Health inspection·May 26, 2024

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide privacy, dignity, and respect for one of four sampled residents (Resident 70) when Licensed Vocational Nurse 2 (LVN 2) did not close Resident 70's door and/or pull the resident's privacy curtain during administration of resident's medication via G-tube (a tube inserted through the belly that brings nutrition directly to the stomach This deficient practice had the potential to affect Resident 70's emotional and mental well-being. Findings: A review of Resident 70 's admission Record, indicated the resident was admitted to the facility on [DATE] with diagnoses that included gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food) and hypertension (elevated blood pressure). A review of the History and Physical Examination (H&P), dated 2/13/2024, indicated Resident 70 does not have the capacity to understand and make decisions. A review of the Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 5/14/2024, indicated Resident 70 had impaired cognitive skills (mental action or process of acquiring knowledge and understanding) in decision making. The MDS indicated Resident 70 was total dependent (helper does all of the effort) on staff for eating, oral hygiene, and toilet hygiene. During a medication pass observation, on 5/25/2024 at 8:12 AM. LVN 2 did not close the Resident 70's door or pull the Resident 70's curtain to provide privacy. Resident 70 was observed lying in bed. LVN 2 assisted Resident 70 to lift the resident's blouse up to the chest and pulled down the resident's abdominal binder. LVN 2 placed a stethoscope (a device to listen to the sounds generated internally by the heart, lungs, and internal tract) on the left side of Resident 70's abdominal area to check for resident's G-tube placement and residual (refer to fluid or contents that remains in the stomach). LVN 2 proceeded to administering the resident's medications. During an interview with LVN 2 on 5/25/2024 at 8:45 AM, LVN 2 stated she did not and should have closed the door or close the curtain while providing care to Resident 70. LVN 2 stated it was important to protect the resident's dignity and privacy by making sure curtain and/or door were closed during resident care. During an interview with the Director of Nursing (DON) on 5/25/2024 at 3:12 PM, the DON stated that Resident 70's privacy and dignity should always be maintained by closing doors, curtain, and asking Page 1 of 31 055162 055162 05/26/2024 Monterey Park Conv Hosp 416 N Garfield Ave Monterey Park, CA 91754

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident's permission to enter the room in order to assure adequate privacy during nursing care and treatment. A review of the facility's Policy and Procedure titled, Resident Rights, dated 12/19/2022, indicated that the resident has a right to be treated with respect and dignity, including personal privacy of accommodations, medical treatment, written and telephone communications, personal care, visit, and meetings of family and resident groups. 055162 Page 2 of 31 055162 05/26/2024 Monterey Park Conv Hosp 416 N Garfield Ave Monterey Park, CA 91754

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 provide a clean comfortable, sanitary, and home like environment for three (3) of five (5) sampled rooms by failing to ensure: Residents Affected - Few 1. Rooms A and B's bathroom toilet was free of fecal matter. 2. Room D's bathroom light bulb and wire were covered. This deficient practice caused an unsanitary and unsafe environment and had a potential for residents to be placed at risk for infection and injury. Findings: 1. During an observation in Rooms B and Room C 's bathroom on 5/24/2024 at 4:37 PM, Rooms B and Room C's bathroom toilet seat was observed to have a dry dark brown to blackish in color stool. During a concurrent observation, interview, and record review on 5/26/2024 at 7:55 PM with Licensed Vocational Nurse (LVN 3), LVN 3 stated Rooms B and Room C's bathroom toilet seat was observed to have a dry dark brown to blackish in color stool. LVN 3 stated the toilet needs to be sanitary to prevent infection. LVN 3 stated the staff should have cleaned it after for the next resident to use. LVN 3 also stated the Policy and Procedure (P&P) titled, Safe and Homelike Environment, revised 12/10/2024 indicated in accordance with resident's rights, the facility will provide a safe, clean, comfortable and homelike environment. This includes ensuring the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. 2. During an observation in Room D's bathroom on 5/24/2024 at 5:34 PM, the bathroom light was observed not to be in good repair because it did not have cover. The light bulb and wires were exposed. During concurrent observation interview and record review on 5/26/2024 at 5:13 PM with the Maintenance Supervisor (MS), MS stated the lights were supposed to be covered for the protection of the resident and staff in the event that the light bulb explodes. The MS also stated this was important as indicated with the facility's P&P for the residents to have a safe and homelike environment. 055162 Page 3 of 31 055162 05/26/2024 Monterey Park Conv Hosp 416 N Garfield Ave Monterey Park, CA 91754

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop an individualized baseline care plan with 48 hours of admission for one of 19 sampled residents (Resident 182) who was receiving hemodialysis (process of removing waste products and excess fluid from the body). This deficient practice had the potential not to meet the needs of Resident 182 that included interventions for hemodialysis, safety, and wellbeing, which could lead to harm and hospitalization. Findings: A review of Resident 182's admission Record indicated Resident 182 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease (kidneys suddenly become unable to filter waste products from your blood that can develop rapidly over a few hours or a few days), dependence on renal (kidney) dialysis, and hypertension (high blood pressure). A review of Resident 182's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 5/25/2024, indicated Resident 182's cognitive (ability to think and reason) skills for daily decision making was moderately impaired. The MDS indicated Resident 182 required substantial/maximal assistance (helper does more than half the effort) with eating, oral hygiene, toileting hygiene, shower, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. The MDS also indicated that Resident 182 was receiving hemodialysis. A review of Resident 182's Order Summary Report, dated 5/26/2024, indicated hemodialysis, every Monday, Wednesday, and Friday, ordered on 5/18/2024. During a concurrent record review of Resident 182's medical record and interview with Minimum Date Set Nurse (MDSN) on 5/26/2024 at 4:30 PM, she stated that baseline care plan was to be completed within 48 hours after resident was admitted in the facility. MDSN verified that hemodialysis was not indicated in Resident 182's baseline care plan. MDSN added that it was important to include hemodialysis in baseline care plan so the staff were aware and could appropriately care Resident 182. During an interview on 5/26/2024 at 5:30 PM with the Director of Nursing (DON), the DON stated Resident 182 did not have a baseline care plan for hemodialysis. The DON stated a baseline care plan for Resident 182's hemodialysis was important so staff could be guided on delivering care to Resident 182. The DON stated it was the responsibility of the admitting nurse to develop a baseline care plan after admission. A review of the facility's Policy and Procedure (P&P) titled, Baseline Care Plan, revised on 12/19/2022, indicated, The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The policy also indicated, Interventions shall be initiated that address the resident's current needs including any special needs such as for IV therapy, dialysis, or wound care. 055162 Page 4 of 31 055162 05/26/2024 Monterey Park Conv Hosp 416 N Garfield Ave Monterey Park, CA 91754

