buzz, but they never come. Then you would have to go out there looking for them. Sometimes you would see them at the nurse's station. They would be on their phones or just talking and laughing among themselves. On Saturday, December 4th, 2-3 PM, she was in terrible pain. My husband . went out to get help. My husband said a staff member told him 'I have 23 other patients. I'll get to her when it's her turn.' My husband stayed for about an hour after the request and no one ever came in to help her. On Sunday, December 5th, she called me crying and said I went to the bathroom, I've been laying in feces for over two hours. I told her to just use her call button. She said the call button was on the floor. Two hours? Are they even checking on her? We tried to give them a chance. But one day she called me crying in pain. We finally had to 555856 Page 2 of 29 555856 02/18/2022 Peninsula Post-Acute 1609 Trousdale Drive Burlingame, CA 94010

F 0550 get her out of there. It just wasn't a safe place for her. Level of Harm - Minimal harm or potential for actual harm 3. Review of Resident 24's MDS, dated [DATE], indicated she was admitted to the facility on [DATE] with multiple diagnoses including: anemia (lack of red blood cells), heart problem, kidney problem, urinary tract infection, diabetes, arthritis (degeneration of joints), hip fracture, stroke (death of brain cells due to blockage or disease), malnutrition, history of falls and vision problem. Residents Affected - Some According to Resident 24's MDS, she required extensive assistance of two or more staff with bed mobility, and transfers. She required extensive assistance of one staff with dressing, toilet use, and personal hygiene. Resident 24 was assessed as frequently incontinent of bowel and bladder. Resident 24's BIM score was 14 out of 15. This indicated that she was cognitively intact. During an interview on 2/16/22 at 10:17 AM, Resident 24's daughter stated My mom said it took them a long time to answer her call light. She told me that she soiled herself and she would ask for help and it took them a long time to help her. She said when no one comes, sometimes even her roommate had to help her by either using her call light or calling out to staff for help. 555856 Page 3 of 29 555856 02/18/2022 Peninsula Post-Acute 1609 Trousdale Drive Burlingame, CA 94010

F 0584 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview, and record review, the facility failed to maintain a safe and homelike environment when the Communal Shower Room (CSR) 2 had peeled and torn non-skid strips. Residents Affected - Some This failure posed a safety risk that may result in injuries to the residents and staff. Findings: During a concurrent observation and interview, with the Environmental Services Director (ESD) on 2/16/22 at 11:46 AM, there were dark-colored strips installed at the entrance, in front of the toilet bowl, and beside the bathtub in the CSR 2. The strips had areas that were torn and peeled off. The ESD stated, I want that removed (damaged strips) because it's hard to clean across the lifted areas. I feel like patients could trip if they come in with walker. The ESD also stated that the CSR 2 is used by the residents. During an interview, on 2/17/22 at 12:23 PM, the Maintenance Director (MD) stated that the dark-colored strips on the CSR 2 floor were non-skid strips. The MD stated he was aware of the torn and peeled non-skid strips. The MD also stated that if the non-skid strips were not fixed, It may not be safe (for the residents). A review of the facility policy and procedure (P&P) titled, Maintenance Service, dated 12/2009, the P&P indicated, .Policy statement . Maintenance service shall be provided to all areas of the building, grounds, and equipment . Policy Interpretation and Implementation .1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to: a. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. b. Maintaining the building in good repair and free from hazards . 555856 Page 4 of 29 555856 02/18/2022 Peninsula Post-Acute 1609 Trousdale Drive Burlingame, CA 94010

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two out of 13 sampled residents (Residents 53 and 168) were free from neglect when: 1 . Resident 53 reported a staff was rude and failed to help him change out of his wet adult brief. As a result, Resident 53 still have ongoing unpleasant memory of this event and is fearful of working with this staff. 2. Resident 168's family requested pain medication from a nurse. This request was ignored for almost an hour while the Resident was in severe pain. As a result, Resident 168 continued to have severe pain for an hour. Findings: A thorough review of staff response to request for assistance was initiated during this survey due to two factors: i. There were three prior complaints alleging delay in staff response and/or substandard response to requests for assistance. ii. review of resident council meeting minutes for the last three months (November 2021 to January 2022) indicated slow response to requests for assistance may be a systemic issue. The meeting minutes indicated 10 out of 15 feedbacks (66.7%) identified slow call light response time as a problem within the facility. 1. Review of Resident 53's records titled Clinical Admission notes, dated 1/20/22, indicated he was admitted to the facility on [DATE] with multiple diagnoses including: a recent fall resulting in a left hip fracture and a right upper arm bone fracture. His Clinical Admission notes indicated he had .complaints of pain upon assessment 4/10 to left hip while moving, 4/10 right humerus (upper arm) while moving hand or arm patient has lots of discomfort. (this is a 10-point pain scale, with 4 to 6 = moderate pain and 10 = worst possible pain). Review of Resident 53's MDS (Minimum Data Set, a standardized clinical assessment), dated 1/23/22, indicated his had no problems with his cognition (brain-based skills) or his memory. According to his MDS, he required extensive assistance of one staff with bed mobility, dressing, toilet use, and personal hygiene. He was totally dependent on staff for bathing and was frequently incontinent of urine. During an interview, on 2/16/22 at 11:47 AM, Resident 53 was asked about call light response. Resident 53 said there was a pattern of staff neglect at the facility. Resident 53 stated About two and a half weeks (after admission) I had to wait (about) 45 minutes for help to change my (adult brief). When the CNA (Certified Nursing Assistant) finally came, she made me feel like I was just a burden. The CNA looked like she was pissed off when she came in. She threw the clean (adult brief) on the bed and said someone else will be in later to help. I was so angry. I was sitting in my wet (adult brief). Even though I was in pain when I move my arm and legs. I had to reach with my other good leg and grab the (adult brief) with my toes bring it up to my good arm. Then I have to take off my wet 555856 Page 5 of 29 555856 02/18/2022 Peninsula Post-Acute 1609 Trousdale Drive Burlingame, CA 94010

