Health inspection·October 22, 2021

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain the respect and dignity of one of seven sampled residents (Resident 14). This deficient practice had the potential to result in psychological harm to the resident. Findings: A review of the admission Record dated October 21, 2021, indicated Resident 14 was admitted to the facility on [DATE], with the diagnosis of hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness) affecting left side, and dementia (a group of thinking and social symptoms that interferes with daily functioning) without behavioral disturbance. A review of the Minimum Data Set (MDS-a standardized assessment and care screening tool), dated October 05, 2021, indicated Resident 14's cognitive skills for daily decision making was severely impaired, required limited to extensive assistance by staff for activities of daily living (ADL's), was always incontinent of bladder and frequently incontinent of bowel movement. During a review of the minimum data set [an assessment tool (MDS)] a quarterly assessment dated [DATE], it indicated Resident 14 has a brief interview mental status score of 7 which indicated Resident 14 was severely impaired cognitively (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). For assistance with activities of daily living (ADL), Resident 14 required extensive assistance with bed mobility, transfer, walk in room/corridor, eating, and dressing. Resident 14 required total dependence with toilet use. On October 19, 2021 11:37 AM during the Initial Tour of the facility, Resident 14 was observed lying in bed with right leg straight and left leg bent. The resident's pants were observed half way down to his knees and his incontinent brief was exposed to the individual who was in his room. On October 19, 2021 11:46 PM, during observation and interview with Certified Nurse Assistant (CNA 1), CNA 1 stated that she changed Resident 14's incontinent brief and forgot to pull up the resident's pants. When asked if it was okay for the resident to expose himself, LVN 4 stated it wasn't okay. On October 22, 2021 11:16 AM, during interview with Registered Nurse Supervisor, (RNS 3), RNS 3 supervisor stated that privacy was important to all residents here. Exposing resident's brief would compromise resident's privacy. RN supervisor further stated that CNA should complete her task (changing brief/clothes) before moving to another task. Page 1 of 10 055162 055162 10/22/2021 Monterey Park Conv Hosp 416 N Garfield Ave Monterey Park, CA 91754

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were provided with a safe, clean, comfortable, and homelike environment for 1 out of 4 sampled residents (Resident 3). Resident 3's wheelchair cusion was observed with a torn back. This failure had the potential to make the residents feel like they are not in a comfortable homelike environment. Findings: During an observation on 10/19/21, at 12:13pm, Resident 3 was observed lying in bed with wheelchair at bedside. The back of the chair was torn in multiple spots, with cushion exposed. A record review of Resident 3's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses of left femur fracture (a break, crack, or crush injury of the thigh bone), Alzheimer's disease (a progressive disease od the brain that destroys memory and other important mental functions), repeated falls, contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that cause the joints to become stiff) of right and left ankle, and abnormal gait (the way a person walks) and mobility (ability to move freely). During a concurrent interview and observation on 10/21/21, at 12:43pm, with certified nursing assistant (CNA 5), CNA 5 stated that maintenance personnel is responsible for the upkeep of residents wheelchairs. CNA 5 was shown Resident 3's torn wheelchair and stated that the chair backing was not good, and should not be like that. During an interview on 10/22/21, at 8:12 am, with Maintenance 1 (M1), M1, he stated that maintenance made rounds on equipment at least weekly. During rounds, staff also report any broken equipment to maintenance. M1 stated that he tells staff that they are our eyes, so if they see anything broken to come tell us because we may miss it on rounds. M1 stated that they repair wheelchairs, they have extra parts for replacement, or can replace with new wheelchair. During a concurrent observation and interview on 10/22/21, at 8:16 am, with M1, M1 observed Resident 3's wheelchair and stated he will repair right away and removes wheelchair from Resident 3's room. A record review of Residents 3's Minimum Data Set (MDS-Resident Assessment and Care Screening), dated 9/24/21, indicated that Resident 3 uses a wheelchair as a mobility device. A review of the facility's P&P titled, Building Systems General Maintenance Inspections, dated 3/1/16, indicated that the facility is to maintain building systems in good working order, inspecting them at intervals which comply with state, federal and company standards to repair as necessary. 055162 Page 2 of 10 055162 10/22/2021 Monterey Park Conv Hosp 416 N Garfield Ave Monterey Park, CA 91754

