Health inspection·April 7, 2023

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 4/4/23 at 1015 hours, an observation and concurrent interview was conducted with Resident 27. Two lozenges were observed in a silver blister pack (a form of tamper-evident packaging where an individual pushes individually sealed tablets through the foil to take the medication). Resident 27 stated she had been taking the lozenges because of dry mouth. Resident 27 stated the nurses were aware she had these lozenges at bedside. Residents Affected - Few Medical record review for Resident 27 was initiated on 4/4/23. Resident 27 was readmitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 27 was cognitively intact and had no upper extremity impairment. Review of Resident 27's Order Summary Report failed to show a physician's order to administer the ACT dry mouth lozenge and for self-administration of medications. Review of Resident 27's plan of care failed to show a care plan problem was developed to address the resident's self-administration of the lozenges. Further review of Resident 27's medical record failed to show an assessment was conducted for self-administration of medication. On 4/4/23 at 1055 hours, an observation and concurrent interview and medical record review for Resident 27 was conducted with LVN 4. LVN 4 verified the findings. LVN 4 stated any medications including lozenges should have a physician's order. LVN 4 verified Resident 27 had lozenges at bedside. LVN 4 verified there were no physician's orders to administer the lozenges and self-administer the medications for Resident 27. On 4/4/23 at 1306 hours, a follow-up interview and concurrent medical record review for Resident 27 was conducted with LVN 4. LVN 4 stated the residents needed to be assessed in order for them to have any medications at bedside and a physician's order to self-administer the medications. LVN 4 verified Resident 27 did not have an assessment to self-administer the medications. On 4/6/23 at 0832 hours, an interview and concurrent medical record review for Resident 27 was conducted with the DON. The DON verified the findings and stated when a resident insisted to administer own medications, the facility would have to assess the resident. The DON stated the assessment, care plan problem, and physician's order were needed to address the resident's self-administration of the medications. Page 1 of 31 055518 055518 04/07/2023 Newport Nursing and Rehabilitation Center 1555 Superior Avenue Newport Beach, CA 92663

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Based on observation, interview, medical record review, and facility P&P review, the facility failed to determine if it was safe for two of 17 final sampled residents (Residents 27 and 497) to self-administer the medications. * Resident 497 was observed with a bottle of Carboxymethylcellulose Ophthalmic Solution 0.5% (a medication used to relieve dry and irritated eyes) at the bedside table. Resident 497 did not have a physician's order to keep the medication at his bedside. Resident 497 did not have an assessment, or a care plan problem addressing the self-administration of medication. * Resident 27 was observed with ACT dry mouth lozenges (formulated with xylitol to help soothe dry mouth and moisturize mouth tissue) at the bedside. Resident 27 did not have an assessment, physician's order, or a care plan problem addressing the self-administration of medication. In addition, there was no physician's order to administer the lozenges. These failures had the potential for Residents 27 and 497 to administer the medications inaccurately. Findings: Review of the facility's P&P titled Resident Self Administer Medications dated March 2018 showed a resident may only self-administer medication after the IDT has determined which medication may be self-administered. Determination of a resident's ability to self-administer medications shall be documented in resident's medical record and care plan. 1. On 4/4/23 at 0945 hours, a concurrent observation and interview was conducted with Resident 497. A bottle of Carboxymethylcellulose Ophthalmic Solution 0.5% was observed at Resident 497''s bedside table. Resident 472 stated he brought this eye drop bottle from home, had been taking the eye drops for years, and had been administering the eye drops by himself since he was admitted to the facility. Medical record review for Resident 497 was initiated on 4/4/23. Resident 497 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 497's physician's H&P examination dated 4/4/23, showed Resident 497 had the capacity to understand and make decisions. Review of Resident 497's Order Summary Report showed an order dated 4/3/23, to administer Carboxymethylcellulose Sod PF Ophthalmic Solution 0.5% one drop in both eyes every one hour as needed for dry eyes. However, Resident' 497's April 2023 Order Summary Report failed to show an order of Carboxymethylcellulose Sod PF Ophthalmic Solution 0.5 to be kept at Resident 497's bedside. Review of Resident 497's evaluations failed to show Resident 497 was assessed for medication self-administration. Review of Resident 497's care plan failed to show a care plan problem was developed to address the resident's self-administration of the Carboxymethylcellulose Ophthalmic Solution 0.5% eyedrops. On 4/4/23 at 1007 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the findings above. RN 1 reviewed Resident 497's orders and did not find an order for 055518 Page 2 of 31 055518 04/07/2023 Newport Nursing and Rehabilitation Center 1555 Superior Avenue Newport Beach, CA 92663

F 0554 Resident 497 to self-administer Carboxymethylcellulose Ophthalmic Solution 0.5% eye drops. RN 1 stated the facility must assess Resident 497's capability of self-administration of his medications. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055518 Page 3 of 31 055518 04/07/2023 Newport Nursing and Rehabilitation Center 1555 Superior Avenue Newport Beach, CA 92663