F 0600 (adult brief) to put on the clean one. Level of Harm - Actual harm During a concurrent interview and record review, on 2/18/22 at 9:21 AM, Resident 53 was provided with his charting titled Progress Notes, dated 2/16/22 at 4:00 PM and 2/17/22 at 8:37 AM. Resident 53 stated these documentation were not an accurate account of his feelings about the incident. Resident 53 stated I'm still angry when I think back about what happened. This feeling of being helpless . it's painful to think about what happened. Resident 53 stated he is still on the lookout for this CNA. Resident 53 stated I don't know who she is because she was wearing a mask. I don't really want to work with her because of what she did. I feel scared. Residents Affected - Few 2. Review of Resident 168's records titled Resident Face Sheet, dated 12/2/21, indicated she was admitted to the facility on [DATE] with multiple diagnoses including: history of falls resulting in fractures of the left thigh bone, left forearm bone, left upper arm bone, arthritis of the bones of the right hip, depressed mood, glaucoma, age related bone loss resulting in fragile and brittle bones. Review of Resident 168's MDS, dated [DATE], indicated her BIM (Brief Interview for Mental Status test used to determine cognition and memory condition) was 13/15 (a score of 13-15 indicated the subject was cognitively intact). According to her MDS, she required extensive assistance of two staff for bed mobility and transfers. She required extensive assistance of one staff for dressing, toilet use and personal hygiene. Additionally, she was assessed as being frequently incontinent of bowel and bladder. According to her MDS, she experienced pain almost constantly, making it hard for her to sleep at night and to do her day-to-day activities. Her pain level was assessed as 8 out of 10 (this is a 10-point pain scale, with 7 to 9 = very severe pain and 10 = worst possible pain) Review of Resident 168's Medication Administration records, dated 12/2/21 to 12/9/21, indicated she was experiencing severe pain almost on a daily and/or more frequent basis. Staff documented Resident 168 reported very severe pain levels (7-9 out of 10) at least 14 times during her stay. On 12/8/21 at 8:00 PM, staff documented Resident 168 had pain level 10 out of 10 (worst possible pain). During a telephone interview, on 2/16/22 at 12:20 PM, Resident 168's daughter stated when family visited, they witnessed numerous occasions when staff were slow in responding to call lights/request for assistance. Resident 168's daughter stated, You would buzz and buzz, but they never come. Then you would have to go out there looking for them. Sometimes you would see them at the nurse's station. They would be on their phones or just talking and laughing among themselves. On Saturday, December 4th, 2-3 PM, she was in terrible pain. My husband . went out to get help. My husband said a staff member told him 'I have 23 other patients. I'll get to her when it's her turn.' My husband stayed for about an hour after the request and no one ever came in to help her. On Sunday, December 5th, she called me crying and said I went to the bathroom, I've been laying in feces for over two hours. I told her to just use her call button. She said the call button was on the floor. Two hours? Are they even checking on her? We tried to give them a chance. But one day she called me crying in pain. We finally had to get her out of there. It just wasn't a safe place for her. Review of Resident Progress Notes, dated 12/9/21, indicated At approximately 09:30 am .daughter .of patient . (stated) that her mother was in severe pain. Daughter .insisted that her mother be transferred to . Hospital immediately for further evaluation/pain management. MD ordered to have her sent to (hospital). Review of the facility's Abuse Prevention Program (not dated) indicated Our residents have the 555856 Page 6 of 29 555856 02/18/2022 Peninsula Post-Acute 1609 Trousdale Drive Burlingame, CA 94010

F 0600 right to be free from abuse, neglect, . (The facility will) Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents. Level of Harm - Actual harm Residents Affected - Few 555856 Page 7 of 29 555856 02/18/2022 Peninsula Post-Acute 1609 Trousdale Drive Burlingame, CA 94010

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to ensure allegations of neglect for three of 13 sampled residents (Residents 53, 168 , and 24) were reported within the prescribed timeframes, when the alleged incidents on 2/16/22 was reported on 2/18/22 to the required authorities. This failure had put residents at risk for safety. Findings: During an interview on 2/16/22 at 3:13 PM, the Administrator and Director of Nursing (DON) were made aware of allegations of neglect regarding Residents 53, 168 and 24. The facility staff was made aware of the alleged residents' neglect on 2/16/22, and the facility reported the incident on 2/18/22 to the required authorities. Review of Resident 53's Progress Notes, dated 2/16/22 at 4:00 PM and 2/17/22 at 8:37 AM, indicated the facility was aware of allegations of neglect regarding call light response. During interview on 2/18/22 at 12:34 PM, the Administrator and Director of Nursing were asked to provide documented evidence these allegations of neglect were reported to the required authorities. The facility was unable to provide documented proof that these allegations were reported within 2 hours as required. 555856 Page 8 of 29 555856 02/18/2022 Peninsula Post-Acute 1609 Trousdale Drive Burlingame, CA 94010

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement policies and procedures for accurate provision of pharmaceutical services when: 1.Licensed staff failed to accurately reconcile metoprolol (a medication to treat blood pressure) for Resident 368, 2.Tramadol (a medication for pain that is regulated) 50mg (milligram) for Resident 60 was not accurately reconciled on control drug count sheet and medication administration record (MAR). These failures had a potential for Resident 368 to experience adverse effects, Resident 60 having unmedicated pain, and controlled substance discrepancy leading to diversion (stealing of medications). Findings: 1.During record review on 2/15/22, the MAR from Hospital 1 showed Resident 368 received metoprolol 25mg half a tablet by mouth two times a day or 12.5mg by mouth two times a day. A review of the Facility's MAR indicated Resident 368 had a physician order for metoprolol 25mg (milligram - a unit of measure) by mouth two times a day and had received the medication as ordered since admission on [DATE]. Review of Resident 368's clinical record indicated that he had received metoprolol as ordered by physician from 2/14/22 thru 2/15/22. During an interview and record review with DON (Director of Nursing) on 2/17/22 at 9:42 AM, DON stated 2 people must perform a medication reconciliation for a new admit to the facility as soon as possible the next day during the week and for admits on Friday thru Sunday, medication reconciliation must be performed on Monday. DON further explained that any discrepancies must be immediately reported to DON and a medication error report must be filled out. DON stated it is important for residents to receive correct medication for their overall well-being and to address their clinical conditions. Review of the facility's policy and procedure (P&P) titled, Reconciliation of Medication on Admission, dated 2017, indicated, Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating accurate list of both prescription . Medication reconciliation .in the correct dosages and routes .helps to ensure that all medications, routes and dosages on the list are appropriate . Review the list carefully to determine if there are discrepancies/conflicts . If there is a discrepancy or conflict in medications .determine the most appropriate action to resolve the discrepancy . If the discrepancy was unresolved, document how the discrepancy was communicated to the charge nurse, physician, pharmacy, and/or next shift. 2.During a concurrent interview and record review on 2/14/22 at 2:54 PM with Licensed Vocational Nurse (LVN) 5, reviewed controlled substance accountability sheet for Resident 60 that read tramadol 50mg take half tablet by mouth every 4 hours as needed for pain administered on 2/12/22 at 6:33 PM. LVN 5 reviewed the MAR which showed the tramadol was given 2/13/22 at 6:33 PM. LVN 5 explained that 555856 Page 9 of 29 555856 02/18/2022 Peninsula Post-Acute 1609 Trousdale Drive Burlingame, CA 94010

F 0755 any discrepancies are supposed to be reported immediately to DON. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review with DON on 2/17/22 at 9:31 AM, DON explained that at shift exchange a narcotic reconciliation is supposed to performed. DON stated at shift change the nurses do not review the administration times. DON stated that at the next administration the nurse should review the previous administration and report and discrepancies to DON. DON stated that nurses are expected to call regardless of time. DON explained narcotic count sheets are important for counting medications, dispensing medications, accountability, preventing diversion and should match the MAR. Residents Affected - Few Review of the facility's P&P titled, Controlled Substances, dated 2019, indicated, Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift Any discrepancies in the controlled substance count are documented and reported to the DON immediately. 555856 Page 10 of 29 555856 02/18/2022 Peninsula Post-Acute 1609 Trousdale Drive Burlingame, CA 94010