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to dispose medication properly. During a medication pass observation for Resident 136, a Licensed Vocational Nurse 1 (LVN 1) dropped a medication (tamsulosin, a medication used to treat enlarged prostate which is a gland that secretes fluid that nourishes and protects sperm) 0.4 milligram (mg, a unit of measurement) on the floor and picked it up and put it back into a medication cup. LVN 1 did not know that tamsulosin needed to be administered half an hour before or after meals. LVN 1 did not dispose of the medication she dropped on the floor with another licensed staff as a witness and/or document the disposal of the medication in a disposition binder. Residents Affected - Few These deficient practices had the potential for another resident to receive the contaminated medication and/or have adverse reactions due to timing of administration of the medication during meals. Findings: During a medication pass observation and interview for Resident 136, on 10/22/21 8:03 am, LVN 1 prepared tamsulosin 0.4 mg 1 capsule. LVN 1 dropped Resident 136's medication (tamsulosin), picked it up off the floor, and put it in a medication cup. LVN 1 prepared another tamsulosin 0.4 mg 1 capsule for administration. Continuing with the medication pass observation and interview on 10/22/21 at 8:32 am, LVN 1 was at Resident 136's bedside to administer tamsulosin 0.4 mg 1 cap. Resident 136 was eating breakfast. LVN 1 did not know the medication had to be administered half an hour before or after meals. LVN 1 was stopped from administration. During an interview on 10/22/21 at 9:39 am, a Registered Nurse 3 (RN 3) stated that Flomax (tamsulosin) needed to be handled with gloves and was administered for Benign Prostate Hypertrophy (BPH, a condition in which the prostate is enlarged). During an interview and record review with LVN 1, LVN 3 (charge nurse of LVN 1), and RN 3, on 10/22/21 at 10:52 am, LVN 1 stated she picked up the medication (Resident 136's tamsulosin) off the floor and put it in the medication cup and did not give it to Resident 136. LVN 1 stated she disposed the medication in a container in the medication room. LVN 1 stated she was busy and did not record it in the disposed medication binder. LVN 1 also stated that she did not have a witness of the disposal of the medication. RN 3 stated when disposing medications, licensed nurses have to have a witness and then record the disposed medication in the binder right away. LVN 3 concurred with RN 3. RN 3 stated that a review of the disposed medication binder, did not indicate documentation of the disposal of Resident 136's medication (tamsulosin). A review of the facility's policy and procedure titled, Preparation and General Guidelines, dated 1/2017, indicated medications were administered as prescribed in accordance with good nursing principles and practices and only by the person legally authorized to do so, and personnel authorized to administer medication do so only after they have familiarized themselves with the medication. A review of the facility's policy and procedure titled, Disposal of Medications and Medication-Related Supplies, dated 1/2017, indicated medication destruction occurred only in the presence of two licensed nurses. The licensed nurses and/or pharmacist witnessing the destruction ensured that the following information was entered on the medication disposition form: 055162 Page 3 of 10 055162 10/22/2021 Monterey Park Conv Hosp 416 N Garfield Ave Monterey Park, CA 91754

F 0658 1. Date of destruction, Level of Harm - Minimal harm or potential for actual harm 2. Resident's name, 3. Name and strength of medication, Residents Affected - Few 4. Prescription number, 5. Amount of medication destroyed, and 6. Signatures of witnesses. 055162 Page 4 of 10 055162 10/22/2021 Monterey Park Conv Hosp 416 N Garfield Ave Monterey Park, CA 91754

F 0759 Ensure medication error rates are not 5 percent or greater. 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 medication error rate was less than five (5) percent (%). 35 opportunities of medication administration were observed and three of the 35 medications were not administered in accordance with physician's orders, resulting in a medication error rate of 8.5 %. During a medication pass observation with Resident 67, a Licensed Vocational Nurse 1 (LVN 1) crushed three medications: Xyzal (a medication used to treat allergies and itching), amlodipine (a medication used to treat high blood pressure), and losartan (a medication used to treat high blood pressure), mixed all three medications, and administered them to Resident 67. Residents Affected - Few This deficient practice had the potential for drug to drug interaction and for the resident to be at risk for adverse reactions. Findings: During a medication pass observation with Resident 67, on 10/22/21 at 7:41 am, LVN 1 crushed the following medications in the same medication cup for administration: 1. Xyzal 5 milligrams (mg, a unit of measurement) one tab 2. amlodipine 5 mg one tab 3. losartan 100 mg one tab LVN 1 mixed the medications together with water and administered the mixed medications to Resident 67 at the bedside. During an interview on 10/22/21 at 7:44 am, LVN 1 stated that she always crushed the medications, mixed them together, and gave it to the residents who were not able to swallow the medication as whole. LVN 1 was not able to state if any of the medications could be mixed together and not have a drug-to-drug interference and/or possibly have decreased effectiveness. During an interview on 10/22/21 at 7:47 am, a Registered Nurse 3 (RN 3) stated the medications should be crushed individually and given to Resident 67 individually. RN 3 stated that the licensed nurse cannot mix the medications together. A review of Resident 67's Face Sheet (a record of admission), indicated the resident initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and essential hypertension (a condition present when blood flows through the blood vessels with a force greater than normal). A review of Resident 67's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 9/17/21, indicated the resident sometimes made self-understood or understood others. The resident had severe impairment in cognitive skills (ability to make daily decisions). Resident 67 required total dependence (full staff performance every time) from staff for toileting and personal hygiene. A review of Resident 67's monthly physician's order for October 2021, indicated the resident was 055162 Page 5 of 10 055162 10/22/2021 Monterey Park Conv Hosp 416 N Garfield Ave Monterey Park, CA 91754