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, interview, and medical record review, the facility failed to ensure the quality of care was provided to two of 17 final sampled residents (Residents 41 and 296) as evidenced by: Residents Affected - Few * No information related to Resident 296's pacemaker was documented. The apical pulse for Resident 296's pacemaker was not monitored and recorded. * Resident 41's anti-embolism stockings were not consistently placed on the resident. These failures had the potential for the residents to not receive quality of care. Findings: 1. On 4/4/23, medical record review for Resident 296 was initiated. Resident 296 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 296's H&P examination dated 3/30/31, showed Resident 296 was admitted to the facility with diagnoses including high blood pressure, coronary artery disease, and permanent atrial fibrillation. Review of Resident 296's March 2023 Order Summary Report showed an order dated 3/27/23, for Resident 296's left upper chest pacemaker. Review of Resident 296's plan of care showed a care plan problem to monitor Resident 296's apical pulse daily and notify Resident 296's physician when Resident 296's pulse was less than 60 beats per minute or greater than 100 beats per minute. On 4/7/23 at 1314 hours, a concurrent interview and medical record review was conducted with RN 3. RN 3 verified Resident 296's apical pulse was not documented and was supposed to be monitored and documented. RN 3 also verified there was no information in Resident 296's medical record related to the resident's pacemaker. 2. On 04/06/23 at 1451 hours, a concurrent observation and interview was conducted with LVN 3 and Resident 41's responsible party. Resident 41 was observed wearing non skid socks and no anti-embolism stockings. LVN 3 verified Resident 41 was not wearing his anti-embolism stockings. When Resident 41's socks were removed, Resident 41's feet were observed swollen and with markings at the ankles and top of feet. When asked about Resident 41's anti-embolism stockings, Resident 41's responsible party stated Resident 41 was not wearing them the day before or on this date. Medical record review for Resident 41 was initiated on 4/4/23. Resident 41 was admitted to the facility on [DATE]. Review of Resident 41's H&P examination dated 3/11/23, showed Resident 41's diagnoses included high blood pressure and status post hip surgery. Review of Resident 41's March and April 2023 Treatment Administration Records showed Resident 41 was to wear his knee high anti-embolism stockings during the day and removed at bedtime. 055518 Page 4 of 31 055518 04/07/2023 Newport Nursing and Rehabilitation Center 1555 Superior Avenue Newport Beach, CA 92663

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary treatment and services were provided to help improve or correct performance or prevent further deformity for one of 17 final sampled residents (Resident 10). * Resident 10 was observed wearing cervical collar (commonly used by those who have had a surgical intervention of the cervical spine, to immobilize the neck) while in bed. The facility failed to ensure Resident 10 followed the physician's order to apply TLSO (thoracic lumbar sacral orthosis, brace used to limit motion in the thoracic, lumbar and sacral regions of the spine) brace when the resident was out of bed. In addition, the facility failed to monitor Resident 10's application of the cervical collar while in bed. This failure had the potential for Resident 10 to develop complications from the orthotic device application. Findings: On 4/5/23 at 0933 hours, and 4/7/23 at 0808 hours, Resident 10 was observed in bed wearing a cervical collar. Medical record review was initiated on 4/4/23. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's H&P examination (undated), showed Resident 10 had the capacity to understand and make decision. Review of Resident 10's Order Summary Report showed a physician's order dated 3/16/23, for weight bearing status: weight bearing as tolerated with TLSO brace while out of bed every shift. Further review of Resident 10's medical record did not show a physician's order for the use of the cervical collar while in bed. In addition, there was no documentation of the monitoring of Resident 10 for the cervical collar application. On 4/7/23 at 0810 hours, an observation for Resident 10 and concurrent interview was conducted with CNA 4. CNA 4 verified Resident 10 had a cervical collar on while in bed. CNA 4 stated Resident 10 was able to put the cervical collar on himself, but he needed the back brace when he was out of bed. On 4/7/23 at 0812 hours, an interview was conducted with Resident 10. Resident 10 was observed in bed wearing a cervical collar. Resident 10 stated he put the cervical collar on himself to minimize mobility of his neck because of surgery. On 4/7/23 at 0944 hours, a follow-up interview was conducted Resident 10 with the Rehabilitation Director present. Resident 10 was observed sitting in a wheelchair, with a cervical collar and TLSO brace applied. Resident 10 stated he wore the cervical collar with the brace when he was out of bed, and he also wore the cervical collar alone while in bed. On 4/7/23 at 0947 hours, an interview and concurrent medical record review for Resident 10 was conducted with the Rehabilitation Director. The Rehabilitation Director verified the above findings. The Rehabilitation Director verified the physician's order was for the TLSO while the resident was out 055518 Page 5 of 31 055518 04/07/2023 Newport Nursing and Rehabilitation Center 1555 Superior Avenue Newport Beach, CA 92663

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of bed. The Rehabilitation Director verified there was no physician's order for the resident to wear the cervical collar while in bed. The Rehabilitation Director stated Resident 10 was non-compliant. When asked if there was any documentation of Resident 10's non-compliance, the Rehabilitation Director could not find any. On 4/7/23 at 0953 hours, an interview and concurrent medical record review for Resident 10 was conducted with RN 2. RN 2 verified the above findings. When asked if Resident 10 was reported to be non-compliant with wearing his cervical collar and TLSO brace, RN 2 stated she was not aware of Resident 10's non-compliance. When asked for any documentation of monitoring when Resident 10 had a cervical collar on while in bed, RN 2 could not find any documentation. 055518 Page 6 of 31 055518 04/07/2023 Newport Nursing and Rehabilitation Center 1555 Superior Avenue Newport Beach, CA 92663

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, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services for one of 17 final sampled residents (Resident 37). * The facility failed to ensure Resident 37's oxycodone hydrochloride (a narcotic pain medication) Drug Control Receipt/Record/Disposition Form did not match Resident 37's MAR. This failure posed the risk for diversion of controlled medications. Findings: Review of the facility's P&P titled Controlled Substances revised April 2019, under the section for Administration, showed the nurse administering the medication is responsible for recording the time of administration. On 4/5/23 at 1110 hours, review of Resident 37's Drug Control Receipt/Record/Disposition Form and MAR was conducted with the IP. Review of Resident 37's oxycodone Drug Control Receipt/Record/Disposition Form showed Resident 37 was administered oxycodone 5 mg two tablets on 3/19/23 at 2044 hours. Medical record review for Resident 37 was initiated on 4/5/23. Resident 37 was admitted to the facility on [DATE]. Review of Resident 37's March 2023 MAR, under the Administration Details section, failed to show documentation of administration of oxycodone on 3/19/23 at 2044 hours. The March 2023 MAR failed to show documentation of administration of oxycodone on 3/19/23 at 2044 hours. The IP acknowledged Resident 37's Drug Control Receipt/Record/Disposition Form did not match Resident 37's MAR for March 2023. Review of Resident 37's Order Summary Report showed a physician's order dated 2/28/23, to administer oxycodone hydrochloride 5 mg two tablets by mouth every three hours as needed for severe to very severe pain. On 4/6/23 at 1341 hours, an interview and concurrent medical record review of Resident 37's Drug Control Receipt/Record/Disposition Form and MAR was conducted with the DON. The DON acknowledged the above findings. On 4/7/23 at 0720 hours, an interview and medical record review for Resident 37's Drug Control Receipt/Record/Disposition Form and MAR was conducted with LVN 6. LVN 6 verified and acknowledged the above findings. LVN 6 further stated she forgot to document in Resident 37's MAR. 055518 Page 7 of 31 055518 04/07/2023 Newport Nursing and Rehabilitation Center 1555 Superior Avenue Newport Beach, CA 92663

