Health inspection·June 4, 2021

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 protect a resident's medical information and provide privacy during morning care for two of two sampled residents (Residents 50 and 67) by failing to: a) Provide privacy to Resident 67 during a bed bath and having the privacy curtain open and the resident being cold and exposed to passersby. b) Leave Resident 50's medical record open on the computer screen and unattended for an extended amount of time. These deficient practices resulted in Resident 50's personal information exposed to other staff members and residents and had the potential to violate other resident's right to privacy of medical information. Resident 67 feeling uncomfortable due to body exposure and cold during a bed bath. Findings: a) During a review of Resident 67's admission Record (Face sheet), the Face Sheet indicated Resident 67 was admitted to the facility on [DATE]. Resident 67's diagnosis including history of falling, localized edema (swelling caused by excess fluid trapped in the body's tissues), and constipation (condition in which there is difficulty in emptying the bowels, usually associated with hardened feces). During a review of Resident 67's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 7/29/2020, the MDS indicated Resident 67 had cognitive (ability to make decisions, understand, learn) impairment for daily decision making. The MDS assessment indicated Resident 67 required extensive assistance for activities of daily living ([ADL]) bed mobility, transfer, dressing, eating, toilet, and personal hygiene. During a review of Resident 67's Care Plan titled, Activities of Daily Living, dated 4/12/2021, the care plan indicated Resident 67 require assistance with ADLs due to limitation in mobility, history of falls and weakness. The staffs' intervention indicated Resident 67 would be dressed appropriately, provide good perineal care every shift and when necessary and staff would maintain resident's privacy and respect their rights. During an observation on 6/02/2021 at 9:00 a.m., Certified Nurse Assistance 3 (CNA 3) was observed performing morning care bed bath to Resident 67 with the resident's room door widely open and the privacy curtain partially opened. Resident 67 was hear telling CNA 3 in two separate occasions not Page 1 of 24 055170 055170 06/04/2021 Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few being comfortable with the curtain been open and asked CNA 3 to close the curtain to provide privacy. Resident 67 was observed exposed from the chest and arms and was noted shivering. Resident 67 also, requested to be covered because he was cold, but CNA 3 stated she would be done soon. During a concurrent observation of Resident 67's bed bath and interview on 6/2/2021 at 9:09 a.m., CNA 3 was observed using a wet white towel to clean Resident 67 perineal area front and back, and continued to use the same towel to clean Resident 67's chest. CNA 3 stated she used only one towel to clean the resident because the resident was not soiled. CNA 3 stated she did not cover the resident during the bed bath because the water was hot, and she was going to be done with the bed bath soon. CNA 3 stated the privacy curtain was used to provide privacy to the residents during care, but she forgot to close the curtain when she was providing care for Resident 67. During an interview on 6/4/2021 at 11:15 p.m., the Director of Staff Development (DSD) stated she had done in-service on peri care once for the year of 2021 and always reminds staff to announce what they are doing to the resident, provide privacy, dignity and respect. DSD stated she always reminds staff to expose the area they are cleaning and cover the rest of the body and be responsive towards resident's concern. During an interview on 6/4/2021 at 11:14 a.m., the Director of Nursing ( DON ) stated when staff was providing care to residents and the residents complained of feeling cold, the staff was responsible to stop care, check the water temperature, get a blanket and cover the residents before continuing with the care and ask the residents if they preferred to be covered or to have the water changed. During a review of facility's undated P/P, the P/P indicated residents should be examined and treated in a manner that maintains the privacy of their bodies. A closed door or drawn curtain shields the resident from passersby. The P/P indicated privacy of a Resident's body shall be maintained during toileting, bathing, and other activities of personal hygiene, except when staff assistance is needed for the resident's safety. b) During a review of the admission record (Face Sheet), the face sheet indicated Resident 50 was admitted to the facility on [DATE]. Resident 50's diagnoses included weakness, tremors, and major depressive disorder (mental health disorder with episodes of sadness, tiredness, irritability and sleep disorder). During an observation on 6/3/2021 at 8:50 a.m., a computer in the Activities Office, was observed unattended and with the computer screen displaying Resident 50's electronic medical record. During an interview on 6/3/2021 at 9:01 a.m., the Activities Director (Act. Dir) acknowledged she had left her office with Resident 50's medical record on the computer screen open and was aware it violated Resident 50's right to privacy. During a review of facility policy and procedures (P/P) titled, Resident Rights, revised 4/2018, the P/P indicated the resident had the right to personal privacy and confidentiality of his/her personal and clinical records. 