Health inspection·June 13, 2023

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 1 complained of pain when LVN 1 tried to flush or touch the G-tube. On 5/16/2023 at 2:00 PM, Physician 2 assessed G-tube for milk leaking from the stoma. Physician 2 removed the old percutaneous endoscopic gastrostomy (PEG - a procedure in which a flexible feeding tube is placed through the abdominal wall and into the stomach) and was unable to place a foley catheter (a thin, flexible catheter used specially to drain urine from the bladder) into the stoma. Physician 2 ordered to transfer Resident 1 to the general acute care hospital (GACH) for G-tube placement. A review of the Licensed Nurse Record by LVN 1 dated 5/16/2023, indicated Resident 1 had a G-tube malfunction. The Licensed Nurse Record indicated Physician 2 ordered to transfer to the GACH for further evaluation and G-tube placement due to stoma being closed. A review of the GACH Progress Note by Physician 1 dated 5/17/2023, indicated Resident 1 was found with a leaking G-tube which had been draining into Resident 1's abdomen for a while. The GACH Progress Note indicated there was some inflammation around Resident 1's abdominal area. The GACH Progress Note indicated Resident 1 was treated with antibiotic. A review of the GACH Progress Note by Physician 1 dated 5/19/2023, indicated Resident 1 had an infection of the G-tube site. The GACH Progress Note indicated Resident 1 received IV antibiotics for the infection. [NAME] blood cell (WBC - cells of the immune system that are involved in protecting the body against both infectious disease and foreign invaders) count 21.90 (reference range 4.80 - 10.80 cells per cubic millimeter. A review of the GACH Operative Report by Physician 2 dated 5/24/2023, indicated Resident 1 received an open permanent gastrostomy tube construction. A review of the GACH Microbiology Lab Report dated 6/2/2023 indicated culture wound from the abdomen had Klebsiella pneumoniae (a type of gram-negative bacteria that can cause different types of healthcare-associated infections, including pneumonia [infection in the lungs], bloodstream infections, wound or surgical site infections, and meningitis [an inflammation of the protective membranes covering the brain and spinal cord]) and Escherichia coli (E. coli - bacteria normally live in the intestines of people and animals). A review of the GACH Progress Note by PHY 1 dated 6/7/2023, indicated wound culture showed E. coli and Klebsiella pneumoniae. Plan to continue with IV antibiotic treatment meropenem (used to treat skin and abdominal infections caused by bacteria and meningitis in adults and children three months of age and older) plus vancomycin (used to treat and prevent various bacterial infections). During a telephone interview with family member 1 (FM 1) on 6/13/2023 at 8:28 AM, FM 1 stated a week prior to 5/15/2023, Resident 1 had been complaining of pain where his G-tube was located. FM 1 stated she checked the G-tube and saw milky liquid leaking around the G-tube. FM 1 stated during the week of 5/7/2023 she informed the Treatment Nurse (TX) of the leaking G-tube. FM 1 stated TX checked the GT site, changed the G-tube dressing, and informed FM 1 the G-tube was fine. During an interview with Certified Nursing Assistant (CNA) 1 on 6/13/2023 at 12:36 PM, CNA stated Resident 1 had pulled out his G-tube in the past. CNA 1 stated she had seen Resident 1 fumbling with his G-tube on occasions. CNA 1 stated Resident 1 had a habit of scratching himself around the G-tube and the dressing needed to be replaced. During an interview with TX on 6/13/2023 at 12:58 PM, the TX stated Resident 1 had kept pulling on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055181 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055181 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Gabriel Conv Center 8035 E Hill Drive Rosemead, CA 91770 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few his G-tube. The TX stated Resident 1 had slight granulation around the GT site since he kept pulling his G-tube. TX stated there was a little bit of milk around the G-tube. TX stated she observed the G-tube site with FM 1 and did not see anything abnormal. TX stated Resident 1's G-tube was normal, therefore she did not notify Physician 1. During an interview with Licensed Vocational Nurse (LVN) 1 on 6/13/2023 at 1:32 PM, LVN 1 stated on 5/15/2023 she saw Resident 1's G-tube site leaking milky color a little bit more than usual and contacted Physician 1. During an interview with the Director of Nursing (DON) on 6/13/2023 at 2:17 PM, the DON stated the nurses should contact the physicians if there was anything wrong with a resident's G-tube. During an interview with TX on 6/13/2023 at 3:19 PM, TX stated she noticed granulation around the G-tube site for over a week along with five percent drainage on the dressing prior to Resident 1's transfer to GACH. TX stated she also had to place an abdominal pad over the G-tube site since Resident 1 was holding his G-tube close to his body. TX stated she did not contact Physician 1, since these findings were normal. During an interview with LVN 2 on 6/13/2023 at 3:52 PM, LVN 2 stated on 5/15/2023 the G-tube site was hard and was noted with a little drainage. During a telephone interview with Physician 1 on 6/13/2023 at 3:53 PM, Physician 1 stated upon Resident 1's arrival to the GACH emergency department on 5/16/2023, the surgeon was summoned and confirmed that the G-Tube was dislodged possibly for a few days already. Physician 1 stated the surgeon had to wait while Resident 1's G-tube matures before placing a new G-tube. During an interview with the DON on 6/13/2023 at 4:42 PM, the DON stated there is a concern for infection when drainage/leaking is present. The DON stated it was not known what was going on inside Resident 1's abdomen, even though the abdomen could be clean on the outside. The DON stated leaking could create further complications. The DON stated there was a possibility Resident 1 would get sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death) and peritonitis (a redness and swelling [inflammation] of the lining of the belly or abdomen) when there was a G-tube malfunction. A concurrent review of Resident 1's care plan initiated on 1/23/2023 with the DON, indicated interventions for G-tube are to provide care daily and assess for redness, pain, swelling, increase temperature and discharges and report to the doctor promptly. A review of the facility's policy and procedure titled, Gastrostomy/Jejunostomy Site Care, revised March 2023, indicated assess the stoma site for signs of redness, pain or soreness, swelling, or drainage. Report any of these signs of infection immediately to your supervisor and the resident's physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055181 If continuation sheet Page 3 of 3