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of five unnecessary medication sampled residents (Resident 41) was free from unnecessary psychotropic medication (any drug that affects brain activity). * The facility failed to monitor the side effects for Resident 41's use of Trazadone (anti-depressant medication). This had the potential for inaccurate side effect monitoring for Resident 41's physician not having the necessary information if Resident 41 had side effects from medication. Findings: Review of the facility's P&P titled Psychotropic Medication Use revised July 2022 showed the residents, families, and/or the representative are involved in the medication process. Psychotropic medication management includes indication for use, dose, duration, adequate monitoring for efficacy and adverse consequences, and preventing, identifying and responding to adverse consequences. Medical record review for Resident 41 was initiated on 4/7/23. Resident 41 was admitted to the facility on [DATE]. Review of Resident 41's April 2023 Order Summary Report showed a physician's order dated 3/23/23, to administer Trazadone HCl 50 mg one-half tablet (25 mg) by mouth at bedtime for depression manifested by inability to sleep (25 mg). Review of Resident 41's MAR for April 2022 showed Resident 41 was administered Trazadone 25 mg at bedtime as ordered by the physician. Further review of the medical record failed to show an order or documentation to monitor for side effects of the Trazadone. On 4/7/23 at 1023 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 reviewed the orders for Trazadone and verified there was no order or documentation to show monitoring of side effects for the Trazadone order. On 4/7/23 at 1031 hours, a concurrent interview and medical record review was conducted with RN 2. RN 2 verified the above findings. RN 2 stated the purpose of having an order for monitoring the side effects of Trazadone was to anticipate if Resident 472 would exhibit the side effects of the medication and to notify the physician for accurate information with Resident's 472's Trazadone use. 055518 Page 8 of 31 055518 04/07/2023 Newport Nursing and Rehabilitation Center 1555 Superior Avenue Newport Beach, CA 92663

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 15.38%. Two licensed nurses (LVNs 4 and 5) who were observed during the medication administration were found to have made errors. Residents Affected - Few * LVN 4 failed to administer the correct dose of Clearlax oral powder (medication to treat occasional constipation) to Resident 294. * LVN 5 failed to administer Resident 24's medications as ordered by the physician. In addition, LVN 5 failed to administer Resident 344's medications with food or meals as ordered by the physician. These failures had the potential to negatively affect the residents' health. Findings: According to the facility's P&P titled Administering Medications dated June 2016 showed it is the facility's policy that medications shall be administered in a safe and timely manner, and as prescribed. Further review of the policy showed that medications must be administered in accordance with the orders. 1. On 4/4/23 at 0755 hours, a medication administration observation was conducted with LVN 4 for Resident 294. LVN 4 prepared and administered the following medications to Resident 294: - one capsule of Omega-3 (supplement) 1000 mg, - two tablets of vitamin C (supplement) 500 mg, - one tablet of vitamin D3 (supplement) 400 IU 10 mcg, - one tablet of Mucinex Extended Release (cough medicine) 600 mg, - one capsule of stool softener 250 mg, - one cap of Clearlax powder (bowel management) 17 gm mixed with 4-5 ounces of water in a five-ounce cup, - one half tablet of sotalol (antihypertensive) 80 mg, - one tablet of prednisone (steroids) 10 mg, - one tablet of losartan potassium (antihypertensive) 50 mg, - one capsule of furosemide (antihypertensive) 40 mg, - one tablet of folic acid (supplement) 1 mg, - one capsule of fluoxetine (antidepressant) 40 mg, 055518 Page 9 of 31 055518 04/07/2023 Newport Nursing and Rehabilitation Center 1555 Superior Avenue Newport Beach, CA 92663

F 0759 - one capsule of duloxetine hydrochloride (antidepressant) 60 mg, Level of Harm - Minimal harm or potential for actual harm - one tablet of carbidopa-levodopa (medication to treat Parkinson's disease (a progressive disorder that affects the nervous system and parts of the body)) 25-100 mg, Residents Affected - Few - one nebule of levalbuterol hydrochloride (medication to treat bronchospasm) 0.63 mg/3 ml, and - one tablet of doxycycline hyclate (antibiotic) 100 mg. After administering the medications, LVN 4 was observed adding a small amount of water to the five-ounce cup with the Clearlax powder, stirred, and gave it to Resident 294; however, Resident 294 did not drink all the mixture. LVN 4 placed the cup on top of Resident 294's over bed table. On 4/4/23 at 0834 hours, LVN 4 was asked about the cup with the Clearlax mixture, LVN 4 showed the cup, and a small amount of whitish residue was left in the cup. On 4/4/23 at 1501 hours, an interview was conducted with LVN 4. LVN 4 acknowledged and verified the above findings. LVN 4 stated she tossed the cup with the medication residue in the trash. LVN 4 further stated it should not have any residue left in the cup because Resident 24 would not have the proper medication dosage. 2.a. On 4/4/23 at 0932 hours, a medication administration observation was conducted with LVN 5 for Resident 24. LVN 5 prepared and administered the following medications to Resident 24: - one drop to both eyes of brimonidine tartrate/timolol solution (medication to treat glaucoma (a condition of increased pressure within the eyeball, causing gradual loss if sight)) 0.2-0.5%, - one tablet of vitamin C (supplement) 500 mg, - one tablet of baby aspirin (medication to lower the risk of heart attack and stroke) 81 mg, - one tablet of calcium-vitamin D (supplement) 600 mg-5 mcg, - one tablet of B12 (supplement) 500 mcg, - one tablet of folic acid (supplement) 1 mg, and - one capsule of hydroxyurea (medication to treat leukemia (blood cancer), head, and neck cancer) 500 mg. Medical record review for Resident 24 was initiated on 4/4/23. Resident 24 was admitted [DATE], and readmitted on [DATE]. Review of Resident 24's Order Summary Report showed an order dated 3/15/23, to instill one drop of brimonidine tartrate/timolol solution 0.2-0.5% to left eye two times a day. Further review of the medical record showed an order dated 8/11/22, to administer one tablet of multiple vitamins and minerals one time a day. However, during the medication administration observation, LVN 5 administered one drop of brimonidine tartrate/timolol solution 0.2-0.5% to both eyes, instead of only the left eye as ordered, and multiple vitamins and minerals was not administered to the resident as ordered 055518 Page 10 of 31 055518 04/07/2023 Newport Nursing and Rehabilitation Center 1555 Superior Avenue Newport Beach, CA 92663