055170 Page 2 of 24 055170 06/04/2021 Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide advance directives to three (3) of three (3) sampled resident (Residents 17, 50, and 59) This deficient practice had the potential to result in unclear guidance to health providers regarding the resident's medical wishes in the event of the resident becoming unresponsive. Findings: a) During a review of Resident 17's admission Record (Face Sheet), the face sheet indicated Resident 17 was re-admitted to the facility on /29/2021. Resident 17's diagnosis included dysphagia (difficulty swallowing). During a review of Resident 17's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 4/3/2021 indicated Resident 17 had cognitive (ability to make decisions of daily living) impairment. The MDS indicated Resident 17 was total dependent of a-staff assist for activities of daily living such as bed mobility, transfer, walk in room, walk in corridor, dressing, toilet use, and personal hygiene. During a review of Resident 17's History and Physical (H/P) dated 6/2/2021, the H/P indicated Resident 17 did not have the capacity to understand and make decisions. b) During a review of Resident 59's face sheet, the face sheet indicated Resident 59 was admitted to the facility on [DATE]. Resident 59's diagnosis included Parkinson's disease (brain disorder that causes shaking, stiffness, and difficulty with walking, balance, and coordination) and difficulty walking. During a review of Resident 59's MDS, dated [DATE] indicated Resident 59 had cognitive impairment. The MDS indicated Resident 59 was total dependent in activities of daily living such as bed mobility, transfer, walk in room, walk in corridor, dressing, toilet use, and personal hygiene. During a review of Resident 59's H/P, dated 1/26/2020, indicated Resident 59 had the capacity to understand and make decisions. c) During a review of Resident 50's face sheet indicated Resident 50 was admitted to the facility on [DATE]. Resident 50's diagnosis included multiple sclerosis (disease of the brain and spinal cord) and generalized weakness. During a review of Resident 50's H/P, dated 3/26/2021, the H/P indicated Resident 50 had the capacity to understand and make decisions. During a concurrent interview and review of Residents 17, 50 and 59's Advance Directives, on 6/2/2021 at 11:57 a.m., the Social Service Director (DSS) stated and confirmed there was no Advance Directives on file for Residents 17, 50 and 59. The SSD stated she did not make an attempt to provide the residents with an Advance Directive or with a conservator for the residents requiring representation. 055170 Page 3 of 24 055170 06/04/2021 Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 6/4/2021 at 11:04 a.m., the Director of Nursing (DON) stated upon admission of the residents, the SSD, Minimum Data Set Director, Activity Coordinator and DON met and discuss care plans, care, immunizations, and advance directives. The [NAME] stated Advance Directives were obtained in case of emergency to direct the staff on the care of the resident. During a review of the facility's undated Policy and Procedure (P/P) titled Advance Directive-Acknowledgement, indicated an advance directive acknowledgement will be provided to residents and/or responsible parties upon admission. They will be informed on the availability of options of medical care providers advance directive regarding the residents' health care decisions. 055170 Page 4 of 24 055170 06/04/2021 Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to accurately check the blood sugar (BS) for one of one sampled resident (Resident 45) and use test strips per manufacturers recommendations. Residents Affected - Some This deficient practice resulted in a staff placing a few test strips in a medication cup (open to air) and taking it from one resident's room to another room and had the potential for inaccurate blood sugar results and monitoring of Resident 45's diabetes (irregular blood sugar levels). Findings: During a review of Resident 45's admission Record (Face Sheet), the face sheet indicated Resident 45 was admitted to the facility on [DATE]. Resident 45's diagnoses included diabetes mellitus, hypertension (high blood pressure) and anemia (low blood count). During a review of Resident 45's Minimum Data Set (MDS- a standardized assessment and care planning tool), dated 4/21/2021, the MDS indicated Resident 45 was cognitively (ability to make decisions of daily living) intact, and required physical assistance for activities of daily living such as getting dressed, toileting, eating and personal hygiene. During an observation on 6/2/2021 at 11:32 a.m., licensed vocational nurse (LVN) 1 was observed cleaning Resident 45's finger with an alcohol swab, and immediately pricked the finger and checked the blood sugar. During an interview on 6/3/2021 at 2:38 p.m. LVN 1 acknowledged it was important to wait for the alcohol to dry on Resident 45's finger before pricking it. LVN 1 stated the alcohol could affect the outcome of the blood sugar check with the blood sugar resulting higher than it is. During a review of the National Health Institute (NIH: a governmental agency responsible for biomedical and public health research.), the steps for measuring blood glucose (blood sugar): wash hands and put on gloves, choose the site for the blood sample, use an alcohol swab to clean the site and let the alcohol dry, use the lancet to draw blood. How to measure blood glucose (nih.gov) During an observation on 6/2/2021 at 11:32 a.m., LVN 1 took several blood sugar test strips from an airtight container and placed them in a medicine cup. LVN 1 used a strip (from the medicine cup) for Resident 43 and continued to the next resident's room with the same open container of test strips. During an interview on 6/3/21 at 2:38 p.m. LVN 1 acknowledged the test trips should be kept in an airtight container until they are ready for use. Transporting them in an open container from room to room is a potential risk for moisture damage or infectious agents. According to The Federal Food and Drug Administration (a governmental agency responsible for protecting and promoting health through supervision of items such as food, tobacco, and prescription medications), Blood sugar testing strips should be kept in a closed container to give accurate results. How to Safely Use Glucose Meters and Test Strips for Diabetes. During an interview on 6/3/21 at 9:02 a.m., Infection Preventionist Nurse (IP) acknowledged that blood sugar test strips should not be taken from resident's room to resident's room in an open 055170 Page 5 of 24 055170 06/04/2021 Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660

F 0684 container due to risk of infection, and contamination. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's undated policy titled, Infection Control, indicated the facility had established and would maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infections. Residents Affected - Some 055170 Page 6 of 24 055170 06/04/2021 Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660

