Health inspection·March 23, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview, and record review, the facility failed to ensure privacy of one of 12 residents (Resident 75) while providing care. This failure had the potential to cause emotional distress to the resident. Findings: During a medication pass observation, on 3/21/23 at 4:26 p.m., registered nurse E (RN E) prepared medications for Resident 75. RN E entered Resident 75's room and did not pull the curtain closed or close the door. RN E suctioned secretions in the resident's tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow direct access to the breathing tube) and mouth. RN E uncovered Resident 75's abdomen area and administered medications via gastrostomy tube. During an interview, on 3/21/23 at 4:53 p.m., RN E confirmed she did not pull Resident 75's curtain to provide privacy and should have. Review of the facility's policy, Resident Privacy and Confidentiality, revised 7/2018, indicated, Nursing staff will use curtains to provide full visual privacy during resident care, toileting, treatments, and issues of dignity and other requested times. This includes closing doors, removing residents from public view and providing clothing and draping residents to prevent unnecessary exposure of body parts. Page 1 of 16 555916 555916 03/23/2023 O'Connor Hospital D/P Snf 2105 Forest Avenue San Jose, CA 95128

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on interview and record review, the facility failed to notify the responsible party (RP, the designated person who makes medical decisions for the resident) for one of two residents (Resident 17) when Resident 17 was transferred to an emergency department. This failure had the potential to compromise the residents' admission, transfer, and discharge rights. Findings: Review of Resident 17's progress notes indicated, on 2/26/23, the resident was transferred to the emergency department due to desaturation (drop in blood oxygen level). There was no documentation in the clinical record indicating the resident's RP was informed of Resident 17's transfer. During an interview with registered nurse A (RN A), on 3/23/23 at 11:00 a.m., she acknowledged Resident 17's RP was not notified regarding the transfer. Review of the facility's policy, Rights and Responsibilities, revised on 8/2009, indicated Residents and, when appropriate, their families are informed about the outcomes of care, treatment, and services, including unanticipated outcomes. 555916 Page 2 of 16 555916 03/23/2023 O'Connor Hospital D/P Snf 2105 Forest Avenue San Jose, CA 95128

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for two of 12 residents (Residents 3 and 12), when licensed nurses did not notify the attending physicians regarding medications that were not administered. These failures had the potential to compromise the residents' health and well-being. Residents Affected - Few Findings: 1. Review of Resident 3's clinical record indicated the resident was admitted to the facility with diagnoses including diabetes mellitus (high blood sugar), hypothyroidism (underactive thyroid), spinal injury, and headache. Review of Resident 3's medication administration record (MAR), dated February 2023, indicated, on 2/28/23, Metformin (a medicine to treat diabetes) 500 milligrams (mg, a unit measurement) was not given in the morning and evening, on 2/24/23, Oxybutynin (a medicine used to treat overactive bladder) 5 mg was not given in the morning, afternoon, and evening, and on 2/28/23, Topiramate (a medicine used to treat headache) 50 mg was not given in the morning and evening. Review of Resident 3's MAR, dated March 2023, indicated, from 3/9/23 to 3/11/23, Levothyroxine (a medicine used to treat hypothyroidism) 50 mcg was not given, and from 3/7/23 to 3/9/23, Mexiletine (an anti-arrhythmic drug) 150 mg was not given in morning and in the evening. Review of Patient 3's nurses notes on the MAR, dated February and March 2023, indicated those missed medications were unavailable awaiting for delivery. There was no documentation in the record indicating Resident 3's attending physician was notified regarding the missed medications. During an interview with registered nurse B (RN B), on 3/21/23 at 11:10 a.m., she confirmed Resident 3 did not receive the above medications and his attending physician was not notified of the missed medications. 2. Review of Resident 12's laboratory results, dated 1/30/23, indicated the resident's hemoglobin (the iron-containing oxygen-transport protein present in red blood cells, normally ranges 14-18 in grams per deciliter [g/dl]) and hematocrit (the volume percentage of red blood cells in blood, normally ranges 42-52%) levels were 8.8 g/dl and 27.9%. Review of Resident 12's interdisciplinary team (IDT, team members from different departments involved in a resident's care) progress notes, dated 2/13/23, indicated the resident had anemia (a low number of red blood cells). Review of Resident 12's MAR indicated an order, dated 2/13/23, ferrous gluconate (iron supplement) 25 mg daily with breakfast for anemia. It indicated, from 2/13/23 to 2/27/23, ferrous gluconate was unavailable and the medication was not administered. There was no documented evidence Resident 12's attending physician was notified of the missed medication. During an interview with RN A, on 3/21/23 at 12:46 p.m., she confirmed Resident 12 did not receive his ferrous gluconate for 15 days as ordered and his attending physician was not notified. During an interview with the clinical director (CD), on 3/22/23 at 12:30 p.m., she stated nurses 555916 Page 3 of 16 555916 03/23/2023 O'Connor Hospital D/P Snf 2105 Forest Avenue San Jose, CA 95128