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a care plan for one of five sampled residents (Resident 285) was developed to address non-compliance with medications, as indicated on the facility's care plan policy. This failure had the potential for licensed staff not to utilize interventions for resident to comply with timely administration of medications, which could place Resident 285 at risk for adverse effects from not taking medications as ordered. Findings: A review of Resident 285's admission Records indicated the resident was originally admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (a chronic disease that result in high blood sugar levels in the blood) and cerebral infarction (stroke, a loss of blood flow to part of the brain, causing damage). A review of Resident 285's History and Physical (H&P), dated 5/17/2024, indicated the resident has the capacity to understand and make decisions. A review of Resident 285's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool), dated 5/22/2024, indicated the resident had intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. A review of Resident 285's Care Plans indicated the resident does not have a care plan for non-compliance to resident care. During a concurrent observation and interview on 5/26/2024 at 12:19 PM ins Resident 285's room with Licensed Vocational Nurse 2 (LVN 2), Resident 285 stated to LVN 2 that she does not want to take her medications yet. LVN 2 stated the medications that she was going to give the resident were already late because they should have been given at 9 AM. LVN 2 stated Resident 285 often refuses to take her medications on time. During an interview on 5/26/2024 at 12:29 PM with LVN 2, LVN 2 stated a care plan was not and should have been created for Resident 285's non-compliance. LVN 2 stated care plans are used to address problems that the resident has. LVN 2 added the care plans contain interventions to address resident problems and to keep the resident safe. During a concurrent record review of Resident 285's Progress Notes, dated 5/16/2024, timed at 6:29 AM and interview on 5/26/2024 at 3:53 PM with Quality Assurance Nurse (QAN), QAN stated Resident 285 refused care from facility staff according to an entry on 5/16/2024 indicating Resident 285 refused to take insulin (a medication to control the blood sugar). QAN stated the facility nurses should have initiated a care plan to address the resident's behavior of non-compliance because the resident's non-compliance could be harmful to the resident's health. During an interview on 5/26/2024 at 8:51 PM with the Director of Nursing (DON), the DON stated Resident 285's non-compliance to scheduled care, such as the administration of insulin, should have a 055162 Page 5 of 31 055162 05/26/2024 Monterey Park Conv Hosp 416 N Garfield Ave Monterey Park, CA 91754

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few care plan. The DON stated the care plan should have interventions to address the behavior, such as educating the resident. The DON stated the interventions should include monitoring of the behavior and of any adverse effects of the non-compliance, such as hyperglycemia (high blood sugar levels) if the resident does not take the insulin. The DON stated the care plan was important to promote the resident's well-being. A review of the facility's Policy and Procedure (P&P) titled, Comprehensive Care Plans, revised 12/19/2022, indicated the facility is to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes. The P&P also indicated the objectives will be utilized to monitor the resident's progress. The P&P also indicated the facility will attempt alternate methos for refusal of treatment and services and document such attempts in the clinical record. A review of the facility's P&P titled, Residents' Rights Regarding Treatment and Advance Directives, revised 12/19/2022, indicated services that would be otherwise required, but are refused, will be documented in the resident's comprehensive care plan. 055162 Page 6 of 31 055162 05/26/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility failed to meet professional standards of quality (care and services are provided according to accepted standards of clinical practice) for one (1) of four sample residents (Resident 18) when Licensed Vocation Nurse 2 (LVN 2) failed to apply gentle pressure to the lacrimal (tear) duct to prevent systemic absorption of the medication of Artificial Tear ophthalmic Solution (a medication used to treat dry eye) during medication administration, as indicated on the facility's Administration of Eye Drop or Ointment policy. Residents Affected - Few This deficient practice had the potential for Resident 18 to have an adverse reaction. Findings: A review of Resident 18's admission Record indicated Resident 18 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease (brain disorder that disables a resident from performing everyday activities) and hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood). A review of the History and Physical Examination (H&P) dated 7/25/2023, indicated Resident 18 has fluctuating capacity to understand and make decisions. A review of the Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 3/20/2024, indicated Resident 18 was cognitively (a mental process of acquiring knowledge and understanding) intact. The MDS indicated Resident 18 required partial/moderate assistance (Helper dies less than half the effort) with toileting hygiene and shower/bathe self. A review of Resident 18's Order Summary Report (a summary of all currently active physician orders), dated 5/25/2024, indicated a physician's order to administer Artificial Tears Ophthalmic Solution, instill 1 drop in both eyes two times a day for eye dryness. During a medication pass (MedPass) observation on 5/25/2024 at 8:51 AM, LVN 2 prepared the Artificial Tear Ophthalmic Solution for Resident 18. LVN 2 administered the Artificial Tear Ophthalmic Solution to Resident 18's right eye first by having the resident tilt her head back, pulling down the lower lid, and instilled 1 drop to the right eye. LVN 2 did not place pressure to the lacrimal duct. LVN 2 gave Resident 18 a tissue to wipe excess medication from eye. LVN 2 then removed gloves and washed hands, donned a new pair of gloves, and administered the Artificial Tear Ophthalmic Solution to Resident 18's to the left eye. LVN 2 did not apply pressure to Resident 18's left eye lacrimal duct. Resident 18 was observed using the previous used tissue to wipe excess medications from both eyes. During an interview with LVN 2 on 5/25/2024 at 9:02 AM, LVN 2 stated she should wipe off excess solution for Resident 18's eyes and should use clean tissue for each eye to prevent cross contamination. LVN 2 stated she was not aware of the need to apply pressure to lacrimal duct to prevent systemic absorption of medication. During an interview with the Director of Nursing (DON) on 5/25/2024 at 3:12 PM, the DON stated LVN 2 should gently press the finger to the inside corner of the eye for about 1 minute to keep the liquid from draining into the tear duct. The DON stated LVN 2 should complete administrating eye drops by wiping off excess liquid using a clean tissue for each eye to prevent cross contamination by 055162 Page 7 of 31 055162 05/26/2024 Monterey Park Conv Hosp 416 N Garfield Ave Monterey Park, CA 91754

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few herself. The DON stated LVN 2 should check the standards of practice for administration of eye drop when in doubt. A review of the facility's Policy and Procedure titled, Administration of Eye Drop or Ointment, dated 12/19/22, indicated that eye medications are administered as ordered by the physician and in accordance with professional standards of practice to lubricate the eye or treat certain eye condition. The policy also indicated to instruct resident to close eyes slowly to allow for even distribution over the surface of the eye and apply gentle pressure to the tear duct for one minute or by gently closing the eye for 3 minutes; wipe off excess solution with a clean tissue, use a fresh tissue for each eye to prevent cross contamination. 055162 Page 8 of 31 055162 05/26/2024 Monterey Park Conv Hosp 416 N Garfield Ave Monterey Park, CA 91754