F 0692 Provide enough food/fluids to maintain a resident's health. 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 Registered Dietitian ([RD] health professional with special training in the use of diet and nutrition to keep the body healthy) recommendation were carried, re-evaluate nutrition interventions and implement weekly weight monitoring for one of seven sampled residents (Resident 29). Residents Affected - Few These failures had the potential to negatively impact Resident 29 nutrition status and result in unplanned weight loss. Findings: During a review of Resident 29's admission record (Face sheet), the Face Sheet indicated Resident 29 was admitted to the facility on [DATE]. Resident 29's diagnosis included dysphagia (difficulty or discomfort in swallowing), anemia (condition marked by a deficiency of red blood cells or of hemoglobin in the blood, resulting in pallor and weariness) and hypertension (high blood pressure). During a review of Resident 29's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 4/2/2021, the MDS indicated Resident 29 was severely impaired of cognition (taught process). The MDS indicated Resident 29 required extensive assist of one-person physical assist to eat. The MDS indicated Resident 29 had a swallowing disorder, cough or choking during meals or when swallowing medications. During a review of Resident 29's physician orders, dated 2/10/2021, the orders indicated for Resident 29 to have a no added salt puree texture diet, large portion and thick liquids. During a review of Resident 29's electronic weight log, in the presence of the RD, on 6/3/2021 at 8:25 a.m., Resident 29's had a 3.5 percent (%) weight loss of 6 pounds ([lbs.] units of measurement) in one month from 4/2021 thru 5/2021, a 6.8 % weight loss of 12 lbs. in 3 months from 2/2021 thru 5/2021 and a 21% severe weight loss of 44 lbs. in 6 months from 11/2020 to 5/2021. The RD stated she made recommendations for appetite stimulants on 5/13/2021 if medical doctor (MD) agreed with it, but she was unable to find an order for the appetite stimulant in the physician's order. During an interview on 6/3/21 at 8:27 a.m., the RD stated Resident 29 was on a high protein nourishment ([HPN] diet in which 20% or more of the total daily calories comes from protein) diet for two months but RD did not resume the diet on 4/2021 because Resident 29 appetite was poor. RD also stated Resident 29's poor intake was due to dislike of puree food texture. During a concurrent review of Resident 29's RD recommendations and interview on 6/3/2021 at 8:30 a.m., the Director of Nursing (DON) stated she was not able to find an order for Resident 29's appetite stimulant recommended by the RD. the DON stated there was no nursing notes documentation on whether the recommendation was relayed to Resident 29's primary physician. During an interview on 6/3/21 at 8:45 a.m., the DON stated the Interdisciplinary Team ([IDT] members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) weight variance meeting was conducted on 5/8/2021 regarding Resident 29's nutrition. The DON stated no weekly weights were recommended for monitoring because the concern was Resident 29's dislike of puree foods. 055170 Page 7 of 24 055170 06/04/2021 Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 6/3/2021 at 10:32 a.m., the RD stated the policy for weekly weights and monitoring was for nursing. The RD stated she usually did not make weekly weight recommendations because she thought weekly weights would be automatically initiated for residents with significant weight loss by the nursing staff. During an interview with the DON on 6/3/2021 at 10:35 a.m., DON stated she agreed Resident 29 could have benefit from weekly weight for closer monitoring of the weight change. During an interview on 6/3/21 at 1:25 p.m., Registered Nurse 1 (RN 1) stated when she talked to Resident 29's primary physician about the RD's recommendations, she should had written a note under the nursing progress notes indicating the recommendations had be relayed to the primary physician within 3 days regardless if the primary physician agreed or disagreed with the recommendations. RN 1 stated she received and carried out the RD's recommendations on 5/13/2021, but she did not call Resident 29's primary physician for the appetite stimulant on 5/13/21 because she forgot. During a review of facility's policy and procedure (P/P), titled Consultant Dietitian Recommendation Completion, dated 2019, the P/P indicated it was the policy of the facility to complete Consultant Registered Dietitian Recommendations within 72 hours. The P/P indicated the staff would notify the physician of any recommendations within 72 hours and nurses would document in the progress notes of the recommendations relayed to the physician. During a review of the facility's undated policy and procedure (P/P), titled Weight Change, the P/P indicated to implement weekly weight for residents with significant weight changes and the method to review include .2. Weekly weights. 3. Dietary supplements . 055170 Page 8 of 24 055170 06/04/2021 Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a 35 degree safe gastrostomy tube ([g-tube] creation of an artificial external opening into the stomach for nutritional support) feeding position for one (1) of one (1) sampled residents (Resident 54). This deficient practice had the potential to cause aspiration (when food, liquid, or any other material enters the airway or lungs by accident) pneumonia (infection that inflames the air sacs in one or both lungs with fluid or pus [purulent material], causing cough with phlegm or pus, fever, chills, and difficulty breathing), and impede progress to wellness. Findings: During a concurrent observation and interview, on 6/3/2021 at 3:00 p.m. in the presence of Licensed Vocational Nurse 4 (LVN 4), Resident 54 was observed lying in bed with the head of the bed at a 20 degree angle receiving a gastrostomy tube feeding of Jevity (fiber-fortified tube-feeding formula; for supplemental or sole-source nutrition) infusing at 60 milliliters ([cc] units of measurement) per hour. LVN 4 was observed raising Resident 54's head of the bed to a 30-degree angle and stated the feeding could go into Resident 54's lungs. During a review of Resident 54 admission record (Face Sheet), the Face Sheet indicated Resident 54 was admitted on [DATE] with diagnosis of gastrostomy, hypertension (high blood pressure), and seizures (burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements). During a review of Resident 54's Minimum Data Set (MDS- an assessment and care planning tool,) dated 3/19/2021, the MDS indicated Resident 54 had no speech, rarely/never understood ideas, wants, and rarely/never comprehended others. The MDS further assessed Resident 54 as total dependence on full staff for dressing, eating, and personal hygiene. During a review of Resident 54's physician orders, dated 12/22/2020, the orders indicated enteral (nutrition taken through the mouth or through a tube that goes directly to the stomach or small intestine) aspiration precaution: elevate head of bed at 30-45 degrees at all times during gastrostomy feeding. During a review of Resident 54's care plan titled, G-Tube Feeding, dated 12/4/2020, the care plan indicated Resident 54 was on specify feeding, and was at risk for aspiration, dehydration, and weight loss. The staffs' interventions included to keep the head of bed elevated, assess tolerance to feeding, and check and maintain placement and patency of g-tube. During a review of the facility's undated policy and procedure (P/P) titled, HOB (head of bed) Positioning During Enteral Feeding, the P/P indicated the facility would maintain the HOB elevated at least 35 degrees during enteral feeding administration. 