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and document review, the facility failed to ensure one of 13 sample residents (Resident 74) was free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when: 1. Abilify (antipsychotic medication to treat mental health issues) was administered without a specific condition that was diagnosed and documented in the clinical record and without documented behavioral interventions (individualized non - pharmacological approaches). 2. Celexa (a medication used to treat depression, a persistent feeling of sadness and loss of interest) and Abilify were administered as duplicate therapy (multiple medications for same diagnosis) for depression. These failures had the potential for the resident to receive unnecessary medication which increased the risk of preventable side effects and death. Findings: 1.Review of Resident 74's clinical record indicated that she was [AGE] years old and admitted to the facility on [DATE]. Record showed Resident 74 had a diagnosis of unspecified dementia (loss of thinking, memory, and reasoning that interferes with a person's ability to perform daily life activities) with behavioral disturbance. Review of Resident 74's clinical record indicated that she had a physician order for Abilify 2 mg (milligrams a unit of measure) one tablet by mouth daily in the morning as indicated for depression from 2/12/22 thru 2/14/22 and received three (3) doses. Review of Resident 74's clinical record indicated that she had a physician order for Abilify 2 mg one tablet by mouth daily in the morning as indicated for dementia with behavioral disturbance from 2/15/22 thru 2/16/22 and received two (2) doses. In an interview and record review with Director of Nursing (DON) on 2/17/22 at 9:54 AM, stated that Resident 74 did not have a care plan for anti-psychotic use or a non-pharmacological intervention resident specific plan for behaviors associated with psychosis. DON showed there was no documentation at time of administration for evaluation of continued use of anti-psychotic by Inter- Disciplinary Team (IDT) and the resident's prescriber. DON stated the resident is not a danger to self or others and it is important ensure medications have proper indications. Review of the facility's policy and procedure (P&P) titled, Antipsychotic Medication Use, dated 2015, indicated, Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological .have been identified and addressed Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective Residents who are admitted from the community or .are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use .antipsychotic medications will generally only be considered if the following conditions are also met: the 555856 Page 11 of 29 555856 02/18/2022 Peninsula Post-Acute 1609 Trousdale Drive Burlingame, CA 94010

F 0758 behavioral symptoms present a danger to the resident or others . Level of Harm - Minimal harm or potential for actual harm Review of the facility's P&P titled, Dementia - Clinical Protocol, dated 2015, indicated, As part of initial assessment, the physician will help identify individuals who have been diagnosed as having dementia . The Inter-Disciplinary Team (IDT - a specific group of healthcare providers in the facility that evaluates care issues of residents) will evaluate individuals with new or progressive cognitive impairment . The IDT will review past and current physical, functional and . For the individual with confirmed dementia, the IDT will identify a resident-centered care plan to maximize remaining function and quality of life. The IDT will adjust interventions and the overall plan depending on the individual's response . Residents Affected - Few Review of the facility's P&P titled, Behavioral Assessment, Intervention, and Monitoring, dated 2015, indicated, Interventions will be individualize and part of an overall care environment that supports physical, functional and psychosocial needs, and strives to understand, to prevent or relieve the resident's distress or loss of abilities Interventions and approaches will be based on a detailed assessment of physical, psychological and behavioral symptoms and their underlying causes . Non-pharmacologic approaches will be utilized to the extent possible to avoid or reduce the use of antipsychotic medications to manager behavioral symptoms Lexicomp (an online medication data base) indicated antipsychotics have a boxed warning which is the strongest warning that the Federal Drug Administration (FDA) requires. The warning includes INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. 2. Review of Resident 74's clinical record indicated two medications prescribed for depression. Resident 74 had a physician order for Celexa 10 mg one tablet by mouth daily in the morning as indicated for depression/anxiety from 2/12/22 thru 2/17/22 for a total of six (6) doses. Review of Resident 74's clinical record indicated that she had a physician order for Abilify 2 mg one tablet by mouth daily in the morning as indicated for depression from 2/12/22 thru 2/14/22 for a total of three (3) doses. In an interview and record review with DON on 2/17/22 at 9:54 AM, stated that Resident 74 did receive the Celexa and Abilify for depression as indicated by the resident's MAR. DON stated IDT and resident's prescriber should have done a review of Celexa and Abilify to clarify continued utilization. Review of the facility's P&P titled, Medication Therapy, dated 2007, indicated, Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks All medication orders will be supported by appropriate care processes and practices All decisions related to medications shall include .principles of prescribing for the elderly .identify whether: .potential or suspected side effects are present Periodically, and when circumstances are present that represent a greater risk for medication-related complications .will review the medication regimen for continued indications, proper dosage and duration, and possible adverse consequences 555856 Page 12 of 29 555856 02/18/2022 Peninsula Post-Acute 1609 Trousdale Drive Burlingame, CA 94010

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. Based on observation, interview and record review, the facility failed to label and store drugs in accordance with current professional standards for four of 13 sampled residents (70, 76, 81, and 82) when: 1.Ensure potentially expired medications were not available for use, 2.Properly label resident medications available for use with expiration date when applicable and in accordance with facility policy and procedures (P & P). These failures placed residents 70, 76, 81, and 82 at risk for receiving ineffective or expired medications and had the potential of exposing residents to infections due to cross contamination. Findings: 1.During a concurrent observation and interview on 2//14/22 at 12:11 PM of medication cart 3 at Station 3 with Registered Nurse (RN) 1, one opened vial of Lantus (medication for treating high blood sugar levels) 100 units/1ml (milliliter - a unit of measurement for liquid) 10 ml vial for Resident 76 was observed. The vial did not have a label attached that contained the date opened or an expiration date. RN 1 acknowledged the opened and undated vial and stated the medication was good for 28 days after opening. RN 1 explained that it is important to ensure medications are properly labeled to prevent a resident from receiving expired medications because they could be ineffective and cause the resident to experience symptoms of high blood sugar. Review of the medication administration record (MAR) for Resident 76 indicated resident had received the Lantus 10 units injected at 9 AM daily as ordered by physician from 2/8/22 thru 2/14/22. Review of the manufacturer monograph, in the section Storage and Stability, indicated, Opened Lantus vials, whether or not refrigerated, must be discarded after 28 days . Review of the facility's P&P titled, Labeling of Medication Containers, dated 2019, indicated, Medication labels must be legible at all times Labels for individual resident medications include all necessary information, such as resident's name .expiration date when applicable . 2. During a concurrent observation and interview, on 2/14/22 at 12:15 PM of medication cart 3 at Station 3 with RN 1, observed a plastic zip lock bag for Resident 82 of Wixela (an inhaled medication for treatment of lung diseases) 250 mcg/50 mcg (micrograms - a unit of measure) that did not have an open date or expiration date and no resident identification tag on inhaler. RN 1 acknowledged the opened and undated inhaler. RN 1 explained that it is important to ensure medications are properly labeled to prevent a resident from receiving expired medications that could be ineffective. Review of the MAR for Resident 82 on 2/15/22 at 10:30 AM, indicated resident had received the Wixela 1 puff two times per day as ordered by physician from 2/10/22 thru 2/14/22. Review of the Wixela Inhaler label with RN 1 indicated printed on the side manufacturer instructions for storage that the medication should be discarded 1 month after being removed from foil pouch. 555856 Page 13 of 29 555856 02/18/2022 Peninsula Post-Acute 1609 Trousdale Drive Burlingame, CA 94010