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the Low Air Loss mattress (LAL mattress, designed to prevent and treat pressure ulcer [localized damage to the skin and underlying soft tissue caused by prolonged pressure]) for one (1) of three (3) sampled residents (Resident 234) was functioning properly. Residents Affected - Few This deficient practice had the potential for Resident 234's pressure ulcer to worsen and for the resident to develop new pressure injury. Findings: A review of Resident 234's admission Record indicated the facility admitted Resident 234 on 5/16/2024. Resident 234's diagnoses included abnormalities of gait and mobility, repeated fall, pressure ulcer of sacral region (are wounds that form as a direct result of pressure over a bony prominence). A review of Resident 234's Minimum Data Set (MDS, standardized care and screening tool), dated 5/21/2024, indicated Resident 234's cognitive (processes of thinking and reasoning) skills for daily decision making was intact. The MDS indicated Resident 234 was dependent (helper does all the effort) on toileting, shower /bath self, personal hygiene. The MDS also indicated the resident was at risk for developing pressure ulcer/ injuries. The Resident 234 has 1 or more unhealed pressure ulcers / injuries. The MDS also indicated skin and ulcer/ injury treatment included pressure reducing device for chair, pressure reducing device for bed, turning/ repositioning program, nutrition hydration intervention to manage skin problems, and pressure injury care. During an observation in Resident 234's room on 5/24/2024 at 5:47 PM, Resident 234 was observed in bed sleeping with a LAL mattress setting at 4. The mattress was soft and slightly deflated (lose air or gas from inside, sagging). During a concurrent observation and interview on 5/25/2024 at 8AM with the Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 234 appeared to be sinking at the middle of the LAL mattress. LVN 1 stated The mattress sometimes works and sometimes does not. They called the company last night to change it. During a concurrent interview and record review on 5/26/2024 at 12:59 PM with the Treatment Nurse (TN 1), TN 1 stated Resident 234's weight on 5/24/2024 at 12:25 PM was 136 pounds (lbs). TN 1 stated there was no clear instruction on setting the LAL mattress. TN 1 stated the LAL mattress was not functioning on 5/25/2024 and the facility had called the LAL mattress representative. TN 1 also stated it was important to have a functioning LAL mattress to ensure that it was not too soft, otherwise, Resident 234's sacral area (tailbone) will be in direct contact with the bed frame. During the same interview and record review on 5/26/2024 at 7:31 PM with LVN 3, LVN 3 stated Resident 234's Braden Scale (a commonly used nursing risk assessment tool to determine whether an individual is at risk for pressure injury development), dated 5/16/2024, indicated a score of 14, which indicated moderate risk. During a record review of Resident 234's Order Summary Report dated 5/24/2024 and interview with LVN 3 on 5/26/2024 at 7:31 PM, LVN 3 stated an order to apply low air loss mattress for Resident 234's wound management and to monitor for proper functions. LVN 3 further stated, If the LAL mattress was 055162 Page 9 of 31 055162 05/26/2024 Monterey Park Conv Hosp 416 N Garfield Ave Monterey Park, CA 91754

F 0686 broken, it should be fixed, or resident should be transferred to another bed that was functioning properly. Level of Harm - Minimal harm or potential for actual harm A review of Resident 234's Care Plan, initiated 5/25/2024, indicated impairment to skin integrity with an intervention to apply LAL mattress for wound management and monitor for proper function. Residents Affected - Few A review of the facility's Policy and Procedure (P&P) titled, Pressure Injury Prevention and Management, revised 12/19/2023, indicated the facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/ injury. The P&P also indicated basic or routine care intervention could include but are not limited to Redistribute pressure such as repositioning, protecting and /or offloading heels, etc.) . Provide appropriate, pressure redistributing, support surfaces. 055162 Page 10 of 31 055162 05/26/2024 Monterey Park Conv Hosp 416 N Garfield Ave Monterey Park, CA 91754

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide supervision during toileting and failed to ensure the sensor alarm (helps to alert caregivers when a resident gets out of bed in order to ensure resident safety) was functioning for one (1) of two (2) sampled residents (Resident 34), who was at high risk for falls. This deficient practice resulted to Resident 34 had fall on 2/13/2024 and was sent to General Acute Care Hospital (GACH 1) and another fall on 3/23/2024. Findings: A review of Resident 34's admission record indicated the facility admitted Resident 34 on 5/9/2022 with diagnoses which includes muscle weakness, repeated falls, and lack of coordination. A review of Resident 34's H&P dated 5/26/2024 indicated Resident 34 does not have the capacity to understand make decisions. A review of Resident 34's Minimum Data Set (MDS, standardized care and screening tool), dated 3/15/2024, indicated Resident 34 was severely impaired with cognitive (processes of thinking and reasoning) skills for daily decision making. The MDS also indicated Resident 34 needs partial moderate assistance (helper does less than half the effort. The helper lifts, holds or support trunk or limbs, but provide less than half the effort) on toilet hygiene, personal hygiene. Supervision or touching assistance ( helper provides verbal cue and or touching/ steadying and or contact guard assistance as resident completes activity) on laying to sit on the side of the bed( the ability to move from laying on the back to sitting on the side of the bed), Sit to stand ( the ability to come to standing position from sitting in a chair, wheelchair or on the side of the bed), Chair /bed to chair transfer( ability to transfer to and from a bed to chair), toilet transfer( ability to get on and off a toilet or commode. Walks 10 feet (once standing ability to walk at least 10 feet in the room, corridor or similar space) The MDS also indicated Resident 34 was continent on bowel and bladder (able to control their bladder and/or their bowel of their own accord). During concurrent interview and record review on 5/26/2024 at 10:31 AM with the Quality Assurance Nurse (QAN), QAN stated fall risk assessment, dated 12/18/2023 at 5:40 PM, indicated Resident 34's score was 17 which indicated high risk for fall. During concurrent interview and record review on 5/26/2024 at 11:55 AM with the Director of Rehab (DOR), the DOR stated the physical therapy (PT) notes titled PT Evaluation and Plan of treatment, dated 11/8/2023, indicated Resident 34 was stand by assist (SBA) on transfer. DOR stated, Somebody needs to watch the resident, they should have somebody to stand by to assist the resident. During the same interview and record review with the DOR on 5/26/2024 at 11:55 AM, DOR stated the occupational therapy (OT) notes titled, OT Evaluation and Plan of treatment, dated 2/16/2024 indicated Resident 34 needs contact guard assist (resident required assistance) with toileting, bathing/ transfer, dressing. During concurrent interview and record review on 5/26/2024 at 10:13 AM with the Registered Nurse 055162 Page 11 of 31 055162 05/26/2024 Monterey Park Conv Hosp 416 N Garfield Ave Monterey Park, CA 91754