055170 Page 9 of 24 055170 06/04/2021 Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the attending physician responded to a recommendation made by the consultant pharmacist (CP) on 2/2021 for one of one sampled resident (Resident 44). This deficient practice had the potential to increase the risk of Resident 44's medication therapy not being at an optimal and therapeutic level. Findings: During a review of Resident 44's medical record (Face Sheet(, the Face Sheet indicated Resident 44 was admitted to the facility on [DATE] with diagnoses that included dementia (a brain disease with a group of symptoms that affect memory, thinking and interfere with daily life without behavioral disturbance, hypertension (high blood pressure) and schizophrenia (a long-term mental disorder involving a breakdown in the connection between thought, emotion, and behavior). During a review of Resident 44's Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 1/21/2021, the MDS indicated Resident 44 was cognitively (ability to make decisions of daily living) intact, and required minimal assistance with activities of daily living such as getting dressed, eating, toileting and personal hygiene. Further review of the MDS indicated Resident 44 had not presented any behavioral symptoms such as hallucinations (seeing, hearing, or feeling something that does not exist outside of one's min.) or delusions (a strong belief or judgment that is not grounded in reality). During a review of Resident 44's physician orders indicated an order on 1/14/2021 for Olanzapine Tablet (a medication used to treat hallucinations and delusions) 2.5 milligrams ([mg] units of measurement) by mouth at bedtime for schizophrenia manifested by inability to process internal stimuli causing anger or stress. During a review of Resident 44's physician orders dat3ed 1/21/2021, the orders indicated to monitor Resident 44's episodes of behaviors of inability to process internal stimuli causing anger or stress by hashmarks every shift for the use of olanzapine. During a review of Resident 44's medication administration record (MAR), dated 1/21/2021, the MAR indicated Resident 44 had taken this medication daily since admission, on 1/21/21 until present. During a review of Resident 44's Psychotropic Summary Tally Sheet, the tally sheet indicated Resident 44 had no behaviors starting 1/14/2021 through 5/31/2021. During a review of a pharmacist's monthly medication regimen review (MRR) for Resident 44 for the month of 2/2021 indicated a recommendation, your patient has a dementia disorder and takes olanzapine. The FDA (federal food and drug administration; a governmental agency responsible for protecting and promoting health through supervision of items such as food, tobacco, and prescription medications), warns that antipsychotics (olanzapine) are associated with an increased risk of mortality in elderly individuals with dementia disorders. During a concurrent interview and record review, on 6/4/21 at 1:44 p.m. Registered Nurse 2 (RN 2) 055170 Page 10 of 24 055170 06/04/2021 Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660

F 0756 Level of Harm - Minimal harm or potential for actual harm stated the physician was responsible for reviewing Resident 44's medications and determining if Olanzapine for Resident 44 should be continued or discontinued. RN 2 acknowledged the pharmacists' recommendations had not been addressed, and the olanzapine was not discontinued, or the dosage adjusted. RN 2 stated there should be documentation Resident 44's physician agreed or disagreed with the pharmacist's recommendation and if medications should be continued, adjusted, or discontinued. Residents Affected - Few During a review of the facility policy and procedures (P/P) titled, Consultant Pharmacist Reports, dated 3/2020, the P/P indicated the consultant pharmacist performed a comprehensive MRR at least once a month, evaluating the resident's response to medication therapy to determine if the resident maintained the highest level of functioning and prevent or minimized adverse consequences related to medication therapy. Recommendations were acted upon and documented by the facility staff and or the prescriber. The P/P indicated the Physician accepted and acted upon suggestion or rejection and provided an explanation for disagreement. 055170 Page 11 of 24 055170 06/04/2021 Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660

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 ensure three of three multi-dose insulin (a hormone substitute used to treat irregular blood sugar levels) vials were labeled and properly disposed for three of three sampled residents (Residents 14, 21, and 45). This deficient practice had the potential for Residents 14, 21 and 45 to not received their therapeutic insulin dose and for their health to decline due to receiving expired insulin. Findings: During a review of Resident 14's admission Record (Face Sheet), the Face Sheet indicated Resident 14 was readmitted to the facility on [DATE]. Resident 14's diagnoses included Type 2 Diabetes Mellitus (DM II: irregular blood sugar [BS]levels). During a review of Resident 14's physician orders dated [DATE], the orders indicated and order for Insulin Regular inject subcutaneously (injected into tissue directly under the skin) before meals and at bedtime for diabetes mellitus, per sliding scale: If BS is 60-150 = 0 units If BS is 151-200 = 0 units If BS is 201-250 = 3 units If BS is 251-300 = 4 Units If BS is 301-350 = 6 units If BS is 351-400 = 9 units If 401and higher = 12 units During a review of Resident 21's Face Sheet, the Face Sheet indicated Resident 21 was readmitted to the facility on [DATE]. Resident 21's diagnoses included DM II. During a review of Resident 21's physician's order dated [DATE], the orders indicated to administer Insulin Regular inject before meals and at bedtime for diabetes mellitus, per sliding scale: If BS is 60-150 = 0 units If BS is 151-200 = 0 units If BS is 201-250 = 3 units If BS is 251-300 = 4 Units 055170 Page 12 of 24 055170 06/04/2021 Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660