F 0759 Level of Harm - Minimal harm or potential for actual harm On 4/4/23 at 1525 hours, an interview was conducted with LVN 5. LVN 5 was informed and LVN 5 acknowledged the above findings. b. On 4/4/23 at 1001 hours, a medication administration observation was conducted with LVN 5 for Resident 344. LVN 5 prepared and administered the following medications to Resident 344: Residents Affected - Few - one tablet of ferrous sulfate (iron supplement) 325 mg, - one tablet of metformin (oral diabetes medication) 1000 mg, - one tablet of vitamin C (supplement) 500 mg, - one tablet of famotidine (medication to treat stomach ulcers) 20 mg, - one tablet of lisinopril (antihypertensive) 10 mg, - one tablet of meloxicam (nonsteroidal anti-inflammatory medication) 15 mg, - one tablet of Senna Plus (stool softener) 8.6 mg-50 mg, and - one prefilled syringe of enoxaparin sodium (a blood thinner delivered via injection) 40 mg/0.4 ml. Medical record review for Resident 344 was initiated on 4/4/23. Resident 344 was admitted to the facility on [DATE]. Review of Resident 344's Order Summary Report showed an order dated 3/11/23, to administer one tablet of metformin 1000 mg two times a day with breakfast and dinner; and an order dated 3/11/23, to administer one tablet meloxicam 15 mg one time a day with food; and an order dated 3/12/23, to administer one tablet of ferrous sulfate 325 mg two times ad day with breakfast and dinner. Review of the MAR for the month of April 2023, showed ferrous sulfate and metformin were supposed to be administered at 0800 hours. Further review of the medical record showed that meloxicam was supposed to be given with food. However, the medication administration was performed by LVN 5 at 1001 hours on 4/4/23. On 4/4/23 at 1513 hours, a concurrent interview and medical record review was conducted with LVN 5. When asked what time breakfast was served to residents, LVN 5 stated breakfast was served between 0800-0830 hours. LVN 5 stated Resident 344 had already eaten breakfast when she administered the medications. LVN 5 verified and acknowledged Resident 344's ferrous sulfate, metformin, and meloxicam tablets were supposed to be given with meals or food. LVN 5 further stated she should have offered snacks to Resident 344. 055518 Page 11 of 31 055518 04/07/2023 Newport Nursing and Rehabilitation Center 1555 Superior Avenue Newport Beach, CA 92663

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and the facility P&P review, the facility failed to store the drugs and biologicals in a safe manner. * The facility failed to store Resident 24's difluprednate emulsion (an eye drop medication to treat eye swelling and pain) 0.05% in a locked compartment at bedside. This failure had the potential for the residents, staff, and visitors to have an easy access to the medication. * Multiple outdated Indicaid Covid-19 (a respiratory disease caused by SARS-CoV-2) Rapid Antigen Test buffer solution bottles were observed in Medication Cart A. This had the potential for use of expired medications or biologicals. * Multiple outdated intravenous (into or within a vein) insertion needles were observed in Medication Cart B. This had the potential for use of expired medical supplies. * Medication Cart C had Resident 24's bottle of rhopressa (eyedrops medication) was stored at room temperature. This had the potential for administration of deteriorated medication. Findings: According to the facility's P&P titled Resident Self Administer Medications with effective date March 2018 showed medications self-administered by the resident and which the resident has been determined safe to be maintained at bedside, shall be stored in a locked container to maintain safety. According to the facility's P&P titled Receipt and Storage of Supplies and Equipment revised November 2009 showed all supplies and equipment must be stored in accordance with the manufacturer's recommendations. 1. On 4/4/23 at 0932 hours, a medication administration observation and concurrent interview was conducted with Resident 24 and LVN 5. During the observation, Resident 24 had one bottle of difluprednate emulsion 0.05% at the resident's bedside. When Resident 24 was asked about the medication at the bedside, Resident 24 stated she self-administer the medication and further stated she had the medication for four years. LVN 5 acknowledged Resident 24 was using the medication. Medical record review for Resident 24 was initiated on 4/4/23. Resident 24 was admitted to the facility on [DATE] and was readmitted on [DATE]. Review of the Order Summary Report showed an order dated 4/3/23, to instill one drop of difluprednate emulsion 0.05% to the left eye three times a day to prevent eye pain and swelling, unsupervised, and self-administration. On 4/4/23 at 1520 hours, an interview was conducted with the MDS Coordinator. When asked about Resident 24's difluprednate medication storage at bedside, the MDS Coordinator stated the medication was kept inside Resident 24's bedside table drawer at night and the resident had the medication at bedside during the day to be accessible. 055518 Page 12 of 31 055518 04/07/2023 Newport Nursing and Rehabilitation Center 1555 Superior Avenue Newport Beach, CA 92663