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (RN 1), RN 1 stated Resident 34's care plan initiated 12/16/2021, and revised on 1/4/2024, indicated resident was at risk for fall related to repeated fall and poor safety awareness. Staff interventions indicated to continue to anticipate and meet residents needs/wants such as assisting to toilet and apply smart wireless sensor alarm in bed. RN 1 stated the care plan was not and should have been updated to prevent further injury to the resident. RN 1 stated the care plan should have an intervention to supervise the resident as indicated on the MDS. During concurrent observation in Resident 34's room, interview, and record review with the QAN on 5/26/2024 at 11:44 AM, Resident 34 was in bed. Resident 34 got up from her bed and the smart alarm did not turn on. The QAN verified that the smart alarm did not turn on when Resident 34 stood up. QAN further stated the smart alarm should have turned on when the resident stood up to alert the staff. QAN stated Resident 34's Order Summary Report, dated 5/8/2024 indicated May have cordless smart sensor to alert staff that the resident needs assistance. During concurrent interview and record review on 5/26/2024 at 6:19 PM, Licensed Vocational Nurse 3 (LVN 3) stated Resident 34's Progress Notes, dated 2/13/2024 at 9:21 PM indicated Resident 34 requiring acute hospital transfer due to laceration (a cut or slice of tissue caused by a sharp object, fall, or blunt trauma) for possible suturing (to stitch a wound closed) and further evaluation. During the same interview with LVN 3, LVN 3 stated, Resident 34's progress notes on 2/14/2024 at 7:16 AM, indicated Resident 34 returned from GACH 1 at 1 AM, suffered laceration to the mid forehead due to status post fall, stitches were placed as well as dry dressing; after care of removal of dressing in 10 days. During a record review of GACH 1 records, dated 2/13/2024 at 10:28 PM, it indicated Resident 34's admitting diagnosis was forehead laceration. GACH 1's discharge packet summary dated 2/14/2024 indicated Head Injury Observation Discharge Instructions: Laceration repair with stitches discharge instructions. During a concurrent interview and record review on 5/26/2024 at 11:33 with the QAN, QAN stated Resident 34's progress notes dated 3/23/2024 at 9:21 PM indicated CNA 1 called and informed QAN Resident 34 was found on the bathroom floor, QAN stated it was unwitnessed fall, happened around dinner time, resident was found at the bathroom. QAN also stated nobody was with the resident, CNA 1 was passing the tray. During interview with on 5/26/2024 at 6:19 PM with the LVN 1, LVN 1 stated Resident 34 's needs supervision and was contact guard assist based on MDS, that means somebody needs to be assisting the resident when getting out of bed going to the bathroom. LVN 1 further stated if there was a staff to assist Resident 34 on 2/13/2024 and 3/23/2024, Resident 34 will not fall. During a review of facility's policy and procedure (P&P) titled, Resident Alarm revised 12/19/2022, indicated An alarm is any physical or electronic device that monitors the resident movement and alert the staff, by either audible or inaudible means when movement is detected. The use of alarm does not eliminate the need for adequate supervision of the resident. During a review of facility's P&P titled, Comprehensive Care Plans, revised 12/19/2022 indicated, It is the facility policy to develop and implement a comprehensive person -centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the 055162 Page 12 of 31 055162 05/26/2024 Monterey Park Conv Hosp 416 N Garfield Ave Monterey Park, CA 91754

F 0689 resident's comprehensive assessment. Level of Harm - Minimal harm or potential for actual harm During a review of facility's P&P titled, Care Plan Revision Upon Status [NAME],e revised date 12/19/2022 indicated The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. The Comprehensive care plan will be reviewed revised as necessary when resident experienced status change. Residents Affected - Some 055162 Page 13 of 31 055162 05/26/2024 Monterey Park Conv Hosp 416 N Garfield Ave Monterey Park, CA 91754

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 one of four sampled resident (Resident 182), who was receiving hemodialysis (process of removing waste products and excess fluid from the body) treatment was provided dialysis care and services by failing to assess the resident's right upper chest dialysis access site on 5/20/2024, 5/22/2024, 5/24/2024, in accordance with the facility policy. Residents Affected - Few This deficient practice had the potential for Resident 182 to suffer from complications such as bleeding or infection from the central venous catheter (a catheter [thin tube] that is placed under the skin in a vein, allowing long-term access to the vein. Findings: A review of Resident 182's admission Record indicated Resident 182 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease (kidneys suddenly become unable to filter waste products from your blood that can develop rapidly over a few hours or a few days), dependence on renal (kidney) dialysis, and hypertension (high blood pressure). A review of Resident 182's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 5/25/2024, indicated Resident 182's cognitive (ability to think and reason) skills for daily decision making was moderately impaired. The MDS indicated Resident 182 required substantial/maximal assistance (helper does more than half the effort) with eating, oral hygiene, toileting hygiene, shower, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. The MDS also indicated that Resident 182 was receiving hemodialysis. A review of Resident 182's order summary report dated 5/26/2024, indicated hemodialysis, every Monday, Wednesday, and Friday, ordered on 5/18/2024. A review of Resident 182's order summary report dated 5/26/2024, indicated hemodialysis access site of Quinton catheter (central venous catheter, access for hemodialysis) on right upper chest, monitor for redness, swelling, bleeding, pain, and drainage every shift, ordered on 5/18/2024. During an observation and interview with Resident 182 on 5/24/2024 at 4:18 PM, Resident 182 stated that she goes to dialysis three times a week. Resident 182 stated that they do dialysis and pointed at her right chest. Resident 182 was observed with a right chest dialysis access site. During a concurrent record review of Resident 182's dialysis communication records, dated 5/20/2024, 5/22/2024, 5/24/2024, and interview with Registered Nurse 1 (RN 1) on 5/26/2024 at 11:32 AM, she verified the following: a. Resident 182's dialysis communication record on 5/20/2024 indicated a documentation of right upper chest access site location. It was also documented that bruit (a sound created when blood flows through a narrowed space) and thrill (vibration caused by blood flow) were present. RN 1 also verified that on the same dialysis communication record, the following questions were not answered in the pre dialysis assessment and communication: 055162 Page 14 of 31 055162 05/26/2024 Monterey Park Conv Hosp 416 N Garfield Ave Monterey Park, CA 91754