F 0684 Level of Harm - Minimal harm or potential for actual harm should have followed up with the pharmacy if a medication was not available and contacted the attending physician. Review of the facility's policy, Medication Administration, reviewed on 9/2022, indicated Drugs not given as prescribed: Physician should be notified of missed doses, as appropriate. Residents Affected - Few 555916 Page 4 of 16 555916 03/23/2023 O'Connor Hospital D/P Snf 2105 Forest Avenue San Jose, CA 95128

F 0700 Level of Harm - Minimal harm or potential for actual harm Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Review of Resident 22's physician order, dated 9/11/22, indicated the use of two side rails Residents Affected - Few Review of Resident 73's physician order, dated 5/12/22, indicated the use of two side rails. Review of clinical records of Residents 22 and 73, indicated there were no Resident Bed Rail Consent Forms, indicating the benefit and risks of side rail use were explained to the residents or their families. During an interview on 3/23/23 11:28 a.m., the CD stated staff did not obtain the informed consents regarding the use of side rails, for Residents 22 and 73. Review of the facility's policy, Side rails, dated 4/94 and reviewed 6/21, indicated, To provide a resident with safety devices for medical conditions, or a restraining device to prevent injuries for those residents who have been assessed for the use of restraints and for whom the use of side rails has been determined to be appropriate .informed consent from the physician has been obtained for their use. Based on observation, interview, and record review, the facility failed to ensure informed consents related to the use of side rails were completed for three of 12 residents (Residents 12, 22, and 73). This failure had the potential to put the residents at risk for entrapment and serious injury due to not being aware of the risks and benefits of bed rails. Findings: During an observation, on 3/21/23 at 9:21 a.m., Resident 12 was lying in bed and two side rails were used. During a concurrent interview and record review, with the clinical director (CD), on 3/23/23 at 11:26 a.m., she provided Resident 12's side rail assessment, dated 9/4/22. The CD also provided Resident 12 informed consent dated 3/23/23 and stated there was no informed consent obtained on 9/4/22. 555916 Page 5 of 16 555916 03/23/2023 O'Connor Hospital D/P Snf 2105 Forest Avenue San Jose, CA 95128