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 4/5/23 at 1505 hours, an interview was conducted with the DON. The DON acknowledged Resident 24 was self-administering the difluprednate medication. The DON was informed of the facility's policy regarding the storage of medications at bedside, the DON acknowledged Resident 24 had no locked cabinet at bedside for her difluprednate medication. 2. On 4/5/23 at 0907 hours, an observation of Medication Cart A and concurrent interview was conducted with the IP. There were nine unopened bottles of the Indicaid Covid-19 Rapid Antigen Test buffer solution with the expiration date of 2/6/23. The IP verified the expired supplies. 3. On 4/5/23 at 0919 hours, an observation of Medication Cart B and concurrent interview was conducted with RN 1. The following was identified: - six Covidien Monoject Hypodermic safety needles 18 Gauge x 1 1/2 inch, with the expiration date of 2/27/23, - one Covidien Magellan Hypodermic safety needle 23 Gauge x one inch, with the expiration date of 12/31/22, - three Covidien Magellan Hypodermic safety needles 18 Gauge x one inch, with the expiration date of 5/31/22, - two Covidien Magellan Hypodermic safety needles 18 Gauge x one inch, with the expiration date of 11/30/21, - one B/[NAME] Introcan Safety intravenous catheter 18 Gauge x 1 ¼ inch, with the expiration date of 11/2017, - one B/[NAME] Introcan Safety intravenous catheter 22 Gauge x one inch, with the expiration date of 12/1/22, and - one Med Stream intravenous administration set (secondary), with the expiration date of 9/2019. RN 1 stated she was responsible for checking Medication Cart B for expired supplies. RN 1 verified the above findings. 4. Review of the Lexicomp (clinical drug resource) guide updated 1/24/23, showed to store at two degrees Celsius to eight degrees Celsius (36 degrees Fahrenheit to 46 degrees Fahrenheit) until opened. After opening, may store refrigerated at two degrees Celsius to eight degrees Celsius (36 degrees Fahrenheit to 46 degrees Fahrenheit) until the manufacturer's expiration date or at less than or equal to 25 degrees Celsius (less than or equal to 77 degrees Fahrenheit) for less than or equal to six weeks. Medical record review of Resident 24 was initiated on 4/4/23. Resident 24 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MAR for the month of April 2023 showed an order with the start date of 3/7/23, and discontinued date of 4/3/23, to administer rhopressa ophthalmic solution 0.02% one drop in both eyes one time a day. 055518 Page 13 of 31 055518 04/07/2023 Newport Nursing and Rehabilitation Center 1555 Superior Avenue Newport Beach, CA 92663

F 0761 Level of Harm - Minimal harm or potential for actual harm On 4/5/23 at 1046 hours, an observation of Medication Cart C and concurrent interview was conducted with LVN 1. Resident 24's rhopressa medication was stored at room temperature inside Medication Cart C; however, the label showed to keep medication in the refrigerator. LVN 1 verified and acknowledged the above findings. Residents Affected - Few 055518 Page 14 of 31 055518 04/07/2023 Newport Nursing and Rehabilitation Center 1555 Superior Avenue Newport Beach, CA 92663

F 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menus were followed. Residents Affected - Some * The soup was served to the residents without following recipe and nutritional analysis. * The wrong scoop size was used to serve green beans for the residents on the soft-and-bite size diet. * The regular bread was used instead of garlic bread during the pureed bread preparation for the residents on the soft-and-bite size diet. * The pureed bread was not served to Resident 11 during lunch as per the menu. These failures had the potential for residents not receiving adequate nutrition, and appropriate servings. Findings: Review of the Form CMS-672 titled Resident Census and Conditions of Residents completed by the facility dated 4/4/23, showed 54 of 54 residents residing in the facility received food prepared in the kitchen. Review of the facility's P&P titled Menu dated 11/17 showed the residents receive food in the amount, type, consistency, and frequency to maintain normal body weight and acceptable nutritional values. Menus meet basic nutritional needs by providing meals based on individual nutritional assessment, the individualized plan of care, and established national guidelines and are periodically updated to mitigate the risk of menu fatigue. Menus are reviewed and revised as needed by a qualified dietitian or other qualified nutrition professional. Review of the facility's document titled Soft and Bite Size Texture (undated) showed five residents were on soft-and-bite size diet, with no restrictions to green beans, and bread. 1. Review of the facility's document titled Diet Spreadsheet for Wednesday Week 2 for lunch showed to served farmers pot roast, brown gravy, mashed potatoes, fresh green beans, cheesecake, milk and a choice of beverage. The spreadsheet did not include soup. On 4/5/23 at 1149 hours, a pot of soup was observed during the trayline observation. The soup was not included in the menu. The RD and DSS verified the findings. The RD and DSS stated the soup was something extra they served to the residents who were in the dining room. On 4/5/23 at 1459 hours, an interview and concurrent facility document review was conducted with the RD. The RD verified the above findings. The RD stated the soup was served to the residents who were in the dining room during lunch. When asked if the residents were aware what soup they would be served during lunch, the RD stated the residents did not know what type of soup, but they were aware they would be served soup in the dining room. 055518 Page 15 of 31 055518 04/07/2023 Newport Nursing and Rehabilitation Center 1555 Superior Avenue Newport Beach, CA 92663