F 0761 If BS is 301-350 = 6 units Level of Harm - Minimal harm or potential for actual harm If BS is 351-400 = 9 units If 401and higher = 12 units Residents Affected - Some During a review of Resident 45's Face Sheet, the Face Sheet indicated Resident 45 was admitted to the facility on [DATE] with diagnoses that included DM II. During a review of Resident 45's physicians order dated [DATE], the orders indicated to administer Insulin Regular inject before meals and at bedtime for diabetes mellitus, per sliding scale: If BS is 60-150 = 0 units If BS is 151-200 = 0 units If BS is 201-250 = 3 units If BS is 251-300 = 4 Units If BS is 301-350 = 6 units If BS is 351-400 = 9 units If 401and higher = 12 units During an observation of a medication cart for rooms 10-19 and interview on [DATE] at 2:45 p.m., Licensed Vocational Nurse 1 (LVN 1) acknowledged a vial of Humulin (a type of insulin) for Resident 14 was dated opened on [DATE] and should have been discarded after 28 days. A vial of Humulin for Resident 21 was dated opened on [DATE] and should have been discarded after 28 days, and a vial of Humulin for Resident 45 was dated [DATE] and should have been discarded after 28 days. LVN 1 stated administering the medication after the expiration date had the potential to be ineffective in treating a high blood sugar levels for all three residents which could lead to severe complications. During a review of the facility policy and Procedures (P/P) titled, Guide for Special Handling of Medications, revised 1/2013, the P/P indicated Insulin products storage requirements indicated to store the opened vials at room temperature or in the refrigerator and to discard 28 days after opening or removing from refrigeration. 055170 Page 13 of 24 055170 06/04/2021 Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660

F 0802 Level of Harm - Minimal harm or potential for actual harm Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills as followed: Residents Affected - Some 1. Diet Aide 1 (DA 1) did not know how to utilize the sanitizing test strip instruction and no documented in-service of DA 1 trained on the new test strip instruction after it was changed. 2. [NAME] 1 prepared liquified puree foods (adding more liquids to pureed food to a drinkable consistency) in bulk and did not follow diet manual instruction to ensure adequate portion in each liquified puree diets was served to the residents. 3. DA 2 stored personal food in the walk-in refrigerator and did not know the facility policy regarding personal belonging. These failures had the potential to result in ineffective sanitizer concentration testing, inadequate nutrition and aspiration (occurs when food, saliva, liquids, or vomit is breathed into the lungs or airways leading to the lungs, instead of being swallowed into the esophagus and stomach) for residents requiring liquified pureed diets, and potential cross contamination of foods in the walk-in refrigerator. Findings: a) During an observation on 6/2/2021 at 8:47 a.m., DA 1 demonstrated how to check quaternary ammonium (QUAT - a type of sanitizing solution) sanitizer concentration inside the red bucket. DA 1 dipped the test strip in the bucket for about 10 seconds and the concentration registered on the strip showed 100 parts per million ([ppm] unit of chemical concentration measurement). DA 1 stated it should be between 200-400 ppm. During an observation on 6/2/2021 at 8:49 a.m., dietary service supervisor (DSS) refilled the QUAT sanitizer directly from the chemical pump and re-tested the concentration with the test strip, the strip still showed 100 ppm. DSS read the sanitizer test strip bottle and stated test strip should be inside the sanitizer for 90 seconds before reading. DSS stated their test strip instruction was 10 seconds in the past, but the newer strip required 90 seconds testing time and she had forgotten about the new information. During an interview on 6/2/2021 at 2:20 p.m., the RD stated she did a verbal in-service regarding the new sanitizer test strip and posted a written instruction on the wall. The RD stated DA 1 was likely not present during the verbal in-service. The RD stated no formal written in-service with all kitchen staff was conducted to assess their understanding and knowledge. b) During an observation on 6/2/2021 at 11:47 a.m., [NAME] 1 was observed making liquefied pureed turkey using two 4-ounce (oz - unit of measurement) scoops of pureed turkey and added four 4-oz scoops of broth into a blender, blended and served the liquefied puree turkey using the same 4 oz scoop. [NAME] 1 also, made liquefied pureed vegetables by using two 3-oz scoop, then added broth into a blender to blend the pureed food and served 3-oz scoop portion out the liquefied pureed vegetable utilizing the same scoop. 055170 Page 14 of 24 055170 06/04/2021 Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 6/2/2021 at 2:28 p.m., the RD stated she had not conducted an in-service regarding liquefied pureed diet preparation. The RD stated when the liquefied puree was prepared in bulks, the pureed was thin down with broth and then use the same serving scoop. The RD stated the actual food portion served would be less than the regular pureed food. During a review of facility's diet manual on Liquefied Puree Diet, dated 2020, the manual indicated the regular servings for a pureed diet were to be served and then thinned to a drinkable consistency using appropriate fluids to ensure proper nutrition. c) During an observation on 6/2/2021 at 12:03p.m., DA 2 was observed entering the kitchen and placing a plastic bag inside the walk-in refrigerator. During an interview on 6/2/2021 at 12:04 p.m., the DA 2 stated the plastic bag was contained her personal food. The DA 2 stated she usually kept her food in the walk-in refrigerator since she had not been aware personal food should not be placed with the food in the walk-in refrigerator. During an interview on 6/2/2021 at 12:07p.m., the RD stated the staff should not be storing their personal food in the facility's walk-in refrigerator. During a review of facility's untitled policy related personal belongings, dated 2019, indicated employee's personal belongings (i.e. clothing, food, cellphone, etc.) should be stored in a separate area away from food or items used in food service. 