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 observation, interview, and record review, the facility failed to provide proper pharmaceutical services when: Residents Affected - Some 1. Medications were unavailable and were not administered as ordered for six of 12 residents (Residents 2, 3, 9, 12, 20, and 22); and, 2. The disposition of two of five discontinued narcotic medications (controlled substance medications, drugs with high potential for abuse or addiction) were not documented. These failures resulted in six residents not receiving medications as ordered by the physicians and had the potential to result in misuse of narcotic medications. Findings: 1a. Review of Resident 2's medication administration record (MAR), dated 2/2023, indicated the following: Resident 2 missed three doses of gabapentin (medication used to treat pain or seizures) 300 mg, when it was not given on 2/6/23 and 2/7/23. Under Nurse's Medication Notes, nurses documented gabapentin 300 mg capsule not given awaiting for delivery. Resident 2 missed one dose of amiodarone (medication used to treat heart rhythm problems) 100 mg when it was not given on 2/20/23. Under Nurse's Medication Notes, a nurse documented amiodarone 100 mg not available. Resident 2 missed two doses of amitryptyline (medication used to treat depression) 50 mg when it was not given on 2/1/23 and 2/2/23. Under Nurse's Medication Notes, nurses documented amitriptyline 50 mg tab not available. Resident 2 missed one dose of brimonidine (medication used to lower pressure in the eye) 0.2% eye drops when it was not given on 2/16/23. Under Nurse's Medication Notes, a nurse documented brimonidine not available. b. Review of Resident 3's clinical record indicated the resident was admitted to the facility with diagnoses including diabetes mellitus (high blood sugar), hypothyroidism (underactive thyroid), spinal injury, and headache. Review of Resident 3's medication administration record (MAR), dated February 2023, indicated, on 2/28/23, Metformin (a medicine to treat diabetes) 500 milligrams (mg, a unit measurement) was not given in the morning and evening, on 2/24/23, Oxybutynin (a medicine used to treat overactive bladder) 5 mg was not given in the morning, afternoon, and evening, and on 2/28/23, Topiramate (a medicine used to treat headache) 50 mg was not given in the morning and evening. Review of Resident 3's MAR, dated March 2023, indicated, from 3/9/23 to 3/11/23, Levothyroxine (a medicine used to treat hypothyroidism) 50 mcg was not given, and from 3/7/23 to 3/9/23, Mexiletine (an anti-arrhythmic drug) 150 mg was not given in morning and in the evening. 555916 Page 6 of 16 555916 03/23/2023 O'Connor Hospital D/P Snf 2105 Forest Avenue San Jose, CA 95128

F 0755 Level of Harm - Minimal harm or potential for actual harm Review of Patient 3's nurses notes on the MAR, dated February and March 2023, indicated the resident's missed medications were unavailable awaiting for delivery. During an interview with registered nurse B (RN B), on 3/21/23 at 11:10 a.m., she confirmed Resident 3 did not receive the above medications. Residents Affected - Some c. Review of Resident 9's MAR, dated 12/2022 indicated the following: Resident 9 missed five doses of clonazepam (medication used to treat seizures, anxiety, or dystonia) when it was not given on 12/1/22 and 12/2/22. Under Nurse's Medication Notes, nurses documented clonazepam 1 mg not given, not available. Resident 9 missed two doses of dantrolene (muscle relaxant) when it was not given on 12/16/22 and 12/17/22. Under Nurse's Medication Notes, nurses documented dantrolene 25 mg not given waiting for delivery. d. Review of Resident 12's laboratory result, dated 1/30/23, indicated the resident's hemoglobin (the iron-containing oxygen-transport protein present in red blood cells, normally ranged 14-18 in grams per deciliter [g/dl]) and hematocrit (the volume percentage of red blood cells in blood, normally ranged 42-52%) levels were 8.8 g/dl and 27.9%. Review of Resident 12's interdisciplinary team (IDT, team members from different departments involved in a resident's care) progress notes, dated 2/13/23, indicated the resident had anemia (a low number of red blood cells). Review of Resident 12's MAR indicated an order, dated 2/13/23, ferrous gluconate (iron supplement) 25 mg daily with breakfast for anemia. It indicated, from 2/13/23 to 2/27/23, ferrous gluconate was unavailable and the medication was not administered. During an interview with RN A, on 3/21/23 at 12:46 p.m., she confirmed Resident 12 did not receive his ferrous gluconate for 15 days as ordered. e. Review of Resident 20's MAR, dated 12/2022, indicated the following: Resident 20 missed two doses of lantus (medication to lower blood sugar) 20 units when it was not given on 12/30/22 and 12/31/22. Under Nurse's Medication Notes, a nurse documented lantus inj 20 units med not available, waiting for delivery. Resident 20 missed two doses of baclofen (muscle relaxant) when it was not given on 12/31/22. Under Nurse's Medication Notes, nurses documented baclofen 5 mg not available. Resident 20 missed one dose of folic acid (vitamin) when it was not given on 12/31/22. Under Nurse's Medication Notes, nurses documented folic acid not available. Review of Resident 20's MAR, dated 1/2023, indicated Resident 20 missed seven doses of Vitamin B6 when it was not given from 1/1/23 to 1/7/23. Under Nurse's Medication Notes, nurses documented vit B6 tablet not available, waiting for pharmacy to deliver. Review of Resident 20's MAR, dated 2/2023, indicated Resident 20 missed four doses of pantoprazole 555916 Page 7 of 16 555916 03/23/2023 O'Connor Hospital D/P Snf 2105 Forest Avenue San Jose, CA 95128