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The RD stated she was not made aware of what kind of soup the kitchen would serve, but it would depend on what the cook would prepare. When asked if a recipe or if there was a nutritional analysis done for the soups that were served during lunch, the RD stated there was none because it was just something extra and as an incentive for the residents to come to the dining room. On 4/5/23 at 1526 hours, an interview and concurrent facility document review was conducted with the DSS. The DSS verified the above findings. When asked who decided on what soup to be served to the residents during lunch, the DSS stated the cook decided what to make depending on what they had in the kitchen. When asked if there were any recipes followed by the cook when they prepared the soup served to the residents during lunch, the DSS stated there were no recipes for the soup because this was just extra soup. 2. Review of the facility's document titled Diet Spreadsheet for Wednesday Week 2 for lunch, showed four-ounce (#8 scoop) green beans will be served for the soft-and-bite size diet. On 4/5/23 at 1149 hours, during the tray line observation, [NAME] 1 was observed using #10 scoop (three ounces) to serve green beans. The DSS verified the findings. The DSS verified the serving size was not what was stated on the spreadsheet for soft-and-bite-size diet. When asked about the portion size for green beans for soft-and-bite-size diet, the DSS stated it should have been #8 scoop. 3. Review of the facility's document titled Diet Spreadsheet for Thursday Week 2 for lunch showed to serve garlic bread under regular diet and bread (pureed/ moist) for soft-and-bite size diet. On 4/6/23 at 1154 hours, an observation of the puree preparation and concurrent interview with [NAME] 2 was conducted. [NAME] 2 stated he was preparing a pureed bread for the soft-and-bite size diet. A bowl containing breadcrumbs was observed in the food preparation area. [NAME] 2 stated he prepared the breadcrumbs from regular bread. When asked if a garlic bread should be prepared, [NAME] 2 stated he did not use garlic bread because the spreadsheet only showed pureed bread and not garlic bread. [NAME] 2 proceeded to prepare the pureed bread. On 4/6/23 at 1205 hours, an interview and concurrent facility document review was conducted with the DSS. The DSS verified the above findings. The DSS acknowledged a pureed bread was served to residents on soft-and-bite size diet because the spreadsheet showed pureed bread. On 4/6/23 at 1208 hours, an interview and concurrent facility document review was conducted with the RD. The RD verified the above findings. The RD stated whatever was served in regular diet, should also be served in the pureed form, unless there was a restriction. The RD stated the cook should have used garlic bread instead of a regular bread. 4. Review of the facility's document titled Diet Spreadsheet for Tuesday Week 2 for soft and bit sized for lunch showed to served chicken (chopped) with gravy, mashed potatoes, green beans (chopped), bread sticks (puree), diced pears, milk, and choice of beverage. On 4/4/23 at 1219 hours, an observation and concurrent interview was conducted with CNA 2. During lunch meal observation, Resident 11's meal card showed soft and bit size diet textures, thin liquids, and regular diet. Resident 11's meal tray observed with chopped chicken with gravy, mashed potato no gravy, chopped green beans with no gravy, empty small dish of gravy, and 8 ounces of house nutrition 2.0; and the puree bread was missing. CNA 2 verified there was no puree bread on Resident 11's lunch tray and stated the nurses checked the meal card to make sure the residents got all items listed 055518 Page 16 of 31 055518 04/07/2023 Newport Nursing and Rehabilitation Center 1555 Superior Avenue Newport Beach, CA 92663

F 0803 in their lunch tray. Level of Harm - Minimal harm or potential for actual harm On 4/4/23 at 1221 hours, an interview with LVN 2 was conducted. LVN 2 stated Resident 11's lunch tray and meal card were checked by another nurse and verified the puree bread was missing. Residents Affected - Some On 4/4/23 at 1223 hours, an interview with the DSS was conducted. The DSS verified the above findings and stated the dietary aid checked the diet and placed items on the resident's tray accordingly. The DSS further stated the nurses would check the tray card and meal trays again, and if items were missing, the nurses would request the missing item from the kitchen staff. 055518 Page 17 of 31 055518 04/07/2023 Newport Nursing and Rehabilitation Center 1555 Superior Avenue Newport Beach, CA 92663

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and facility document review, the facility failed to ensure the food served to one of 17 final sampled residents (Resident 296) was attractive to the resident. This failure had the potential for the resident not enjoying his meals. Residents Affected - Few Findings: Medical record review for Resident 296 was initiated on 4/4/23. Resident 296 was readmitted to the facility on [DATE]. Review of Resident 296's H&P examination dated 3/30/31, showed Resident 296 had the capacity to understand and make decisions. Review of Resident 296's April 2023 Order Summary Report showed an order dated 4/1/23, for Resident 296's diet as soft and bite size texture, solid bread okay. On 4/4/23 at 0825 hours, Resident 296 was served pureed bread. Resident 296 stated he did not know what to do with the pureed bread. On 4/4/23 at 1302 hours, Resident 296 was served minced main entrée and pureed bread. Per the facility's menu, the main entrée was supposed to be chicken salad. Resident 296 stated the salad served was too dry and not appealing or appetizing. Resident 296 stated he had been assessed by the facility's ST and was told he was able to eat regular bread. Consequently, Resident 296 declined to eat the lunch served and requested a soup instead. On 4/5/23 at 1309 hours, Resident 296 was served minced main entrée, mashed potatoes, minced green vegetables, pureed bread, and regular diet lemon cake. However, review of the facility's menu, the main entrée was supposed to be farmer's pot roast and the vegetables, green beans. Resident 296 was observed not touching his meal. When asked about the meal served to him, Resident 296 stated he did not like what was served and declined to eat the meal served to him. On 4/6/23 at 1125 hours, a concurrent observation and interview was conducted with the ST. The ST verified Resident 296 was served minced meal with puree bread instead of chopped and regular bread. 055518 Page 18 of 31 055518 04/07/2023 Newport Nursing and Rehabilitation Center 1555 Superior Avenue Newport Beach, CA 92663