F 0698 Copy of most current Physician orders and treatment orders provided? Level of Harm - Minimal harm or potential for actual harm Copy of any lab work done since last dialysis treatment provided? Copy of Advance Directive changes provided if any changes since last dialysis visit? Residents Affected - Few Compliant with fluid restriction since last dialysis center visit? Last meal consumed ____. Percentage consumed ____. Was a sack meal sent with the resident? Any care concerns unre1ated to dialysis (examples like wounds, falls, change of condition) b. For Resident 182's dialysis communication records dated 5/22/2024 and 5/25/2024, RN 1 verified that documentation of right upper chest was documented but did not indicate the type if it's shunt or catheter. RN 1 added that bruit and thrill were documented to be present. RN 1 also stated that on this form, dialysis center assessment was incomplete, where in the following are not answered: Access site assessment Lab results sent with the resident. Food consumed. Medications given. Dialysis treatment provided and the resident's response. Comments or special instructions post dialysis. RN 1 stated Resident 182's access site documentation was incorrect and incomplete for the 3 dialysis communication records that were reviewed. RN 1 stated Resident 182's type of dialysis access site was not and should have been identified and documented. RN 1 added that there should not have been a check mark on the bruit and thrill assessment because Resident 182 did not have a shunt (vascular access in patients receiving regular hemodialysis). RN 1 stated that the documentation might cause confusion when delivering care to Resident 182. During a concurrent record review of Resident 182's dialysis communication records, dated 5/20/2024, 5/22/2024, 5/24/2024, and interview with Director of Nursing (DON) on 5/26/2024 at 5:35 PM, the DON stated Resident 182 had a right upper chest central dialysis access site. The DON verified that Resident 182's dialysis communication record on 5/20/2024, 5/22/2024, 5/24/2024 was incomplete because some of the questions were not answered and left blank. The DON also stated the assessment was inaccurate due to the incorrect dialysis access site documentation. The DON stated since Resident 182 has a right upper chest central line, the check mark on the Dialysis Communication Record for presence 055162 Page 15 of 31 055162 05/26/2024 Monterey Park Conv Hosp 416 N Garfield Ave Monterey Park, CA 91754

F 0698 Level of Harm - Minimal harm or potential for actual harm of bruit and thrill was a wrong assessment. The DON verified that Resident 182's dialysis communication record on 5/22/2024 and 5/24/2024 was incomplete because dialysis center did not complete and answered the following: Access site assessment Residents Affected - Few Lab results sent with the resident. Food consumed. Medications given. Dialysis treatment provided and the resident's response. Comments or special instructions post dialysis. The DON stated the receiving Licensed Vocational Nurse or RN should have called the dialysis center if Dialysis communication record was incomplete. The DON stated, it was important to properly assess residents, document accurately, and complete the Dialysis communication record to make sure that resident will receive the proper care. During a review of the facility's policy and procedure (P&P) titled, Hemodialysis, revised on 9/2/2022, indicated the facility will assure that each resident receives care and services for the provision of hemodialysis and/or peritoneal dialysis consistent with professional standards of practice. This will include: o The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. o Ongoing assessment and oversight of the resident before, during and after dialysis treatments, including monitoring of the resident's condition during treatments, monitoring for complications, implementation of appropriate interventions, and using appropriate infection control practices: and o Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. Policy also indicated the facility will coordinate and collaborate with the dialysis facility to assure that: a. The resident's needs related to dialysis treatments are met. 055162 Page 16 of 31 055162 05/26/2024 Monterey Park Conv Hosp 416 N Garfield Ave Monterey Park, CA 91754

F 0698 b. Level of Harm - Minimal harm or potential for actual harm The provision of the dialysis treatments and care of the resident meets current standards of practice for the safe administration of the dialysis treatments. Residents Affected - Few c. Documentation requirements are met to assure that treatments are provided as ordered by the nephrologist, attending practitioner and dialysis team. d. There is ongoing communication and collaboration for the development and implementation of the dialysis care plan by nursing home and dialysis staff. Policy also indicated the licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form or other form, that will include, but not limit itself to: a. Timely medication administration (initiated, held or discontinued) by the nursing home and/or dialysis facility. b. Physician/treatment orders, laboratory values, and vital signs. c. Advance Directives and code status; specific directives about treatment choices; and any changes or need for further discussion with the resident/representative, and practitioners. d. Nutritional/fluid management including documentation of weights, resident compliance with food/fluid restrictions or the provision of meals before, during and/or after dialysis and monitoring intake and output measurements as ordered. e. Dialysis treatment provided and resident's response, including declines in functional status, falls, and the identification of symptoms that may interfere with treatments. f. Dialysis adverse reactions/complications and/or recommendations for follow up observations and monitoring, and/or concerns related to the vascular access site. 055162 Page 17 of 31 055162 05/26/2024 Monterey Park Conv Hosp 416 N Garfield Ave Monterey Park, CA 91754

F 0698 g. Level of Harm - Minimal harm or potential for actual harm Changes and/or declines in condition unrelated to dialysis. h. Residents Affected - Few The occurrence or risk of falls and any concerns related to transportation to and from the dialysis facility. 055162 Page 18 of 31 055162 05/26/2024 Monterey Park Conv Hosp 416 N Garfield Ave Monterey Park, CA 91754

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 provide pharmaceutical services to meet the needs of one of four sampled residents (Resident 11) by failing to administer resident's Calcitonin Solution (a medication used to treat bone loss) nasal spray, as indicated on the physician order. This deficient practice had the potential for Resident 11's bone to become more fragile or low in bone mass which could put the resident at a greater risk for fracture (break in the bone). Findings: A review of Resident 11's admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and elderly people). A review of the History and Physical Examination (H&P), dated 8/29/2023, indicated Resident 11 does not have the capacity to understand and make decisions. A review of the Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 5/15/2024, indicated Resident 11 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) in decision making. The MDS also indicated Resident 11 required partial/moderate assistance (Helper does less than half the effort) from staff for roll left and right, lying to sitting on side of bed, and sit to stand. During a concurrent observation of medication administration and interview with the Licensed Vocational Nurse (LVN1) on 5/25/2024 at 9:03 AM, LVN 1 was observed preparing the following medications for Resident 11: 1. One tablet of stool softener 250 milligram (MG- a unit of measure for mass). 2. One tablet of Ferrous Sulfate (a medication used to treat anemia-a condition in which the blood does not have enough healthy red blood cells) 325 MG. 3. One tablet of Folic Acid (a medication used to treat anemia [lowered ability of blood to carry oxygen resulting in feeling tired and shortness of breath]) 1 MG. 4. One capsule of Memantine Hydrochloride Extended Release (a medication used to treat dementia [loss of memory and other mental abilities severe enough to interfere with daily life]) seven MG. 055162 Page 19 of 31 055162 05/26/2024 Monterey Park Conv Hosp 416 N Garfield Ave Monterey Park, CA 91754