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (medication to decrease stomach acid) 40 mg when it was not given from 2/4/23 to 2/7/23. Under Nurse's Medication Notes, nurses documented pantoprazole 40 mg packet not given, not available, awaiting delivery. f. Review of Resident 22's physician's progress note, dated 1/7/23, indicated RT [respiratory therapist] feels patient [the resident] is having more difficulty with breathing with persistent rhonchi [continuous gurgling or bubbling sounds typically heard during both inhalation and exhalation]. It indicated to Add DuoNebs [Ipratropium bromide/salbutamol, sold under the brand name Duoneb, a combination medication used to treat chronic obstructive pulmonary diseases] and budesonide nebulization [a medication to decrease inflammation of the airways, making it easier to breathe]. Review of Resident 22's Medication Administration Records (MAR), dated January 2023, indicated an order, dated 1/7/23, Budesonide 0.5 mg twice a day using a nebulizer (a device that turns the liquid medicine into a mist which is then inhaled through a mouthpiece or a mask) and the medication was not administered on 1/7/23 at 11 a.m. and 8 p.m., on 1/8/23 at 8 a.m. and 8 p.m., and on 1/9/23 at 8 a.m. It stated the medication was unavailable. During a concurrent interview on 3/23/23 at 9:39 a.m., registered nurse A (RN A) stated Resident 22's budesonide was unavailable and the resident missed the medication five times from 1/7/23 to 1/9/23. She stated it usually takes two to three days to get a new prescribed medication. 2. During concurrent observation and interview, on 3/22/23 at 9 a.m., with the clinical director (CD), the CD stated when a narcotic medication is discontinued, the nurse brings the remainder of the medications with the narcotic sheet to her, and it is documented on the narcotic form. The CD had five discontinued narcotic medications locked in a cabinet. Two of the medications included Resident 3's zolpidem tartrate (controlled medication used to treat insomnia) and Resident 73's phenobarbital (controlled medication used to prevent seizures or treat anxiety). Review of Resident 3's Controlled Drug Record for zolpidem tartrate indicated it was last administered to Resident 3 on 12/20/22. There was no signature by the licensed nurse under the section, Disposition of Remaining Doses. Review of Resident 73's Controlled Drug Record for phenobarbital indicated it was last administered to Resident 73 on 1/11/23. There was no signature by the licensed nurse under the section, Disposition of Remaining Doses. Resident 3's zolpidem tartrate and Resident 73's phenobarbital were not documented on the Narcotic Destruction Log. The Narcotic Destruction Log had columns to indicate the following: date, time, patient's name, drug and dose, authorization number, licensed nurse signature, and clinical manager signature. During a concurrent interview, the CD confirmed the narcotic medications for Resident 3 and 73 were not on the Narcotic Destruction Log and there was no date and no signatures from the licensed nurse when the narcotics were given to her. Review of the facility's policy, Disposal of Medications, dated 11/2017, indicated, A controlled medication disposition log, or equivalent form, shall be used for documentation. The policy also indicated the log shall contain the following information: resident's name, medication name and strength, prescription number, quantity/amount disposed, date of disposition, and signatures of the required 555916 Page 8 of 16 555916 03/23/2023 O'Connor Hospital D/P Snf 2105 Forest Avenue San Jose, CA 95128