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the dietary texture guidelines were followed for the residents on the soft-and-bit-sized diet. * The facility failed to ensure the chopped pot roast and chopped green beans were served to the residents on the soft-and-bite sized diet. This failure had the potential for the residents not liking the food based on the dietary modification and could affect the residents' quality of life. Findings: Review of the facility's P&P titled Therapeutic Diets revised 10/2017 showed the therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and treatments. A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example: altered consistency diet. Review of the facility's document titled Soft and Bite Size Texture (undated) showed five residents were on soft-and-bite size diet with no restrictions to the pot roast and green beans. Review of the facility's document titled Diet Spreadsheet for Wednesday Week 2 for lunch showed soft-and-bite size diets should be served with chopped pot roast, and chopped green beans. Review of the facility's document titled Aspiration Precaution Soft and Bite-Sized (undated) showed bite-sized pieces no bigger than 1.5 cm x 1.5 cm in size, which is about the width of a standard dinner fork. Food can be mashed/ broken down with pressure from for. A knife is not required to cut the food. Review of the facility's document titled Aspiration Precaution Minced and Moist (undated) showed soft and moist, but with no liquid leaking/ dripping. Biting is not required. Minimal chewing required. Lumps of 4 mm in size for adults. Lumps can be mashed with the tongue. On 4/5/23 at 1149 hours, during the tray line observation, [NAME] 1 was observed serving minced pot roast and minced green beans. The DSS verified the above findings. The DSS stated these were served for the soft-and-bite size diet. On 4/5/23 at 1459 hours, an interview and facility document review was conducted with the RD. The RD verified the above findings. The RD verified the spreadsheet showed chopped pot roast and chopped green beans were to be served for soft-and-bite size diet. The RD verified minced pot roast and minced green beans were served to residents on the soft-and-bite size diet instead of the chopped food. On 4/5/23 at 1526 hours, an interview and facility document review was conducted with the DSS. The DSS verified the above findings. The DSS verified the pot roast and the green beans were served to the residents on the soft-and-bite size diet were more than chopped. The DSS acknowledged the food texture was confusing and would have to ask the ST. 055518 Page 19 of 31 055518 04/07/2023 Newport Nursing and Rehabilitation Center 1555 Superior Avenue Newport Beach, CA 92663

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 4/6/23 at 1125 hours, an interview and facility document review was conducted with the ST. The ST verified the above findings. The ST stated she did not access the spreadsheet and was not aware of what was supposed to be served for the residents on the soft-and-bite size diet. The ST stated the goal was safety so it was still safe to serve the minced food instead of chopped food, however, the residents on the soft-and-bite size diet should have been served with the chopped food based on the prescribed food texture. 055518 Page 20 of 31 055518 04/07/2023 Newport Nursing and Rehabilitation Center 1555 Superior Avenue Newport Beach, CA 92663

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, medical record, facility P&P, and facility document review, the facility failed to follow the residents' preferences when the facility ran out of a food items to be served for breakfast. The facility failed to served fruit cups for one of 17 final sampled residents (Resident 344) and two nonsampled residents (Residents 345 and 346). This failure posed the risk of the residents' nutritional needs not being met and the residents' preferences not being honored. Findings: Review of the facility's P&P titled Menus dated 11/17 showed resident preferences and needs are incorporated into the development of the individual food plan. 1. On 4/4/23 at 0853 hours, during the initial tour of the facility, Resident 344 was observed with her breakfast tray. Resident 344's meal ticket card showed fruit cup, oatmeal. Fruit cup was not observed in Resident 344's breakfast tray. Resident 344 stated she wanted her fruit cup. When asked if the dietary staff offered something else other than a fruit cup, Resident 344 answered no. Medical record review for Resident 344 was initiated on 4/4/23. Resident 344 was admitted on [DATE]. Review of Resident 344's H&P examination dated 3/14/23, showed Resident 344 had the capacity to understand and make decisions. Review of Resident 344's Diet: History and Food Preferences dated 3/13/23, showed, fruit cup under preferences. 2. On 4/4/23 at 0853 hours, during the initial tour of the facility, Resident 345 was observed with her breakfast tray. Resident 345's meal ticket card showed, fruit cup, prunes. Resident 345 stated she was not served fruit cup. Resident 345 stated she would like to have prunes or a fruit cup, and did not have to be both so she asked the CNA to asked the kitchen and the CNA was told by the kitchen staff that they ran out. Resident 345 was not informed of the missing the fruit cup or prunes, and she had to ask the CNA to ask for it from the kitchen. Medical record review for Resident 345 was initiated on 4/4/23. Resident 345 was admitted on [DATE]. Review of Resident 345's H&P examination dated 3/24/23, showed Resident 345 had the capacity to understand and make decisions. Review of Resident 345's Diet: History and Food Preferences dated 3/24/23, showed, fruit cup, prunes under special request for breakfast. 3. On 4/4/23 at 0844 hours, during the initial tour of the facility, Resident 346 was observed with her breakfast tray. Resident 346 stated her fruit cup and butter were missing. Resident 346's meal ticket card showed, fruit cup, prunes, butter ok. Resident 346 stated, the butter was missing but that was okay, but I want my fruit cup. They did not offer anything else. 055518 Page 21 of 31 055518 04/07/2023 Newport Nursing and Rehabilitation Center 1555 Superior Avenue Newport Beach, CA 92663

F 0806 Medical record review for Resident 346 was initiated on 4/4/23. Resident 346 was admitted on [DATE]. Level of Harm - Minimal harm or potential for actual harm Review of Resident 346's H&P examination dated 3/26/23, showed Resident 346 had the capacity to understand and make decisions. Residents Affected - Few Review of Resident 344's Diet: History and Food Preferences dated 3/24/23, showed, fruit cup, prunes under special request for breakfast. On 4/4/23 at 0859 hours, an interview was conducted with the DSS. The DSS verified the above findings. The DSS stated they ran out of fruits because the fruits were delivered late. The DSS acknowledged she did not inform the residents and did not provide any alternative or substitution for the fruit cup. On 4/7/23 at 0832 hours, an interview was conducted with the RD. The RD stated she was not informed the kitchen ran out of fruits to be served for breakfast on 4/4/23, and she was only informed later that day. The RD stated for the food deliveries, the DSS managed the kitchen, and she let the DSS run the kitchen so the RD spent more hours on clinical. 055518 Page 22 of 31 055518 04/07/2023 Newport Nursing and Rehabilitation Center 1555 Superior Avenue Newport Beach, CA 92663