F 0755 5. Level of Harm - Minimal harm or potential for actual harm One tablet of Myrbetriq Extended Release (a medication used to treat overactive bladder) 25 MG. 6. Residents Affected - Few Artificial Tears Ophthalmic Solution (a medication used to treat dry eyes) one drop. 7. One capsule of Gabapentin (a medication used to treat seizure [sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness]) 100 MG. 8. Brimonidine (a medication used to treat dry eyes) one drop. 9. One tablet of Vitamin D3 (a supplement) 25 micrograms (MCG - a unit of measure for mass). LVN 1 stated there were nine total morning medications to administer for Resident 11. During an observation on 5/25/2025 at 9:18 AM, in the Resident 11's room, Resident 11 was observed taking the seven medications by mouth with water and LVN 1 was observed instilling two eye drop medications for Resident 11 as listed above. A review of Resident 11's Order Summary Report (a summary of all currently active physician orders), dated 5/25/25, indicated Resident 11 was also scheduled to receive Calcitonin Solution 200 unit/milliliter (ML) one spray alternating nostrils. During an interview on 5/25/2025 at 10:22 AM, LVN 1 stated she failed to administer the Calcitonin Solution to Resident 11 earlier this morning. LVN 1 stated failing to administer medication to a resident per the physician's order can lead to medical complications possibly resulting in hospitalization. During an interview with the Director of Nurses (DON) on 5/25/2024 at 3:46 PM, the DON stated Licensed Nurse should administer Calcitonin for Resident 11 per physician order, and omitted Calcitonin could result in Resident 11 to be at risk for bone weakening which could lead to bone fracture. A review of the facility`s Policy and Procedure titled, Medication Administration, dated 12/19/22, indicated that medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by physician and in accordance with professional standards of practice. 055162 Page 20 of 31 055162 05/26/2024 Monterey Park Conv Hosp 416 N Garfield Ave Monterey Park, CA 91754

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow its Medication Storage policy by failing to: 1. Remove an expired Humulin R insulin (Insulin Regular Human - a medication used to treat high blood sugar) vial in the refrigerator. 2. Store five (5) unopened Insulin Glargine Flex Pen (a medication used to control high blood sugar) in the refrigerator. This deficient practice increased the risk for Residents on insulin to receive medication that had become ineffective or toxic due to improper storage possibly leading to health complications, which may result to harm and hospitalization. Findings: 1. During a concurrent observation and interview with the Director of Nursing (DON) on [DATE] at 6:33 PM in the Medication Storage room located in Nursing Station 1 (NS 1), a Humulin R insulin vial was observed to be labeled with an open date of [DATE] and discard date of [DATE] in the medication refrigerator. The DON stated the Humulin R vial should be used or discarded within 28 days of opening. The DON stated because Resident 20's Humulin R vial was opened on [DATE], it should have been used by [DATE] in accordance with the manufacturer's recommendations. The DON stated the Humulin R vial was now expired and should have been removed from the cart and discarded. The DON stated expired insulin may be ineffective to control the resident's blood sugar. The DON added, administering expired insulin may cause the resident to develop medical complications which could result in hospitalization. A review of the facility's policy Labeling of Medications and Biologicals, dated [DATE], indicated all opened or accessed vials should be discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. 2. During a concurrent observation and interview with the Director of Nursing (DON) on [DATE] at 6:48 PM in the Medication Storage room located in Nursing Station 1 (NS 1), 5 unopened insulin glargine flex pens were found in the plastic bag on the countertop at room temperature. The DON stated the 5 insulin glargine pens should have been stored in the refrigerator. The DON stated according to the product labeling, unopened insulin glargine pens should be stored in the refrigerator. The DON stated because they were not stored in the refrigerator and cannot determine when they were stored at room temperature, they were now considered expired and were not safe to administer to the resident. The DON stated insulin that was not stored properly could be ineffective at controlling the resident's blood sugar which could cause medical complication to the resident, which possibly can lead to harm and hospitalization. 055162 Page 21 of 31 055162 05/26/2024 Monterey Park Conv Hosp 416 N Garfield Ave Monterey Park, CA 91754

F 0761 Level of Harm - Minimal harm or potential for actual harm A review of the facility's Policy and Procedure titled, Medication Storage, dated [DATE], indicated all medications housed in the facility will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. The policy also indicated that all medications requiring refrigeration are stored in the refrigerator located in the pharmacy and at each medication room. Residents Affected - Some 055162 Page 22 of 31 055162 05/26/2024 Monterey Park Conv Hosp 416 N Garfield Ave Monterey Park, CA 91754

F 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. 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 resident who required adaptive feeding equipment (modified utensils, accessories, glasses, and plates to help improve residents' comfort and independence), utilize a plate guard (unique spill guard which prevents food from accidentally being pushed off the plate) during meal, as indicated on the physician's order, for one of 19 sampled resident (Resident 24). Residents Affected - Few This deficient practice placed Resident 24 at risk for further decline in physical functioning and decline to perform self-feeding skills. Findings: A review of Resident 24's admission Record indicated the resident admitted to the facility on [DATE] and got readmitted on [DATE], with diagnoses including but not limited to bilateral nuclear cataract (a type of cataract [a cloudy area in the lens of your eye] that affects the center of the eye's lens, causing cloudy vision), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and abnormalities of gait (pattern of movement of the limbs) and mobility (the ability to move or be moved freely and easily). A review of Resident 24's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 7/18/2023, indicated Resident 24's cognitive (ability to think and reason) skills for daily decision making was severely impaired. Resident 24 required extensive assistance with one person assist for bed mobility, transfer, walk in room, walk in corridor, locomotion on and off unit, dressing, eating, toilet use, and personal hygiene. A review of the Resident 24's Order Summary Report dated 5/26/2024, indicated a Physician's Order, dated 7/10/2021, for feeding adaptive equipment to provide plate guard for breakfast, lunch, and dinner. During an observation in Resident 24's room on 5/25/2024 at 5:35 PM, Resident 24 was eating dinner without using the utensil that was on the resident's tray. Resident 24's meal tray was observed to have a plate guard. During a concurrent observation in Resident 24's room and interview with Restorative Nurse Assistant (RNA 1) on 5/25/2024 at 5:37 PM, Resident 24's meal tray was observed to have a plate guard. Resident 24 was eating a bowl of dessert using her hand and not the utensil that was provided on the dinner tray. RNA 1 stated that Resident 24 cannot see because of eye problem but Resident 24 was able to feed self if proper directions were provided the resident. RNA 1 stated that Resident 24 should be reminded on what was on her tray such as where the spoon was located and the placement of the plate guard. RNA 1 stated Resident 24 should be checked periodically during meals to make sure that she was eating properly and using the spoon and plateguard. During an interview on 5/26/2024 at 12:40 PM, Occupational Therapist Assistant 1 (OTA 1), stated that residents with visual impairment should be provided with hand over hand assistance during meals. During an interview on 5/26/2024 at 12:55 PM, the Director of Rehabilitation (DOR) stated that 055162 Page 23 of 31 055162 05/26/2024 Monterey Park Conv Hosp 416 N Garfield Ave Monterey Park, CA 91754