F 0755 witnesses. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 555916 Page 9 of 16 555916 03/23/2023 O'Connor Hospital D/P Snf 2105 Forest Avenue San Jose, CA 95128

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interview and record review, the facility failed to ensure the consultant pharmacist (CP)'s recommendations were acted upon for one of 12 residents (Resident 1). This failure had the potential to put the resident at risk for complications and adverse effects from the medication. Findings: Review of Resident 1's physician order, dated 12/8/22, indicated Apixaban (Eliquis, anticoagulant). Review of Resident 1's Consultant Pharmacist (CP) Medication Regimen Review (MRR, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication), dated 1/31/23, indicated the CP made four recommendations for the use of Eliquis: - Monitor for signs/symptoms of bleeding/bruising - Monitor for signs/symptoms of thromboembolism [obstruction of a blood vessel by a blood clot] - Please consider adding the indication .in the order - .re-evaluation date for discontinuation .in the order During an interview and concurrent record review, on 3/22/23 at 1:20 p.m., with registered nurse A (RN A), she reviewed Resident 1's 1/31/23 CP recommendations and Resident 1's Medication Administration Record (MAR), dated March 2023. She stated there was an order, dated 12/8/22, to monitor for signs and symptoms of bleeding, it was entered as FYI [for your information], and there was no documented evidence nurses had monitored for signs and symptoms of bleeding every shift. She reviewed Resident 1's clinical records and confirmed the CP's 1/31/23 recommendations were not implemented. She stated she was unsure if Resident 1's physician was informed of those recommendations to consider. Review of the facility's policy,Medication Regimen Review and Reporting, dated 9/18, indicated resident-specific MRR recommendations and findings are documented and acted upon by the nursing care center and/or physician. The nursing care center follows up on the recommendations to verify that appropriate actions has been taken. Recommendations shall be acted upon within 30 calendar days. 555916 Page 10 of 16 555916 03/23/2023 O'Connor Hospital D/P Snf 2105 Forest Avenue San Jose, CA 95128

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. 2. Review of Resident 16's physician order, dated 11/18/20, indicated Trazodone (antidepressant for treating major depressive disorders) 200 mg at bedtime. During an interview and concurrent record review, on 3/21/23 at 10:47 a.m., with Registered Nurse A (RN A), she stated Resident 16 has been taking Trazodone for the behavior of inability to sleep. She reviewed the episodes of inability to sleep, from 9/22 to 2/23, and stated the resident did not show the behavior that staff had monitored for the use of Trazodone. She stated if the resident did not have the behavior, the GDR should have been considered. She reviewed Resident 16's clinical record and there was no documented evidence the dose reduction for Trazodone was attempted in 2022 and 2023. During an interview with the clinical director (CD), on 3/22/23 at 3:09 p.m., she stated the GDR for Resident 1's Trazodone was not attempted and should have been attempted at least annually. Review of the facility's policy, Restraints, Chemical/Psychotropic Medications, revised 6/2021, indicated for antidepressant medications, GDRs must be attempted in two separate quarters within the first year of a patient's admission or the initiation of the antidepressant medication, unless physician documentation is present in the medical record indicating a GDR is clinically contraindicated. The policy also indicated after the first year, a GDR must be attempted at least annually, unless contraindicated. Based on interview and record review, the facility failed to ensure two of six sampled residents (Residents 15 and 16) were free from unnecessary psychotropic medication (drugs that affects brain activities associated with mental processes and behavior) when Residents 15 and 16 received psychotropic medication without gradual dose reductions (GDR, a tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued); and there was no documented clinical rationale by the physician for why an attempted GDR was not indicated. These failures had the potential to put the residents at risk for experiencing adverse effects from unnecessary psychotropic medications. Findings: 1. Review of Resident 15's physician order, dated 3/11/21, indicated mirtazapine (antidepressant medication used to treat depression) 15 milligrams (mg, unit of measurement) at bedtime. Review of Resident 15's Note to Attending Physician/Prescriber from the pharmacist, dated 1/21/23, indicated to consider a dose reduction unless there is documentation of risk vs benefit and justification for such dose. The note also indicated, See IDT [interdisciplinary team]. During an interview and concurrent record review, on 3/22/23 at 11:09 a.m., the social worker (SW) reviewed Resident 15's 12/19/22 IDT notes and clinical records, and confirmed there was no gradual dose reduction attempted for Resident 15's mirtazapine and there was no documentation from the physician that indicated the reason a GDR was clinically contraindicated. 555916 Page 11 of 16 555916 03/23/2023 O'Connor Hospital D/P Snf 2105 Forest Avenue San Jose, CA 95128