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent observation and interview, on 2/14/22 at 12:19 PM of medication cart 3 at Station 3 with RN 1, observed one package of Advair (a medication used to treat lung diseases) 500/50 mcg inhaler for Resident 70 did not have an open date or expiration date and no resident identification tag on inhaler. RN 1 stated medication should be labeled so can prevent giving to wrong resident. RN 1 explained that it is important to ensure medications are properly labeled to prevent a resident from receiving expired medications that could be ineffective. Review of the MAR for Resident 70 on 2/15/22 at 10:30 AM, indicated resident had received the Advair 1 puff two times per day as ordered by physician from 2/9/22 thru 2/14/22. Review of the Advair package with RN 1 indicated printed on the side, manufacturer instructions that the medication should be discarded 1 month after being removed from foil pouch. During a concurrent observation and interview, on 2/14/22 at 12:23 PM of medication cart 3 at Station 3 with RN 1, observed one package of Breo 100 mcg/25 mcg (a medication used to treat lung diseases) for Resident 81 that did not have an open date or expiration date and no resident identification tag on inhaler. RN 1 stated medication should be labeled so can prevent giving to wrong resident. RN 1 explained that it is important to ensure medications are properly labeled to prevent a resident from receiving expired medications that could be ineffective. Review of the MAR for Resident 81 on 2/15/22 at 10:35 AM, indicated resident had received the Breo 1 puff per day as ordered by physician from 2/9/22 thru 2/14/22. Review of the Breo package with RN 1 indicated printed on the side, manufacturer instructions that the medication should be discarded 6 weeks after being removed from moisture - protective foil pouch. During a concurrent observation and interview, on 2/14/22 at 2:33 PM of medication cart 2 at Station 1-2 with Licensed Vocational Nurse (LVN) 1, observed one opened vial of Humulin R (a medication for treating high blood sugar) that did not have an open date or a resident identification tag. LVN 1 stated medication should be labeled with resident specific tag so can prevent giving to wrong resident. LVN 1 stated mixing insulins (medications that treat high blood sugar) could cause allergic reactions and adverse reactions. During a concurrent observation and interview, on 2/14/22 at 2:37 PM of medication cart 2 at Station 1-2 with LVN 1, observed a Lantus Solostar (medication for treating high blood sugar) with a resident identification tag that was not clearly legible. LVN 1 confirmed the label was not easy to read and could not identify the necessary information for administering the medication. During a concurrent interview and record review on 2/15/2022 at 2:51 PM at Station 1-2 with Infection Preventionist (IP) 1, stated insulins and inhalers should have proper labels to prevent cross contamination that could cause infections. IP stated labels should have first and last name of resident and other information per policy. During a concurrent interview and record review, with Director or Nursing (DON), on 2/17/22 at 9:04 AM, explained that when a resident specific insulin or inhaler is opened it should have proper labeling including a resident identification tag, date opened, and expiration date. DON stated that when a nurse finds a vial or inhaler without a resident identifier to get a new vial. DON indicated the facility policy is not to utilize inhalers and insulins for multiple residents. DON further stated 555856 Page 14 of 29 555856 02/18/2022 Peninsula Post-Acute 1609 Trousdale Drive Burlingame, CA 94010

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few proper labels and dating ensure residents receive the right medication and prevent cross contamination and infections. Review of the facility's P & P titled, Labeling of Medication Containers, dated 2019, indicated, Medication labels must be legible at all times Labels for individual resident medications include all necessary information, such as resident's name .expiration date when applicable . 555856 Page 15 of 29 555856 02/18/2022 Peninsula Post-Acute 1609 Trousdale Drive Burlingame, CA 94010

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on observation, interview and record review the facility failed to ensure the hospital menu met the nutritional needs in accordance with the Medical Director (MD) approved diet manual, physician ordered diets and current standards of practice. This failure resulted in diets not given in accordance with the prescriber's order and diet specification which may result in resident's not receiving food to meet their nutritional needs and/or receiving food that may worsen their clinical conditions. The lack of comprehensive nutritional analysis, in general, affected 47 residents who were receiving meals from the kitchen. Additionally, of the 47 Residents receiving meals there were 19 Residents with physician ordered carbohydrate consistent diets and eight Residents with chopped diets who did not receive meals in accordance with standards of practice. There were also 14 Residents with physician ordered cardiac diets, however the cardiac diet was not part of the facility's Medical Director approved diet manual. Findings: Diet manuals establish a common language and practice for physician's and other health care professionals to use when providing nutrition care to residents. The facility's diet manual and diet ordered by the physician should mirror the nutritional care provided by the facility. The analysis of the menu is the foundation of meal planning to assure that the nutritional needs of residents are met in accordance with the physician order. (CDPH AFL 14-32). Carbohydrate consistent (CCHO) diets are utilized in the management of diabetes. The intent of the CCHO diets is to evenly spread carbohydrates throughout the day and throughout the week. This helps to reduce blood sugar highs and lows. The total amount of carbohydrate in each meal is important and allows flexibility in the diet. Carbohydrates have the largest effect on blood sugar levels as they turn into blood sugar. It is also known complex carbohydrates such as dried beans, which have a higher fiber content, have less effect on blood sugar levels than simpler carbohydrates such as bread. To allow for greater flexibility and patient compliance the CCHO diet does allow for some simple carbohydrates, such as those found in dessert products, however the portions would be smaller. 1 carbohydrate choice is considered to contain 15 grams of carbohydrate (American Diabetes Association, 2022). The Dietary Reference Intakes (DRI) are documents issued by the Institute of Medicine (IOM). The DRI is the general term for a set of references used to plan and assess nutrient intakes. These values vary by age and sex and include the Recommended Dietary Allowance (National Institutes of Health). During meal plating observation and concurrent menu review, on 2/14/22 beginning at 12 PM, the noon meal consisted of lentil soup, a hamburger, potato wedges and fresh fruit. Residents with CCHO diet were not given the lentil soup, or potato wedges. Additional review of the menu for the evening meal on 2/14/21 the portion of brussels sprouts was decreased to ¼ cup rather than ½ cup and the brownie was eliminated in favor of sugar free chocolate pudding. An additional review of the breakfast meal on 2/15/22 also revealed the cold cereal and orange juice were eliminated from the CCHO diet. The only carbohydrate containing food offered was ½ of an English muffin and 4 ounces of milk, a total of 1.5 carbohydrates (22 grams of carbohydrate). It was also noted, daily, there were multiple handwritten alterations of the menu. Similar lower levels 555856 Page 16 of 29 555856 02/18/2022 Peninsula Post-Acute 1609 Trousdale Drive Burlingame, CA 94010