055170 Page 15 of 24 055170 06/04/2021 Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide food preferences for one of six sampled residents (Resident 44). This deficient practice had the potential to result in decreased meal satisfaction and decreased overall caloric intake. Findings: During a review of Resident 44's admission Record (Face Sheet), the face sheet indicated Resident 44 was admitted to the facility on [DATE]. Resident 44's diagnosis included difficulty walking, hypertension (high blood pressure), and depression (constant feeling of sadness and loss of interest, which stops you doing your normal activities). During a review of Resident 44's Minimum Data Set (MDS), a resident assessment and care screening planning tool, dated 1/212021, the MDS indicated Resident 44 was intact of cognitive skill and was able to understand and understood others. The MDS indicated Resident 44 required supervision and set up for eating only. During a concurrent observation and interview on 6/2/21 at 1:00 p.m., Resident 44 stated hey had asked multiple times no to have fried eggs and peas on his tray. Resident 44's lunch tray was observed with peas and with a diet card indicating Resident 44 was not to have peas. Resident 44 stated he had spoken to management in several occasions regarding his food preferences, but no changes had been made. During an interview on 6/3/21 at 9:00 a.m., Dietary Services Supervisor (DSS) stated not having receive a preference diet notice from Resident 44. DSS stated residents fill out a Diet Order Form regarding their food preferences and place it on a card box. During an interview on 6/2/21 at 9:10 a.m., Licensed Vocational Nurse 1 (LVN 1) stated when a resident had a food preference, the nurse either calls the kitchen to let them know or a Diet Order Form is completed. During a record review of the resident's chart, the RD Nutritional Assessment Screening dated 1/18/2021 indicated Resident 44's dislikes were pork, liver, beets, and peas. During a review of the undated facility's policy and procedure (P/P) titled, Diet Orders, revised in 2019, the P/P indicated, the resident's name, diet order, food likes and dislikes, and allergies were noted on the resident's Profile Card and tray card for staff reference. 055170 Page 16 of 24 055170 06/04/2021 Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review, the facility fail to follow the recommended dietary order for Carbohydrate diets ([CCHO] diet with controlled amount of carbohydrates to help prevent the blood sugar from escalating) plain ice cream and substituting it with sherbet (frozen dessert made from sugar-sweetened water with flavoring) for nine (9) of 41 residents (Resident 39, 276, 279, 527, 277, 45, 526, 2 and 16). This deficient practice had the potential for Residents 39, 276, 279, 527, 277, 45, 526, 2 and 16 to not received their therapeutic carbohydrate intake and to increase their blood sugar levels. Findings: During an observation of meal tray distribution, on 6/2/2021 at 12:30 p.m., 9 out of 41 CCHO food trays were observed with sherbet instead of the recommended plain ice cream. a) During a review of Resident 39's admission Record (Face Sheet), the Face Sheet indicated Resident 39 was admitted to the facility on [DATE]. Resident 39's diagnosis included diabetes (disease in which the organ does not produce insulin or not enough insulin to break down sugars in the body). During a review of Resident 39's Minimum Data Set (MDS), a resident assessment and care screening planning tool, dated 4/16/2021, the MDS indicated Resident 39 was moderately impaired of cognition (thought process). b) During a record review of Resident 276's Face Sheet indicated Resident 276 was admitted on [DATE]. Resident 276's diagnoses include metabolic encephalopathy, (a neurological disorder that decreases brain function caused by diseases that impact the metabolism) and diabetes. c) During a record review of Resident 279's Face Sheet indicated Resident 279 was admitted on [DATE]. Resident 279's diagnosis included diabetes. During a record review of Resident 279's MDS, dated [DATE], the MDS indicated Resident 279 was able to understand and understood others. d) During a review of Resident 527's Face Sheet, the face sheet indicated Resident 527 was admitted on [DATE] with a diagnosis of diabetes. During a record review of Resident 527's MDS, dated [DATE], the MDS indicated Resident 527's was able to understand and understood others. e) During a review of Resident 277's Face Sheet, the Face Sheet indicated Resident 277 was admitted to the facility on [DATE]. Resident 277's diagnoses include diabetes. f) During a review of Resident 45's the Face Sheet indicated Resident 45 was admitted to the facility on [DATE]. Resident 45's diagnoses included diabetes. During a review of Resident 45's MDS, dated [DATE], the MDS indicated Resident 45 was able to make himself understood and understood others. 055170 Page 17 of 24 055170 06/04/2021 Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660

F 0808 Level of Harm - Minimal harm or potential for actual harm During an interview on 6/3/2021 at 4:22 p.m., Resident 45 stated he was concern regarding his blood sugars because he was diabetic. g) During a review of Resident 526's Face Sheet, the face sheet indicated Resident 526 was admitted to the facility on [DATE]. Resident 526 diagnoses included diabetes. Residents Affected - Some During an interview on 6/3/2021 at 4:30 p.m., Resident 526 stated the problem with getting something too sweet was he had diabetes. h) During a review of Resident 2's Face Sheet, the Face Sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses include diabetes. i) During a review of Resident 16's Face Sheet, the Face Sheet indicated Resident 16 was admitted to the facility on [DATE]. Resident 16's diagnosis included diabetes, dementia (a decline in mental function and cognition), and aphasia (an inability to speak or express oneself). During an interview on 6/2/2021 at 12:40 p.m., the Dietary Services Supervisor (DSS) stated the CCHO diets for all nine residents should not have sherbet and instead served plain ice cream based on the resident's diet orders. During a review of facility's document tiled, Controlled Carbohydrate Diet (CCHO), dated 2020, the document indicated a controlled carbohydrate diet was a meal plan without specific calorie levels for diabetic residents, but instead of counting calories, the carbohydrates were evenly systematically and consistently distributed through three meals and snacks in an effort to maintain a stable blood sugar level throughout the day. During a review of the facility's Spring Cycle Menus dated 6/2/2021, the menu indicated for the CCHO diet Plain Ice Cream be provided and did not indicate to substitute with sherbet. 055170 Page 18 of 24 055170 06/04/2021 Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660