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 ensure medications were stored securely when one of three medication carts was left unlocked and unattended. This failure had the potential to result in the access of medications by unauthorized personnel. Findings: During a medication pass observation, on 3/21/23 at 8:53 a.m., registered nurse F (RN F) prepared medications for Resident 14. RN F left the medication cart unlocked, entered Resident 14's room, and closed the curtain. RN F administered medications to Resident 14. During an interview, on 3/21/23 at 9:28 a.m., RN F confirmed he left the medication cart unlocked and stated it should be locked. Review of the facility's policy, Storage of Medication, dated 1/2021 indicated, Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access. 555916 Page 12 of 16 555916 03/23/2023 O'Connor Hospital D/P Snf 2105 Forest Avenue San Jose, CA 95128

F 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program implemented their policy. Residents Affected - Some 1. A performance indicator, medication error, did not capture medication omissions. 2. A performance indicator, Medication Management, did not monitor gradual dose reduction (GDR) of psychoactive medications and implementation of the consultant pharmacist (CP)'s recommendations from Medication Regimen Review (MRR, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication). Those failures had the potential to miss opportunities for identifying issues and improving the selected indicators for quality care of residents. Findings: Review of Clinical Manager's Monthly Report indicated the QAPI program monitored medication errors, including wrong resident, wrong medication, wrong dose, wrong time, and wrong route. Omission of a prescribed medication was not included and monitored as medication errors. Review of the facility's policy, Medication, Errors, dated 4/2009, indicated a medication error is defined as administration; to the wrong resident, at the wrong time, of the wrong dose, via the wrong route, of the wrong medication and omission of a prescribed medication. During an interview on 3/23/23 at 9:49 a.m., the clinical director (CD) stated recently staff escalated the issues regarding unavailable medications (refer to F755) and the QAPI program did not monitor omission of medications as medication errors. Review of Clinical Manager's Monthly Report indicated the QAPI program monitored psychoactive medication use and there was a question asking Were monthly drug [medication] regimen reviews completed? There was no documented evidence the QAPI program monitored if the GDR of psychotropic medications were attempted for the residents in use and the CP's recommendations from the MRR were implemented. During a concurrent interview, on 3/23/23 at 9:49 a.m., the CD stated the QAPI program had not monitored if the GDR of the psychoactive medication was attempted (refer to F758) and the pharmacy consultant's recommendations from the MRR were implemented (refer to F756). The CD stated the Pharmacy Consultant was not a part of the QAPI program. Review of the facility's policy, Quality Assurance/Performance Improvement (QAPI) Plan & Overview, dated 2023, indicated the QAPI program's objectives are to identify opportunities to improve resident care and correct clinical performance concerns, both directly and indirectly It indicated the data sources included the monitoring and evaluation of clinical care provided by the staff and the collection of outcome data including quality indications and resident care assessment and evaluations. Mandatory indicators included medication error rate. For data gathering, the clinical director and other designated team members will use a systematic process to collect necessary data based on rationale for use. Tools for data gathering included pharmacy drug regimen review reports. 555916 Page 13 of 16 555916 03/23/2023 O'Connor Hospital D/P Snf 2105 Forest Avenue San Jose, CA 95128