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many of carbohydrate were seen on the remaining meals from 2/14/22 -2/16/22. On two of three days reviewed the orange juice was eliminated for the CCHO diet. Orange juice is a source of Vitamin C, which is important in forming blood vessels, bone health and the body's healing process (Mayo Clinic, 2022). There was no substitution listed for the elimination of Vitamin C. During an interview, on 2/15/22 at 1:50 PM, the Registered Dietitian (RD) and Dietary Manager (DM) indicated the menu was purchased through their food vendor. The DM acknowledged making changes on the menu, which were in turn approved by the RD. They also indicated while there were menu changes there was no re-evaluation of the nutritional analysis of the menu, as the analysis was also completed by the food vendor and would not include any facility alterations. The RD and DM also confirmed the diet manual was not consistent with the menu, rather was obtained from a different source. Concurrent review of the CCHO sample meal plan in the diet manual, approved by the Medical Director, dated 2015, revealed the approved CCHO meal plan was intended to contain 4 carbohydrates at each meal, equaling 60 grams. The surveyor requested a daily meal by meal (breakfast, lunch dinner and snacks) breakdown of the CCHO diet. The RD and DM also stated that all residents received a physician's order for a multi-vitamin upon admission. The nutritional analysis, as requested, was not received as of 2/11/22. While the facility did submit a daily nutritional analysis it was not complete and would have not accurately reflected the menu changes made by the DM and approved by the RD. The analysis did not fully reflect the DRI. The submitted nutrient analysis had no Vitamin E value, was low in Vitamin D and Iron, and was absent of any B vitamins, remaining minerals or folic acid. Random review of physician's orders for seven sampled Residents (Residents 16, 32, 38, 40, 53, 61 and 270) revealed only two of seven sampled had an order for a multi-vitamin. Review of position description titled Registered Dietitian Nutritionist revised 2017 included development and evaluation or regular and therapeutic diets, oversight of food preparation, service and storage and oversight of regulatory compliance as essential job functions. During meal plating observation on 2/14/22, at 12:15 PM, in the kitchen, [NAME] 1 (C1) was observed preparing the noon meal tray for Resident 38, the tray had a meal ticket indicating a regular chopped diet. C1 was observed cutting a hamburger patty in a bun into half. It was also noted there were greater than five residents with physician ordered Cardiac Diets. During a concurrent interview with the RD and the DM, on 2/15/22, at 1:37 PM, the RD stated, regular chopped diet is for resident who cannot cut regular meat on their own, it's for resident with fracture or surgery on the arm. RD stated, she reviews and sign menu and any changes from a set menu provided by the vendor. Concurrent review of the Medical Director approved diet manual and the RD approved menu revealed the RD approved the facility to offer a cardiac menu, however there was no cardiac diet in the Medical Director approved diet manual. During an interview, on 2/16/22, at 10:26 AM with the Speech Therapist (ST), the ST stated, regular chopped diet is an alternative to regular ground diet, the hamburger patty should have been chopped to bite size pieces, placed inside the bun, cut in quarters. It is for self- feeding, for residents 555856 Page 17 of 29 555856 02/18/2022 Peninsula Post-Acute 1609 Trousdale Drive Burlingame, CA 94010

F 0800 who can utilize utensils. Level of Harm - Minimal harm or potential for actual harm Review of the facility's document titled 2015 Diet Manual, dated 05/2015, confirmed the diet manual indicated, CHO (Chopped) and Cardiac (heart healthy) diets were not included on the manual as a diet approved by the MD (Physician). Residents Affected - Many During an interview on 2/15/22, at 1:53 PM, the RD verified a cardiac diet was not included on the facility diet manual as an approved diet. During an interview on 2/18/22, at 11:20 AM, the RD acknowledged, CHO written on resident tray card is a chopped diet. This CHO designation was not clearly defined in the facility's Diet Manual. 555856 Page 18 of 29 555856 02/18/2022 Peninsula Post-Acute 1609 Trousdale Drive Burlingame, CA 94010

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observations, interview and record review the facility failed to ensure effective Registered Dietitian (RD) oversight of food services when there were lapses in safe food handling standards of practice, and independent evaluation of food service operations. Lack of a Registered Dietitian's oversight may result in 1. consumption of contaminated food, 2. provision of inadequate nutrition to residents, 3. Provision of incorrect food texture or 4. an increase in food related illnesses (Cross Reference F800, F812 and F880). Findings: 1. During observations, on 2/14/22, at 11:55 AM, C1 was seen using her right hand to open the door to the back of the kitchen. C1 then took off the glove on her right hand. C1 did not wash her hands and proceeded to put another glove on her right hand. During an observation, on 2/15/22, at 10:28 AM, in the kitchen, C1 was observed placing cucumber peels in the garbage can. After dumping the peels, C1 removed both her gloves. C1 did not wash her hands and proceeded to fold white towels. During an observation, on 2/15/22, at 10:40 AM, in the kitchen, Dietary Aide (DA) 1 was observed with gloves on both hands. DA 1 opened the refrigerator with her gloved hands and placed two containers of tuna salad inside the refrigerator. DA 1 was observed rinsing her gloves under running water at the sink. DA 1 then proceeded to slice onions with her gloved hands. Review of the facility's inspection check list titled CAHF Food &Nutrition -RDN Monthly Inspection Checklist (this document is used internally for medical and peer - review committee functions, including Quality Assurance), updated 6/15/20, the checklist indicated the facility failed practice when dietary staff were observed not washing their hands after removing gloves. While the facility identified the infection control lapse, the practice continued. 2. During a tray line observation, on 2/14/22, at 12:15 PM, in the kitchen, C1 was observed preparing Resident 38's meal tray indicating a physician ordered regular chopped diet. C1 was observed cutting the hamburger patty in a bun in half. It was also noted there were greater than five residents on physician ordered cardiac diets. During an interview, with the RD and the DM (Dietary Manager) on 2/15/22, at 1:37 PM, the RD stated, regular chopped diet is for resident who cannot cut regular meat on their own, with fracture or surgery on the arm. During an interview with the Speech Therapist (ST) on 2/16/22, at 10:26 AM, the ST stated, regular chopped diet is an alternative to regular ground diet, hamburger patty should be chopped to bite size, placed inside the bun, cut in quarter, more to self- feeding for resident who can utilize utensils. During an interview, on 2/16/22, at 3:18 PM, the RD stated, Kitchen audits done by DM using Monthly Inspection Checklist. I am doing more clinical work outside of the kitchen due to COVID. RD indicated, she is not physically in the kitchen, she counter signs the inspection checklist supplied by the 555856 Page 19 of 29 555856 02/18/2022 Peninsula Post-Acute 1609 Trousdale Drive Burlingame, CA 94010