F 0759 ordered for the following medications to be administered: Level of Harm - Minimal harm or potential for actual harm 1. amlodipine besylate tablet (tab) 5 mg 1 tab by mouth (PO) in the morning (QAM) for hypertension, hold if systolic blood pressure (SBP, measures the force your heart exerts on the walls of your arteries each time it beats) less than 110. Residents Affected - Few 2. losartan potassium tab 100 mg 1 tab PO QAM for hypertension hold if SBP less than 110. A review of Resident 67's physician's order, dated 10/15/21, indicated an order to administer Xyzal 5 mg PO QDay for itching for 10 days. A review of facility's policy and procedure titled, Preparation and General Guidelines, dated 1/2017, indicated medications were crushed between two souffle cups (small paper medication cups) or comparable device to prevent contact between the medication and the crushing device. If contact occured, the crushing device was to be properly cleaned prior to further use. 055162 Page 6 of 10 055162 10/22/2021 Monterey Park Conv Hosp 416 N Garfield Ave Monterey Park, CA 91754

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview, the facility failed to store and prepare food items served to facility residents by failing to: Residents Affected - Some 1. Ensure that refrigerated and frozen food were properly labeled, dated, monitored for expiration date, and discarded after expiration date. 2. Ensure staff (Cook 1) follows proper hand hygiene while preparing food after touching a trash can and then proceeded on cooking facility residents' lunch. These deficient practices had the potential to result in foodborne illness to all residents served by the facility kitchen. Findings: 1. During initial kitchen tour with the Dietary Supervisor (DS 1), on 10/19/2021 at 8:48 a.m., an opened bacon box was observed in the facility's freezer. The opened bacon box had a label indicating a received date, on 9/2/21, best by (expiration date) date, on 10/3/21, and opened date, on 10/6/21 (3 days after the expiration date). During an observation with DS 1, on 10/19/2021 at 8:50 a.m., an opened turkey ham package was observed in the facility's freezer. The opened turkey ham package had a label indicating a received date, on 8/27/21, best by date, on 9/27/21, and the opened date was blank. During an observation with DS 1, on 10/19/2021 at 8:55 a.m., four single packed sandwiches and 3 cups of cottage cheese were observed inside the facility refrigerator. The labels were dated 10/18/21. During an interview on 10/19/2021 at 8:55 a.m., DS 1 stated the four sandwiches and the cottage cheese were prepared yesterday and were supposed to be thrown away. During an observation on 10/19/2021 at 8:58 a.m., a one gallon of chopped garlic was observed in the refrigerator and had labels indicating opened date 10/4/21 and best by date, on 10/13/21, (6 days after the expiration date date). 2. During kitchen tour on 10/21/2021 at 11:41 a.m., [NAME] 1 used oven mitts to discard a pan content into the trash can. [NAME] 1 then placed the mitts on the side of the stove and placed hands on running water for 3 seconds at the food preparation sink and proceeded on cooking. During an observation with DS 1, on 10/21/2021 at 11:43 a.m., [NAME] 1 observed and continued to handle cooking spoon and stirring a dish on the stove without performing proper hand washing. During an interview, on 10/21/2021 at 11:44 a.m., [NAME] 1 stated that he dipped his hands in the bucket of sanitation agent in the food preparation sink after he took the oven mitts off his hands. During an interview on 10/21/2021 at 11:45 a.m., DS 1 stated hand washing should be done on the hand washing sink using soap and water and not on the food preparation sink with sanitizing agent. 055162 Page 7 of 10 055162 10/22/2021 Monterey Park Conv Hosp 416 N Garfield Ave Monterey Park, CA 91754

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview, on 10/21/2021 at 11:46 a.m., [NAME] 1 stated he should have washed his hands on the hand washing sink using soap and water. A review of facility's policy and procedure for Handwashing/Hand Hygiene, dated 1/2021, indicated all personnel shall follow the handwashing/ hand hygiene procedure to help prevent the spread. Employees must wash their hands for at least twenty (20) seconds using soap and water. Employees must wash their hand under the following conditions that included after removing gloves or aprons, and after completing a duty and before handling food (hand washing with soap and water). 055162 Page 8 of 10 055162 10/22/2021 Monterey Park Conv Hosp 416 N Garfield Ave Monterey Park, CA 91754