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program implemented their policy to have a quarterly QAPI meeting. This failure have the potential to miss opportunities for identifying issues and improving the selected indicators for quality care of residents. Residents Affected - Few Findings: Review of the facility's QAPI program and concurrent interview, on 3/23/23 at 9:49 a.m., with the clinical director (CD), she stated the unit based QAPI meeting should have been done quarterly, the last meeting was held on 9/19/22, and the last quarterly meeting, in December 2022, was not done. Review of the facility's policy, Quality Assurance/Performance Improvement (QAPI) Plan & Overview, dated 2023, indicated the clinical director will present the quarterly reports of analyzed statistical data to the facility's QAPI committee on a quarterly basis. The clinical director will coordinate and chair a quarterly unit based QAPI meeting. 555916 Page 14 of 16 555916 03/23/2023 O'Connor Hospital D/P Snf 2105 Forest Avenue San Jose, CA 95128

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 ensure infection control practices were implemented when: Residents Affected - Some 1. A licensed nurse did not change gloves and perform hand hygiene between tasks; 2. Staff used gloves to cover respiratory tubing; and 3. Multiple face masks were hanging by the bed. These failures had the potential for development and transmission of communicable diseases and infections in the facility. Findings: 1. During a medication pass observation, on 3/21/23 at 8:53 a.m., RN F prepared medications for Resident 14. RN F donned gloves in Resident 14's room. RN F dropped an item on the ground and picked it up. RN F did not remove his gloves and perform hand hygiene. RN F administered medications to Resident 14 via gastrostomy tube (GT, a surgical opening into the stomach for administration of nutrition and medications). RN F removed his gloves and donned new gloves without performing hand hygiene. RN F placed an eye drop medication in Resident 14's right eye. RN F removed his gloves and donned new gloves without performing hand hygiene. RN F placed an eye drop medication in Resident 14's left eye. During an interview on 3/21/23 at 12:30 p.m., RN F stated he should have changed his gloves and performed hand hygiene. Review of the facility's policy, Hand Hygiene, revised 6/2018, indicated hand sanitization with an alcohol-based product may be performed when hands are not visibly soiled, or in the following circumstances: when moving from a contaminated body site to a clean body site during patient care, before donning gloves, and after removing gloves. 2. During a medication pass observation, on 3/21/23 at 1:10 p.m., RN G prepared and administered medications via GT to Resident 15. RN G removed his gloves, sanitized his hands, and donned new gloves. RN G removed respiratory tubing from Resident 15's tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow direct access to the breathing tube) mask. RN G dispensed the medication in the nebulizer (a device that turns the liquid medicine into a mist which is then inhaled through a mouthpiece or a mask) and connected it to Resident 15's tracheostomy mask. RN G removed one of the gloves he was wearing and wrapped it over the respiratory tubing and left it on Resident 15's bed. During a concurrent interview, RN G confirmed he used a worn glove to cover the respiratory tubing and stated he was taught to do it that way. During an observation, on 3/21/23 at 9:35 a.m., in room [ROOM NUMBER] and room [ROOM NUMBER], there were respiratory tubings connected to humidifiers with one end covered with gloves hanging by the bed. 555916 Page 15 of 16 555916 03/23/2023 O'Connor Hospital D/P Snf 2105 Forest Avenue San Jose, CA 95128

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with Health Services Assistant D (HSA D), on 3/21/23 at 9:48 a.m., she stated she was told to use gloves to cover respiratory tubing. During a concurrent observation and interview, with respiratory therapist C (RT C), on 3/21/23 at 1:14 p.m., in room [ROOM NUMBER], there was a respiratory tubing covered with a glove inside a plastic bag. RT C stated she would use a plastic bag to store respiratory tubings not being used, but she did not know the reason there was a glove covering the respiratory tubing inside the plastic bag. 3. During an observation, on 3/21/23 at 9:35 a.m., in room [ROOM NUMBER], there were multiple face masks hanging by the bed. During an interview with HSA D, on 3/21/23 at 9:48 a.m., she stated family members and the residents used the face masks. HSA D stated she was unsure which face masks were used or clean. During an interview with the infection preventionist manager (IPM), on 3/22/23 at 1:02 p.m., she stated staff should not use gloves to cover items such as respiratory tubings. IPM also stated face masks should not be left at bedside if not used. 555916 Page 16 of 16