F 0801 kitchen manager without actual verification. Level of Harm - Minimal harm or potential for actual harm 3. During initial tour, on 2/14/22 at 10:15 AM, there was a container of tuna salad in the refrigerator with a preparation date of 2/12/22. Residents Affected - Some In an interview, on 2/14/22 at 2:30 PM, C1 pulled six cans of tuna from the dry storage. Review of the cooldown log indicated the last menu item recorded was on 1/28/22, at 6:00 a.m., listed as Chx [chicken] stew. There was no temperature monitoring of the tuna salad prepared on 2/12/22. 4. During a concurrent observation and interview, on 2/16/22, at 9:37 AM, with DA 3, in the kitchen, DA 3 stated, We clean the food cart with water and bleach before and after the tray line. DA 3 obtained a white transparent spray bottle with clear liquid solution, DA 3 stated, We spray the food cart by mixing 10 fluid ounces bleach and 25 fluid ounces water, then wipe it down. DA 3 also indicated the was no ability to test the strength of chlorine solution. During an interview, on 2/16/22, at 3:18 PM, the RD stated, Kitchen audits done by DM using Monthly Inspection Checklist. I am doing more clinical work outside of the kitchen due to COVID. RD indicated, she is not physically in the kitchen, she counter signs the inspection checklist supplied by the kitchen manager without actual verification. Review of position description titled Registered Dietitian Nutritionist revised 11/2017 listed oversight of food preparation and service as an essential job function. 555856 Page 20 of 29 555856 02/18/2022 Peninsula Post-Acute 1609 Trousdale Drive Burlingame, CA 94010

F 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observations, interview and record review the facility failed to ensure meals were plated in accordance with the approved menu. Residents Affected - Some This failure can result in diet not given in accordance with the prescriber's order and diet specification which may result in resident not receiving the full therapeutic effect of the resident nutritional need and/ or provision of inadequate nutrition to residents. Findings: During a tray line observation, on 2/14/22, at 12:15 PM, in the kitchen, Cook1 (C1) was observed plating resident lunch trays. The following was noted: a. Resident 61 with a physician ordered pureed liberal renal diet received mashed potatoes. Concurrent review of the therapeutic spreadsheet (a document used by kitchen staff to determine types and quantities of food to be plated for each diet) approved by the Registered Dietitian on 10/10/21 indicated renal diets should have received parslied noodles in place of potato. b. Resident 71 had a physician ordered carbohydrate consistent diet with twice the amount of protein at the noon meal. Resident 71's meal was plated as a diet with the regular amount of protein. c. All residents with physician ordered Carbohydrate Consistent (CCHO) diets received ½ cup of peas. Peas were not listed on the approved menu. Review of meal tray tickets for 2/16/22 revealed there were 19 residents with ordered CCHO diets. During an interview, on 2/16/22, at 3:18 PM, the Registered Dietician (RD) stated, Kitchen audits done by Dietary Manager (DM) using Monthly Inspection Checklist. I am doing more clinical work outside of the kitchen due to Covid. RD indicated, she is not physically in the kitchen, she counter signs the inspection checklist supplied by the kitchen manager without actual verification. Review of position description titled Registered Dietitian Nutritionist revised 11/2017 listed oversight of food preparation and service as an essential job function. 555856 Page 21 of 29 555856 02/18/2022 Peninsula Post-Acute 1609 Trousdale Drive Burlingame, CA 94010

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 Based on observations, interview and record review the facility failed to ensure meals were palatable (refers to the taste and/or flavor of the food, acceptable to the taste) when the pureed entrée for the noon meal lacked flavor and was not like the regular entrée. Residents Affected - Few This deficient practice had the potential to affect resident's appetite which may result in poor dietary intake that could potentially compromise their health and nutritional status. Findings: During general dining observation, on 2/14/21 at 12:56 PM, It was noted Resident 4's tray consisted of a plain hamburger; stir fried vegetables consisting of grilled peppers and onions; watermelon and grape juice. Resident 4 refused the grilled vegetables stating they were Not tasty, cold, don't want to eat it. They were tasteless (referring to the vegetables). During a concurrent observation and interview, on 2/16/22, at 1:15 PM, with Registered Dietician (RD), a test tray was conducted in the hallway by the activity room area. The pureed beef stew did not taste like the regular beef stew. The RD tasted the pureed beef stew and stated, Pureed stew tasted bland. There's no taste. Review of Registered Dietician (RD) approved facility menu dated 10/10/21 listed the noon meal as a blue cheese hamburger with lettuce, tomatoes, onions and pickles. There was no blue cheese, onions or pickles. Stir fried vegetables were not listed on the menu. 555856 Page 22 of 29 555856 02/18/2022 Peninsula Post-Acute 1609 Trousdale Drive Burlingame, CA 94010

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on meal plating observations, speech therapy interview and departmental document review the facility failed to ensure meal production was consistent with standards of practice when residents with orders for a chopped diet were served a regular hamburger that was cut in half. Additionally, the facility lacked specific diet manual guidance on what constitutes a chopped diet. This deficient practice had the potential to negatively impact nutritional intake for residents with limited range of motion of their hands/arms, and residents with chewing and swallowing deficits. Findings: During a tray line observation, on 2/14/22, at 12:15 PM, in the kitchen, [NAME] 1 (C1) was observed preparing a meal tray for Resident 38. The tray had a meal ticket for a regular chopped diet. C1 was observed cutting the hamburger patty in a bun in half. During an interview, with the Registered Dietician (RD) and the Dietary Manager (DM) on 2/15/22, at 1:37 PM, the RD stated, regular chopped diet is for residents who cannot cut regular meat on their own, with fracture or surgery on the arm. RD and DM acknowledged, that the RD reviewed approved and signed menu along with the changes. During an interview, with the Speech Therapist (ST) on 2/16/22, at 10:26 AM, the ST stated, regular chopped diet is an alternative to regular ground diet, hamburger patty should be chopped to bite size pieces, placed inside the bun, then cut in quarters. It's more to self- feeding, for resident who can utilize utensils. Review of the facility diet manual, on 2/15/22, at 1:53 PM, the diet manual did not indicate physician approval or standardized staff guidance for preparing a chopped diet. 555856 Page 23 of 29 555856 02/18/2022 Peninsula Post-Acute 1609 Trousdale Drive Burlingame, CA 94010