F 0810 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 24 requires assistance with feeding, wherein staff should set up the tray, and ensure for the resident to do hand over hand with scooping food from the plate guard, and guiding spoon from plate to mouth. DOR stated that resident with visual impairment required a lot of verbal cues and staff should check Resident 24 every now and then during meals. Resident can feed self, but staff should recheck her and not to leave her eating with her hands because if she was given the direction to use the spoon, she will be able to feed herself with it. During an interview on 5/26/2024 at 3:29 PM, Licensed Vocational Nurse 4 (LVN 4) stated Resident cannot see, but she can feel things. LVN 4 added that because Resident 24 has visual impairment, location of spoon and plate should be instructed to her every mealtime, so she can be able to hold onto the spoon before staff leaves the room. LVN 4 stated assisting Resident 24 with meals was important for her nutrition to promote independence and to prevent weight loss. During an interview on 5/26/2024 at 3:44 PM. Registered Nurse 2 (RN 2) stated Resident 24 has visual impairment but can follow commands. RN 2 stated Resident 24 should be provided with hand-on-hand assistance/cuing during meals for her to be able to know what was on the meal tray. RN 2 stated Resident 24 did not have a care plan to address visual impairment and the need for cuing and use of adaptive utensil and techniques. A review of facility's Policy and Procedure (P&P) titled, Activities of Daily Living (ADLs), revised on 12/19/2022, indicated that the facility will be based on the resident's comprehensive assessment and consistent with the resident's needs and choices to ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services may consist of eating to include meals and snacks. It also indicated that a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. A review of facility's P&P titled, Use of Assistive Devices, revised on 12/19/2022, policy indicated to provide a reliable process for the proper and consistent use of assistive devices for those residents requiring equipment to maintain or improve function and/or dignity. It also indicated that the facility staff will provide appropriate assistance to ensure that the resident can use the assistive devices. This may include education or therapy sessions for training on the use of the device, set up assistance, supervision, or physical assistance as needed. 055162 Page 24 of 31 055162 05/26/2024 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, interview, and record review, the facility failed to follow proper food handling practices in accordance with its policy and procedure by failing to ensure: Residents Affected - Some 1. A container of [NAME] was not broken. 2. A container of cookies was sealed properly. 3. A can opener was clean and free of gunk and rust. 4. Trash can lid was closing properly. Trash can was observed to be full beyond capacity. These deficient practices had the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness ([food poisoning] with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever) and can lead to other serious medical complications and hospitalization. Findings: During an observation in the facility's kitchen on 5/24/2024 at 1:55PM, the following were observed: 1. The yellow container of [NAME] rice storage was broken. The corner of the hard plastic lid was missing. 2. One container of cookies was not sealed. 3. A can opener was dirty with dried food residue, gunk (unpleasantly sticky or messy substance), and was rusty (a reddish-brown substance that forms on the surface of iron and steel as a result of reacting with air and water). 4. Trash can lid was closing properly. Trash can was observed to be full beyond capacity. During concurrent observation, and interview on 5/25/2024 at 3:45 PM with the Dietary Supervisor (DS), DS stated the plastic cover of the [NAME] rice was broken, the container of cookies was not properly closed, and the can opener was dirty with dried food residue, gunk and was rusty. The DS also stated the trash can was overflowing. DS also stated all food containers were supposed to be tightly closed to avoid pest inside the container for infection control. DS stated all lids and containers were supposed to be in good condition and not broken. DS added, the can opener should be washed after 055162 Page 25 of 31 055162 05/26/2024 Monterey Park Conv Hosp 416 N Garfield Ave Monterey Park, CA 91754

F 0812 every use to keep it clean. DS stated the trashcan were not supposed to be overflowing to prevent infection. Level of Harm - Minimal harm or potential for actual harm A review of facility Policy & Procedure (P&P) titled, Sanitation Inspection, revised 12/19/2022, indicated it is the P&P of the facility as part of the department's sanitation program, to conduct inspections to ensure food services areas are clean, sanitary and in compliance with applicable state and federal regulations. The P&P also indicated all food services area shall be kept clean, sanitized, free from litter, rubbish and protect from rodents, roaches flies and other insects. Residents Affected - Some A review of the facility P&P titled, Food Storage, dated revised 12/20/2019 indicated Improper food storage is the main reason for foodborne illness. 055162 Page 26 of 31 055162 05/26/2024 Monterey Park Conv Hosp 416 N Garfield Ave Monterey Park, CA 91754