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 staff preformed hand hygiene when entering and exiting four (4) resident rooms (Rooms 108, 109, 110, and 107) during a lunch meal tray delivery. Residents Affected - Some This failure had the potential to spread infections to other residents and/or staff. Findings: During an observation on 10/19/21 starting at 12:31 pm to 12:38, the following was observed of Certified Nursing Assistant 5 (CNA 5) during a meal tray delivery to residents in the following rooms: 1. entered room [ROOM NUMBER] with a lunch tray and placed the tray on the resident's bedside table for bed B. CNA 5 exited room without washing hands. 2. entered room [ROOM NUMBER] holding two cups and placed the cups on two residents' bedside tables. CNA 5 exited room [ROOM NUMBER] without washing hands. 3. entered room [ROOM NUMBER] to provide assistance to bed A. CNA 5 exited room [ROOM NUMBER] without washing hands. 4. grabbed straws from a nearby medication cart, entered room [ROOM NUMBER] and handed out straws to the residents in the room. CNA 5 exited room [ROOM NUMBER] without washing hands. 5. entered room [ROOM NUMBER] and exited room [ROOM NUMBER] without washing hands with a food plate lid and placed the lid on a cart in the hallway. 6. CNA 5 went to the meal cart in the hallway to grab another meal tray, and entered room [ROOM NUMBER], passed out the meal tray. While in room [ROOM NUMBER], CNA 5 opened a resident's closet, looked through the closet, closed the closet, and exited room [ROOM NUMBER] without washing hands. 7. CNA 5 then entered room [ROOM NUMBER], grabbed a piece of linen out of the closet, exited room [ROOM NUMBER] without washing hands. During an interview on 10/19/21 at 12:50 pm, CNA 5 stated that she could not remember if she washed her hands when entering and exiting residents' rooms because she was passing out food trays. CNA 5 stated that in the future she would make sure she cleaned her hands when going in and out of residents' rooms for infection control. During an interview on 10/19/21 at 3:41 pm, the Infection Preventionist Nurse (IP) stated that all staff should be preforming hand hygiene before entering and after exiting rooms for infection control. A review of the facility's policy and procedure (P &P) titled, Handwashing/Hand Hygiene, dated January 2021, indicated that the facility considered hand hygiene the primary means to prevent the spread of infections. Employees must preform hand hygiene before and after resident contact and before and after assisting a resident with meals. 055162 Page 9 of 10 055162 10/22/2021 Monterey Park Conv Hosp 416 N Garfield Ave Monterey Park, CA 91754

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of the 29 resident rooms, a multiple residents room (room [ROOM NUMBER]) met the minimum square footage requirement of 80 square feet (sq. ft.) per resident. This deficient practice had the potential to affect the care, comfort, and services to the residents. Findings: During an interview on 10/20/21, the Administrator (ADM) stated that one of the residents' room (room [ROOM NUMBER]) did not meet the minimum requirement of 80 sq. ft per person and would submit a room waiver request for room [ROOM NUMBER]. A review of the facility's room waiver request, dated 10/19/21, indicated that room [ROOM NUMBER] measured at 223 sq. ft. and that the residents' needs were accommodated and that there were no adverse effect to the health and safety and welfare of the residents occupying these rooms. A review of the facility's Client Accommodations Analysis indicated that room [ROOM NUMBER] measured at 223 sq. ft and was currently occupied by three residents. The minimum square footage requirement for a multiple resident bedroom should be at least 80 sq. ft. The minimum square footage requirement for a three-bedroom is 240 sq. ft. room [ROOM NUMBER] was below the minimum requirement by 17 sq. ft. and could lead to possible inadequate nursing care to the residents in room [ROOM NUMBER]. During an observation on 10/21/21 at 9:13 am, room [ROOM NUMBER] had three beds and three residents (Residents 9, 24, and 77) occupying the beds in the room. All three residents were wheelchair bound and do not get out of bed by themselves. The residents had enough space for a bedside table, night stand, and a wheelchair for each resident. During an observation and interview on 10/21/21 at 9:13 am, a Certified Nursing Assistant 3 (CNA 3) was assisting Resident 9 onto a wheelchair. CNA 3 stated that she had enough space when assisting/taking care of the residents who occupied the room. During the survey period from 10/19/21 to 10/22/21, residents and staff were interviewed and presented no complaints regarding the size of their room. The Department is, therefore, recommending the waiver request for room [ROOM NUMBER]. 055162 Page 10 of 10