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on food production observations, dietary staff interview and dietary document review the facility failed to ensure food was stored and/or prepared in a sanitary manner when there were 1) lapses in infection control, 2) lack of comprehensive cooldown monitoring of potentially hazardous foods prepared from ingredients at room temperature; 3) improper washing/sanitation of food service equipment; 4) ineffective sanitizer strength; and 5) storage of unlabeled and/or undated items. This failure had the potential to put residents at risk for foodborne illnesses (any illness resulting from the consumption of foods contaminated by bacteria, viruses, or parasites). Findings: 1. During a tray line observation, on 2/14/22, at 12:15 PM, in the kitchen, [NAME] 1 (C1) was observed preparing meal trays. C1 was wearing a black smock (a loose garment worn over street clothing) unbuttoned in the front. Parts of C1's smock was observed touching the plated food when C1 was plating the food to the meal trays. During an interview, on 2/15/22, at 2:00 PM, the Dietary Manager (DM) stated, C1 should have buttoned and secured her smock to ensure her smock was not touching food items. 2. Potentially hazardous foods (PHF) are those capable of supporting bacterial growth associated with foodborne illness. PHF's include protein products such as meat. PHF's require time/temperature control during preparation and storage. It is the standard of practice to ensure foods prepared from ingredients at room temperature are monitored to ensure the product reaches 41 degrees Fahrenheit or below within four hours (USDA Food Code, 2017). During initial tour, on 2/14/22 beginning at 10:15 AM, there was a container of tuna salad in the refrigerator with a preparation date of 2/12/22. In an interview on 2/14/22 beginning at 2:30 PM with C1, C1 pulled six cans of tuna from the dry storage. C1 also stated that tuna was prepared when it was on the menu and occasionally as a special request. Review of the departmental document titled Special Cool Down Log (SCDL), the SCDL indicated, guided staff to utilize the cool down log for potentially hazardous foods prepared from ingredients at ambient temperature (room temperature) such as canned tuna. The last menu item recorded was on 1/28/22, at 6:00 a.m., listed as Chx [chicken] stew. There was no temperature monitoring of the tuna salad prepared on 2/12/22. 3a. During a concurrent observation and interview, on 2/16/22, at 9:37 AM, with Dietary Aide (DA) 3, in the kitchen, DA 3 stated, We clean the food cart with water and bleach before and after the tray line. DA 3 obtained a white transparent spray bottle with clear liquid solution, DA 3 stated, We spray the food cart by mixing 10 fluid ounces bleach and 25 fluid ounces water, then wipe it down. DA 3 staff was not testing the strength of chlorine cleaning solution. A review of the information on the gallon container of Monogram® disinfectant bleach on 2/16/22, at 9:40 AM, indicated, it could be used as a sanitizer for dishes, utensils, refrigerator, and freezer. The direction for use was one tablespoon bleach to one gallon water (0.5 fluid ounce of bleach 555856 Page 24 of 29 555856 02/18/2022 Peninsula Post-Acute 1609 Trousdale Drive Burlingame, CA 94010

F 0812 to 153.7 fluid ounce of water). Level of Harm - Minimal harm or potential for actual harm A review of the facility document titled Food Carts(FC) dated 2018, indicated, cleaning procedure (2.) prepare a hot solution of detergent following manufacturer's instructions. Then rinse with clean warm water. (3.) prepare quat sanitizing solution following manufacturer's instructions and spray or wipe down cart. These documented FC cleaning procedures were not reflective of current practice. Residents Affected - Many b. During a concurrent observation and interview, on 2/16/22, at 11:55 AM, C1 rinsed the Robot Coupe (a commercial food processor/blender) at the sink without washing in the dishwasher. C1 then placed beef stew in the Robot Coupe. C1 stated, beef stew is for the mechanical soft diet. When C1 was asked the item she blenderized before the beef stew, C1 stated, I forgot. Failure to properly sanitize and/or clean a kitchen equipment before use did not ensure prevention of cross contamination from the previous preparation and/or introduction of unwanted ingredients into current food items. A review of facility's policy and procedure (P&P) titled, Kitchen Sanitation, dated 2001 revised October 2008, the P&P indicated, (3.) All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. 4. During a concurrent observation and interview, on 2/16/22, at 10:00 AM, in the kitchen, there was a red bucket with a white towel soaked in a solution in the sink. C1 stated the red bucket contained sanitizing solutions and tested the solution with a test strip. The test strip was for multi-quat (Quaternary Ammonia) sanitizer and indicated a low result of 100 PPM (parts per million). C1 stated, solution's been there for a while. C1 then tested a fresh solution and obtained a normal reading of 200 PPM. A review of the policy and procedure (P&P) titled Kitchen Sanitation (KS) revised on October 2008, indicated, Kitchen sanitation (4.) sanitizing of environmental surfaces must be performed with one of the following solutions: (b.) 150-200 ppm quaternary ammonium compound (QAC). 5. During an observation, on 2/14/22, at 10:09 AM, in the kitchen, an opened thickened cranberry juice and Ready Care® water were inside the refrigerator, adjacent to the window, with no opened date or use by date label. During an interview on 2/14/22, at 10:09 AM, the Registered Dietician (RD) acknowledged opened cranberry juice and ready care water should have been dated with use by date when opened. A review of an e-mail message from the manufacturers' customer service representative, dated 2/14/22, at 11:03 AM, indicated, [NAME] Ready Care® the product has an opened shelf life of seven days once opened and properly refrigerated. It is recommended that the contents be discarded after seven days. Failure to label these items had the potential for outdated items to be served to residents. During a kitchen observation, on 2/14/22, at 10:22 AM, of the center two-door refrigerator there was, an unlabeled/undated prepared sandwich placed inside an open white sandwich bag exposing the end part of the sandwich. During an interview, on 2/14/22, at 10:24 AM with DA 1, DA 1 stated, I don't know what sandwich 555856 Page 25 of 29 555856 02/18/2022 Peninsula Post-Acute 1609 Trousdale Drive Burlingame, CA 94010

F 0812 that is . DA 1 proceeded to ask DA 4, DA 4 stated, I don't know. Level of Harm - Minimal harm or potential for actual harm During an interview, on 2/14/22, at 10:25 AM, with the RD, the RD stated, I don't know what sandwich that is, sandwich is going to dry out, it won't taste very good. Residents Affected - Many During an interview, on 2/15/22, at 2:00 PM, with the DM, the DM stated, normally, made the sandwich for dialysis resident, bag should be sealed and placed in the refrigerator with use by date and meat label. During an observation, on 2/14/22, at 10:24 AM, inside the center two-door refrigerator there was a clear plastic bin with a use by date 2/28/22. Inside the bin there were greater than three deli meat products in clear small plastic bags. There were no labels on the meat. Additionally, there was one unlabeled, undated, and unsealed small plastic bag with deli meat inside. During an interview, on 2/14/22, at 10:25 AM, with DA 1, DA 1 stated, it's turkey deli. DA 2 acknowledged, it's a turkey deli. During an interview, on 2/15/22, at 2:00 PM, with the DM, the DM stated, I pull out deli meat from the refrigerator every three to five days. Acknowledged by stating, I got it, deli meat was not labeled in a Ziploc plastic bag. Review of facility policy titled Food Receiving and Storage, dated 10/2017 indicated, .14e. other opened containers must be dated and sealed or covered during storage . 555856 Page 26 of 29 555856 02/18/2022 Peninsula Post-Acute 1609 Trousdale Drive Burlingame, CA 94010