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 ensure safe and sanitary food storage and hand hygiene practice in the kitchen when: Residents Affected - Many 1. Ice machine ice deflector (inner plastic cover in the ice storage bin) and internal compartment were dirty. 2. Not all foods were dated when received and opened, and not all foods were labeled to indicate content. 3. Resident food trays were not air dried completely before stacking. 4. Visible dust build up on the vent above the steam table and the dishwashing area. 5. Egg salad made on 6/2/2021 in the walk-in refrigerator was not monitored for safe cool down process (hot food cooled down within a certain time frame to prevent harmful bacterial growth). 6. Two diet aides (DA 1 and DA 2) did not follow hand washing procedure to prevent recontamination (become dirty again) when washing hands. 7. Lack of temperature monitoring for resident's food refrigerators in both nursing stations (East and [NAME] station) to ensure refrigerators were functioning and maintaining within temperature of 41-degree Fahrenheit (unit of measurement) or below. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 77 out of 82 medically compromised residents who received food and ice from the kitchen, and those who store and consume personal foods from the nursing station food refrigerator. Findings: 1) During an observation on 6/2/2021 at 8:17 a.m., in presence of the Dietary Service Supervisor (DSS), rusty brown color residues were observed and removed on the ice deflector in the lower ice machine bin. The DSS stated and agreed the ice deflector was dirty, and stated it was the responsibility of the maintenance department for cleaning the lower bin and upper internal compartment of the ice machine monthly. During a review of the ice machine cleaning log posted by the ice machine, the log indicated last cleaning of the ice machine by the maintenance department was conducted on 3/2021. During an interview on 6/2/2021 at 9:14 a.m., the Maintenance Supervisor (MS) stated he cleaned the ice machine internal compartments and ice bin every month. The MS stated he last cleaned the ice machine on 5/2021, but he forgot to sign off on the cleaning log for the months of 4/2021 and 5/2021. During a concurrent observation and interview on 6/2/2021 at 9:15 a.m., the MS stated he could see the brown color residues being wiped off from the ice deflector when it was wiped down with a white paper towel. 055170 Page 19 of 24 055170 06/04/2021 Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a concurrent observation and interviews on 6/2/2021 at 9:18 a.m., in the presence of the DSS, the MS was observed removing the cover from the upper compartment of the ice machine and stated the inside of the water curtain (inner plastic cover of the upper compartment) had brown and greyish color residues build up. The MS stated there were brown and pink colored residues on the plastic section of the water distribution tube (area that runs water to form ice). Both the MS and DSS stated they were aware the ice machine was dirty and not safe to use until it was thoroughly cleaned and sanitized. During a review of facility's policy and procedure (P/P) titled Ice machine cleaning, dated 2019, the P/P indicated the ice machine (bin) would be cleaned and sanitized once a month and Maintenance staff would clean and sanitize the motor (evaporator) every 3 to 6 months, depending on manufacture's recommendation. The P/P indicated the assigned staff in cleaning the ice machine would record date of cleaning. 2) During a concurrent observation and interview on 6/2/2021 at 8:21 a.m., the DSS stated there were two-gallon vanilla ice cream in the freezer without a received date. The DSS stated the staff should have dated the ice cream when received and dated again when it was opened. During an observation of the walk-in refrigerator on 6/2/2021 at 8:28 a.m., there was one container labeled as thickener, but it did not have a date on the container. During an observation on 6/2/2021 at 8:35 a.m., there was one undated bulk container labeled as dry pancake mix. During a concurrent observation and interview on 6/2/21 at 8:44 a.m., the DSS stated there was one bowl with unknown content inside the walk-in refrigerator dated 6/2/21. The DSS stated the staff should have labeled the container indicating the food inside the container. During a review of facility's P/P titled, Refrigerator and Freezer Storage, dated 2019, the P/P indicated all items should be properly covered, dated, and labeled. The P/P indicated food items should have delivery date- upon receipt, open date - opened containers. 3) During an observation in the kitchen on 6/2/2021 at 8:24 a.m., a stack of resident's food trays stored under the food preparation counter were observed with water droplets in between each tray. During an interview on 6/2/2021 in the presence of the DSS, the dishwasher (DW 1) stated trays should be air dried after washing. During a review of facility's P/P titled Dishwashing Procedures-Dish machine, dated 2019, indicated dishes and utensils would be air dried before storage. 4) During a concurrent observation and interview on 6/2/21 at 8:37a.m., the DSS stated there was visible black dust build up on the vent above the steam table and build up on the ceiling by the vent. The DSS stated she saw the dust and agreed it was dirty and it should be cleaned again. During a concurrent observation and interview on 6/2/21 at 9:01 a. m., the DSS stated there was visible black dust build up on the vent above the dishwasher. During a review of facility's P/P titled Cleaning Schedule, dated 2019, indicated the dietary staff 055170 Page 20 of 24 055170 06/04/2021 Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many would maintain a clean and sanitary kitchen through compliance with a written cleaning schedule. The P/P indicated all areas and equipment in the kitchen would be cleaned and sanitized on a daily or weekly basis. 