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to dispose garbage and refuse (disposable material, which includes both recyclable and non-recyclable material) from the kitchen properly when two bags of kitchen trash were observed on the ground right outside at the back of the facility kitchen. Residents Affected - Some This failure had the potential to result in the attraction and spread of vermin (animals that are believed to be harmful, or that carry diseases, e.g., rodent's parasitic worms or insects) that could potentially infiltrate the facility, affect the resident care areas and pose a disease threat to residents of the facility. Findings: During a concurrent observation and interview on 5/25/2024 at 8:38 AM with the maintenance supervisor (MS), observed two bags of kitchen trash on the ground near outside the back of the facility kitchen. MS stated the trash was not and should be inside the dumpster (a movable waste container designed to be brought and taken away by a special collection vehicle). MS stated the kitchen staff left the trash on the ground instead of dumping it in the dumpster. MS stated trash needs to be inside the dumpster to prevent attraction of rats, insects like ants, or fly. MS stated, This was an infection control issue. During interview on 5/25/2024 at 3:45 PM with the Dietary Supervisor (DS), DS stated, Sometimes the company that takes care of the trash leaves the dumpster on the street. They do not return the dumpster to the facility's assigned location. DS stated, We have nowhere to throw the trash, so they are left outside the building momentarily. DS stated the trash should be inside the dumpster to avoid the rats or any animals going into the trash, which was an infection control issue. A record review of the facility's policy and procedure (P&P) titled, Disposal of Garbage and Refuse, revised 12/19/2022, the P&P indicated the facility shall properly dispose of kitchen garbage and refuse. The dumpster shall be emptied according to the facility contract. Garbage should not accumulate or be left outside of the dumpster. The P&P also indicated storage areas, enclosure and receptacles for refuse shall be maintained in good repair and clean at frequency necessary to prevent them from developing buildup of soil or becoming attractant for insects and rodents. 055162 Page 27 of 31 055162 05/26/2024 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 followed the facility's infection control policy for one of 19 sampled residents (Resident 70) when staff was observed not using a gown while providing high-contact resident care activities to Resident 70. Residents Affected - Few This deficient practice had the potential to result in Resident 70 developing an infection and spread of infection among staff and residents. Findings: A review of Resident 70's admission Records indicated the resident was originally admitted to the facility on [DATE] with diagnoses that included sepsis (a serious condition in which the body responds improperly to an infection) and urinary tract infection (infection of the urinary tract). A review of Resident 70's History and Physical (H&P), dated 2/13/2024, indicated the resident does not have the capacity to understand and make decisions. The H&P also indicated Resident 70 has a Gastrostomy Tube (g-tube, tube inserted through the belly to the stomach used to give medications, nutrition, and the like). A review of Resident 70's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool), dated 2/14/2024, indicated the resident has severe cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. A review of Resident 70's Care Plans for Enhanced Standard Precaution (ESP) [related to] Gastrostomy Tube use indicated a goal to prevent/reduce Multi-Drug Resistant Bacteria (bacteria that is resistant to medications) transmission through the use of gowns and gloves while caring for the resident. The staff interventions included were to apply enhanced standard precautions (ESP, also referred as enhanced barrier precautions) to prevent the spread of infections for specific care activities such as toileting and changing incontinence briefs. During an interview on 5/24/2024 at 7:19 PM with Quality Assurance Nurse (QAN), QAN stated Resident 70 is on ESP. QAN stated staff should wear a gown and gloves when providing care to the resident. During an observation on 5/24/2024 at 7:21 PM with Certified Nursing Assistant 2 (CNA 2), CNA 2 was observed going inside Resident 70's room without wearing a gown. During an interview on 5/24/2024 at 7:27 PM with CNA 2, CNA 2 stated he went inside Resident 70's room to clean Resident 70's soiled diaper. CNA 2 stated he forgot to wear a gown. CNA 2 stated he should have worn a gown because the resident is on ESP. During an interview on 5/25/2024 at 4:58 PM with Infection Preventionist Nurse (IPN), IPN stated residents with g-tubes and wounds are placed on ESP because they are high risk of contracting infections. IPN stated changing diapers or cleaning a resident is a high contact activity that requires staff to wear a gown and gloves while providing care. IPN stated not using the correct personal protective equipment (PPE), such as a gown and gloves, during high contact care puts residents at risk of getting infections. 055162 Page 28 of 31 055162 05/26/2024 Monterey Park Conv Hosp 416 N Garfield Ave Monterey Park, CA 91754

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 5/26/24 at 8:51 PM with the Director of Nursing (DON), the DON stated staff should wear the appropriate PPE during high contact care such as cleaning a resident. The DON stated ESP is used to prevent the spread of infections to the residents of the facility. DON stated not following ESP puts residents at risk for contracting infections. A review of the facility's Policy and Procedure (P&P) titled, Infection Prevention and Control Program, revised 12/19/2022, indicated all staff shall use PPE according to established facility policy governing the use of PPE. A review of the facility's P&P titled, Enhanced Barrier Precautions, copyrighted on 2022, indicated ESP is implemented for the prevention of transmission of multidrug-resistant organism. The P&P indicated ESP refer to the use of gown and gloves during high contact resident care activities. The P&P also indicated high-contact resident care activities include bathing, dressing, providing hygiene, and changing briefs or assisting with toileting. 055162 Page 29 of 31 055162 05/26/2024 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. Based on observation, interview, and record review, the facility failed to ensure one of 29 resident rooms, a multiple resident room (Room E) met the minimum square footage requirement of 80 square feet (sq. ft. unit of measurement) per resident. This deficient practice had the potential to affect the care, comfort, and services to the residents. Findings: A review of the facility's room waiver request, dated 5/24/2024, indicated Room E measured at 223 sq. ft. and that the residents' needs were accommodated and that there were no adverse effects to the health and safety and welfare of the residents occupying these rooms. A review of the facility's Client Accommodations Analysis, dated 5/24/2024, indicated Room E measured at 223 sq. ft and was currently occupied by three residents. During an observation on 5/24/2024 at 1:38 PM, Room E had three beds and three residents (Residents 1, 19, and 40) occupying the beds in the room. All three residents were on the bed and appeared comfortable. Room E had enough space for a bedside table, nightstand, and a wheelchair for each resident. During the survey period from 5/24/2024 to 5/26/2024, 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 E. 055162 Page 30 of 31 055162 05/26/2024 Monterey Park Conv Hosp 416 N Garfield Ave Monterey Park, CA 91754

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure a string was attached to the call light in the bathroom for one of 19 sampled residents (Resident 39). Residents Affected - Few This deficient practice resulted in the call light not being easily accessible to Resident 39 which had the potential to result in a delay in the provision of care and assistance leading to falls, accidents, and injuries. Findings: A review of Resident 39's admission Record indicated she was admitted to the facility on [DATE] with diagnosis including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and elderly residents). A review of the Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 4/8/2024, indicated Resident 39 cognitive skill (mental action or process of acquiring knowledge and understanding for daily decision-making) was moderately impaired. The MDS also indicated Resident 39 required partial/moderate assistance (Helper does less than half the effort) from staff for toilet hygiene and lower body dressing. A review of Resident 39's Care Plan, initiated on 4/3/2024, indicated resident has an Activity of Daily Living (ADL) self-care performance deficit related to Parkinson's disease and restless legs syndrome. Staff interventions included was to encourage the resident to use bell to call for assistance. During an observation in Resident 39's bathroom on 5/24/2024 at 7:27 PM, there was a wall switch which was about three (3) feet (ft. - measurement unit for height) about ground level. The wall switch was observed between the bathroom door and the toilet. During a concurrent interview and observation in Resident 39's bathroom, with the Maintenance Supervisor (MS) on 5/24/2024 at 7:40 PM, the MS stated the switch was about 3ft above the ground level. MS stated the switch was not reachable if the resident was on the floor. MS stated it could possibly delay response time, especially during emergency, by not allowing resident to activate the call light. During an interview on 5/24/2024 at 7:43 PM, Resident 39 stated, I feel safe to have pull string cord light in the bathroom so I can get help when I experience discomfort or fall or during an emergency. During an interview with the Director of Nurses (DON) on 5/25/2024 at 3:46 PM, the DON stated Resident 39's bathroom should have a call light with string that the resident could pull and call staff for assistance. A review of the facility's Policy and Procedure titled, Call Lights: Accessibility and Timely Response, dated 12/19/22, indicated that the call system be accessible to the resident at each toilet and bath or shower facility. The call system should be accessible to a resident lying on the floor. 055162 Page 31 of 31