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to implement infection control practices when: Residents Affected - Some 1. Certified Nursing Assistant (CNA) 2 did not perform hand hygiene before putting on and after removing gloves during resident care activities, and did not remove his gown before leaving Resident 28's room, who was under observation for COVID-19 infection; 2. CNA 3 did not perform hand hygiene before putting on and after removal of gloves; and 3. Two kitchen staff did not perform hand hygiene before putting on and after removing gloves. These deficient practices had the potential to spread infection to the residents, staff, and visitors. Findings: 1. During an observation on 2/14/22 at 12:44 PM, Certified Nursing Assistant (CNA) 2 was inside Resident 28's room, assisting the resident in using the commode (a portable toilet). CNA 2 was wearing protective personal equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) that include gloves and a gown. During further observation, CNA 2 picked up the basin from the commode used by Resident 28 and left the room wearing the same gloves and gown. CNA 2 then walked across the hallway outside Resident 28's room towards the communal shower room, opened the door, and entered the shower room. At 12: 46 PM, CNA 2 stepped out of the communal shower room and removed his gloves and gown at the entrance of Resident 28's room. Without performing hand hygiene, CNA 2 donned new gloves and a gown, and entered Resident 28's room. During an interview on 2/14/22 at 12:48 PM, CNA 2 stated that he should have changed his gown and gloves before exiting Resident 28's room and performed hand hygiene after removing and before putting on gloves. CNA 2 stated, To not spread germs (referring to hand hygiene). 2. During an observation on 2/16/22 at 9:52 AM, CNA 3 put on a gown and gloves without performing hygiene and entered Resident 28's room. At 9:56 AM, CNA 3, removed her gown and gloves and exited Resident 28's room. CNA 3 did not perform hand hygiene after removal of gown and gloves. In a concurrent interview, CNA 3 stated that she should have performed hand hygiene before putting on and after removing PPE. During an interview on 2/16/22 at 11:51 AM, the Director of Nursing (DON) stated that staff are supposed to perform hand hygiene before putting on and after removal of PPE and the staff are expected to remove their gown before coming out of the resident's room, to prevent the spread of infection A review of the facility policy and procedure titled, Handwashing/Hand Hygiene, dated 8/19, indicated, .Policy Statement . The facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap . and water for the following situations: . m. Before and after entering isolation precaution settings .8. Hand hygiene is the final step after removing and disposing of personal protective 555856 Page 27 of 29 555856 02/18/2022 Peninsula Post-Acute 1609 Trousdale Drive Burlingame, CA 94010

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some equipment . Applying and Removing Gloves .1. Perform hand hygiene before applying non-sterile gloves .3. When removing gloves, pinch the glove at the wrist and peel away from the hand, turning the glove inside out .5. Perform hand hygiene . A review of the undated facility policy and procedure titled, Personal Protective Equipment - Using Gowns, indicated .Purpose .To guide the use of gowns. Objectives .1. To prevent the spread of infections; 2. To prevent soiling of clothing with infectious material; 3. To prevent splashing or spilling blood or body fluids onto clothing or exposed skin . Equipment and Supplies .1. Disposable gowns .Miscellaneous . 1. Use gowns only once and then discard into an appropriate receptacle inside the exam or treatment room .3. Use gowns only when indicated or as instructed .4. Follow established handwashing procedures .8. After completing the treatment or procedure, gowns must be discarded in the appropriate container located in the room .Procedure Guidelines .Putting on the Gown .1. Obtain the gown (disposable or reusable) .3. Wash hands .Removing the Gown .4. Remove the gown by rolling it away from the body. Handle the inside of the gown only .6. If the gown is disposable, discard it into the waste receptacle inside the room. If the gown is reusable (washable), discard it into the soiled laundry container inside the room. 7. Wash hands . 3. During observation on 2/14/22, at 11:55 AM, [NAME] 1 (C1) was seen using her right hand to open the door to the back of the kitchen. C1 then took off the glove on her right hand. C1 did not wash her hands and proceeded to put another glove on her right hand. During an observation on 2/15/22, at 10:28 AM, in the kitchen, C1 was observed placing cucumber peels in the garbage can. After dumping the peels, C1 removed both her gloves. C1 did not wash her hands and proceeded to fold white towels. During an observation on 2/15/22, at 10:40 AM, in the kitchen, Dietary Aide (DA) 1 was observed with gloves on both hands, placed two containers of tuna salad inside the refrigerator touching the refrigerator handle, rinsed gloves on the running water at the sink then sliced onions. DA1 did not wash hands, did not change gloves before slicing the onions. During an interview on 2/15/22, at 10:40 AM, in the kitchen with C1, C1 stated, wash hands after removing gloves and before putting on a new one. During an observation on 2/15/22, at 10:40 AM, in the kitchen, DA1 was observed with gloves on both hands. DA1 opened the refrigerator with her gloved hands and placed two containers of tuna salad inside the refrigerator. DA1 was observed rinsing her gloves under running water at the sink. DA1 then proceeded to slice onions with her gloved hands. During an interview on 2/15/22, at 10:40 AM, C1 was asked about glove use and hand washing. C1 stated, wash hands after removing gloves and before putting on a new one. C1 did not have an explanation why she failed to implement this practice. During a review of facility policy titled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, dated October 2017, the policy indicated .Employees must wash their hands: . whenever entering or re-entering the kitchen. After engaging in other activities that contaminated the hands.Gloves are considered single-use items and must be discarded after completing the task for which they are used. The use of disposable gloves does not substitute for proper handwashing. 555856 Page 28 of 29 555856 02/18/2022 Peninsula Post-Acute 1609 Trousdale Drive Burlingame, CA 94010

F 0908 Keep all essential equipment working safely. 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 maintain patient care equipment in safe operating condition when: Residents Affected - Some 1. Two drawers of infection control cabinet lack wheels and were resting on the floor, and one drawer had a cracked plastic top, which had the potential to contaminate the PPE (personal protective equipment) stored within the drawers and prevents staff from effectively sanitizing the outside of the drawers. 2. The water pressure gauge of the facility dishwashing machine did not exceed 12 PSI that was not within the manufacturer's recommended Pounds per Square Inch (PSI) of 15-25 PSI. This failure may decrease the dishwasher's effectiveness in cleaning dishes, utensils and other kitchen items. Findings: 1. During initial observation on 2/14/22 at 11:40 AM, an infection control plastic container/drawer was found without wheels on the floor outside room [ROOM NUMBER]. Another infection container was found without wheels on the floor outside room [ROOM NUMBER] on 2/14/22 at 2:52 PM. During an interview on 2/14/2022 at 12:50 PM, the Director of Nursing (DON) acknowledged the infection control drawers should have wheels and be elevated off the floor. Additionally, the top of the drawer outside room [ROOM NUMBER] was found to be cracked. The DON acknowledged the drawer should be replaced. 2. During an observation of the dishwasher on 2/14/22, at 3:09 PM, and on 2/15/22 at 2:47 PM, the dishwasher was on its rinse cycle and the water pressure gauge was hovering around 12 PSI. This was below the manufacturer's recommended pressure range of 15 to 25 PSI (this area was marked in green). This observation was shared with the Dietary Manager (DM) on 2/14/22, at 3:09 PM . DM acknowledged the water pressure should be higher and stated, Ecolab Technician (ET) recently serviced the machine. The facility was asked to provide documentation that the dishwasher was serviced and checked to ensure it was functioning as intended. Review of an Ecolab report, dated 2/3/22 at 12:52 PM, indicated ET checked the dishwasher but there was no evidence the ET checked the water pressure of the dishwasher. 555856 Page 29 of 29