5) During a concurrent observation and interview on 6/2/2021 at 8:45 a.m., the DSS observed one container labeled as egg salad dated 6/2/2021 in the walk-in refrigerator. The DSS stated the cool down log was not available because it was not monitored on the cool down log this morning. The DSS stated it should have been monitored for safe cooling procedure. During a review of facility's P/P titled, Safe Cooling Method, dated 2019, indicated all cooked food not prepared for immediate use will be cooled properly to keep bacteria from developing. The P/P indicated a cooling log would be maintained to ensure standards were met. 6) During a concurrent observation an interview on 6/2/2021 at 9:10 a.m., the DA 1 was observed washing her hands and turned off the faucet with washed hands and not with a paper towel. The DA 1 stated the correct hand washing procedure was to use a paper towel to turn off the faucet, but she forgot when she was washing her hands to use one. During an observation on 6/2/2021 at 12:01 p.m., DA 2 was observed washing her hands and turned off the faucet with washed hands and not with a paper towel. During an interview on 6/2/2021 at 12:05 p.m. the DA 2 stated she should have used paper towel to turn off the faucet and not with washed hands. During a review of facility's P/P titled Hand Washing, dated 2019, indicated to protect clean hands by turning faucets off with paper towels. 7) During a concurrent observation of the East station medication room (Residents refrigerator) and interview on 6/2/2021 at 10:10 a.m., Licensed Vocational Nurse 1 (LVN 1) stated there was no thermometer inside to ensure proper temperatures. LVN 1 stated she could not find a thermometer inside and she did not check or record temperature today. LVN 1 stated it was night shift nurse's responsibility to check temperatures. During an interview on 6/2/2021 at 10:14 a.m., LVN 1 stated and confirmed there was no log and stated they only had one temperature log which was for medication refrigerator and not for the food refrigerator. During a concurrent observation of [NAME] Station Medication room and interview on 6/2/2021 at 10:19 a.m., LVN 2 stated there was a thermometer in the food refrigerator but LVN 2 also confirmed and stated the only temperature log they had was for the medication refrigerator. LVN 2 stated she checked food refrigerator temperature this morning, but she did not write it down because they did not have a log. During an interview on 6/2/2021 at 10:24 a.m., the Infection Preventionist (IP) nurse stated they should have a monitoring system for food refrigerator temperatures to ensure food safety and infection control. During a review of facility's undated P/P titled Refrigerator Use, the P/P indicated refrigerator temperatures must be kept at 41 degrees Fahrenheit or less and a thermometer would be kept inside the 055170 Page 21 of 24 055170 06/04/2021 Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660

F 0812 refrigerator to monitor temperatures. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 055170 Page 22 of 24 055170 06/04/2021 Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660

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 follow appropriate infection control procedures as follow: Residents Affected - Some 1. Certified Nurse Assistant 5 (CNA 5) provide hand hygiene to one of one sampled resident (Resident 41) before serving lunch meal tray. 2. Ensure CNA 4 placed a contaminated tissue box that fell on the floor back to Resident's 29 side table that has Resident 29's food tray. These deficient practices had the potential for cross contamination (unintentional transfer of bacteria/germs or other contaminants from one surface to another) and spread of infection. Findings: a) During an observation, on 6/2/2021 at 12:22 p.m., Resident 41 was observed using her hands to turn the wheelchair wheels and CNA 5 was observed giving a lunch tray to Resident 41 and failed to offer or provide hand hygiene before Resident 41 started eating her lunch using a fork and her right hand fingers to eat. During a review of Resident 41's admission Record (Face Sheet), the Face Sheet indicated Resident 41 was admitted to the facility on [DATE]. Resident 41's diagnosis included difficulty walking, type 2 diabetes mellitus (impairment in the way the body regulates and uses sugar [glucose] as a fuel) with diabetic nephropathy (nerve damage caused by long-term high blood sugar levels), and muscle weakness. During a review of Resident 41's Minimum Data Set (MDS- an assessment and care planning tool), dated 5/11/2021, the MDS indicated Resident 41 had clear speech, and was able to understand and understood others. The MDS indicated Resident 41 required extensive assistance of one-person assist and was dependent of a wheelchair for mobility. During an interview on 6/2/2021 at 3:15 p.m., CNA 5 stated being aware she fail to provide handwashing to Resident 41 prior to providing her with the food tray and was aware it could lead to an increase risk for infection. During a review of the facility's undated policy and procedure (P/P), titled Hand Washing, indicated hand washing must be performed before and after eating. The policy indicated hand hygiene continued to be the primary means of preventing transmission of infection. b) During an observation in Resident 29's room on 6/02/2021 at 1:27 p.m., a tissue box fell from Resident 29's side table and CNA 4 was observed picking up the tissue box and placing it back on Resident 29's side table next to the food tray. During an interview with CNA 4 on 6/02/2021 at 2:28 p.m., CNA 4 stated she picked up the tissue box after it fell on the floor and placed it back on Resident 29's side table. CNA 4 stated she should have not placed the contaminated tissue box back on resident's table because it could be a source of 055170 Page 23 of 24 055170 06/04/2021 Pico Rivera Healthcare Center 9140 Verner Street Pico Rivera, CA 90660

F 0880 infection for the resident. Level of Harm - Minimal harm or potential for actual harm During an interview with Infection Preventionist (IP) on 6/04/2021 at 9:17 a.m., IP Nurse stated CNA 4 should have thrown the tissue box if it fell on the floor and replaced it with a new tissue box. IP nurse stated the floor was dirty and the resident may get infection or transfer the dirt from the dirty tissue box to resident's table and to the resident. Residents Affected - Some During a review of the facility's undated P/P titled, Infection Control, indicated the facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. 055170 Page 24 of 24