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 facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. Residents Affected - Some * The facility failed to ensure the ice machine was clean. * The facility failed to ensure the food items in the freezer were properly labeled. * The facility failed to ensure the cooking utensils were in good repair. * The facility failed to ensure the cutting boards were in sanitary condition. These failures had the potential to expose the residents who consumed food prepared in the kitchen to foodborne illnesses. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 4/4/23, showed 54 of 54 residents in the facility received food prepared in the kitchen. 1. According to the USDA Food Code 2022 Section 4-601.11, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) Equipment, Food-Contact and utensils shall be clean to sight and touch. On 4/5/23 at 0815 hours, an observation of the ice machine and concurrent interview was conducted with the Maintenance Director. The ice machine had a brownish substance on a white pipe on the inside of the upper front panel of the ice machine. When wiped off with a paper towel, a brownish substance was observed on the paper towel. The Maintenance Director verified the above findings and stated he would have to clean the ice machine today. 2. Review of the facility's P&P titled Sanitation and Infection Control, Food Storage (Label/ Dates) revised date 3/2010 showed all cooked foods, pre-packaged open contains, protein-based salads, and desserts are labeled, dated, and securely covered. On 4/4/23 at 0753 hours, during the initial tour of kitchen with the DSS, an observation of the pantry area showed two containers of whole thyme and chicken seasoning were opened and not dated. The DSS verified these were not dated and stated these should have been labeled with the opened date. 3. According to the USDA Food Code 2022 Section 4-502.11 Good Repair and Calibration, (A) Utensils shall be maintained in a state of repair and condition that complies with the requirements specified under Parts 4-1 and 4-2 or shall be discarded. On 4/5/23 at 0810 hours, five white rubber spatulas were observed to be chipped. The RD verified the findings. 4. According to the USDA Food Code 2022, 4-501.12, Cutting Surfaces, surfaces such as cutting blocks that are subject to scratching and scoring shall be resurfaced if they can no longer be 055518 Page 23 of 31 055518 04/07/2023 Newport Nursing and Rehabilitation Center 1555 Superior Avenue Newport Beach, CA 92663

F 0812 effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced. Level of Harm - Minimal harm or potential for actual harm On 4/5/23 at 0810 hours, several cutting boards were observed to be heavily marred with knife marks. The RD verified the above findings. Residents Affected - Some 055518 Page 24 of 31 055518 04/07/2023 Newport Nursing and Rehabilitation Center 1555 Superior Avenue Newport Beach, CA 92663

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** 3. Review of the facility's P&P titled Handwashing/ Hand Hygiene revised date 8/2019 showed all personnel shall follow the handwashing/ hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-microbial) and water for the following situations: Residents Affected - Few - before and after assisting a resident with meals - before and after direct contact with residents - after contact with objects (e.g. medical equipment) in the immediate vicinity of the resident a. On 4/4/23 at 1247 hours, during the initial dining observation, CNA 5 was observed not performing hand hygiene before and after assisting the residents with meals. For example: - CNA 5 was observed holding a lunch tray and entering Room C without performing hand hygiene. CNA 5 was observed assisting the resident in Bed A with the food items in the tray. CNA 5 was observed exiting the room without performing hand hygiene; - CNA 5 was observed getting another lunch tray from the meal cart and entering Room D without performing hand hygiene. CNA 5 was observed assisting the resident in Bed B with the food items in the tray. CNA 5 was observed exiting the room without performing hand hygiene; and - CNA 5 was observed getting another lunch tray from the meal cart and entering Room E without performing hand hygiene. CNA 5 was observed assisting the resident with the food items in the tray. CNA 5 was observed exiting the room with the resident's lunch tray, without performing hand hygiene. CNA 5 was observed taking the meal ticket card from the tray, spoke to the charge nurse and walked away. On 4/4/23 at 1453 hours, an interview was conducted with CNA 5. CNA 5 verified the above findings. CNA 5 verified she delivered lunch trays and assisted the residents with their lunch trays. CNA 5 stated she assisted the residents such as opening the straws, placing the straws into the beverage cups, and opening the plate domes. When asked if she performed hand hygiene before and after assisting the residents with their lunch trays, CNA 5 stated she could not remember washing her hands or using the alcohol-based hand rub but that was not the practice in the facility. CNA 5 stated the facility practice was to use the alcohol-based hand rub or wash hands in between residents. On 3/1/23 at 1545 hours, an interview was conducted with the IP. The IP stated the staff were supposed to perform hand hygiene by washing hands or using alcohol hand rub before and assisting residents with their meal trays. Based on observation, interview, medical record review, and facility P&P review, the facility failed to establish and maintain the infection control program and practices designed to help prevent the development and transmission of diseases and infections. * The facility failed to ensure the licensed nurse performed hand hygiene between changing of gloves during the medication administration observation. 055518 Page 25 of 31 055518 04/07/2023 Newport Nursing and Rehabilitation Center 1555 Superior Avenue Newport Beach, CA 92663

F 0880 * The facility failed to ensure CNA 3 used the proper PPE in an enhanced standard/barrier precaution room when assisting Resident 295. Level of Harm - Minimal harm or potential for actual harm * The facility failed to ensure CNA 5 performed hand hygiene when assisting the residents with meals. Residents Affected - Few * The facility failed to ensure the staff performed proper hand hygiene when providing care. These failures posed the risk for transmission of disease-causing microorganisms and infections to the residents. Findings: 1. Review of the facility's P&P titled Glove Use with effective date 8/2017, under the general information section, showed the employees shall perform hand hygiene after removal of gloves. On 4/4/23 at 0755 hours, a medication administration observation was conducted with LVN 4. During the observation, LVN 4 was observed preparing medications of Resident 294. LVN 4 put on gloves then took out the medical equipment from the medication cart, and started cleaning the medical equipmnet with disinfecting wipes. LVN 4 changed her gloves without washing her hands, proceeded to take Resident 294's vital signs (measurements of the body's most basic functions). LVN 4 removed gloves and did not wash her hands. On 4/4/23 at 1501 hours, an interview was conducted with LVN 4. LVN 4 verified and acknowledged the above findings. LVN 4 further stated hand hygiene was important between changing of gloves for infection control purposes. 2. Review of the facility's P&P titled Enhanced Standard/Barrier Precautions with the effective date of 7/22/22, showed it is the facility's policy to implement enhanced standard/barrier precautions fort he prevention of transmission of multidrug-resistant organisms (organisms that are resistant to multiple antibiotics or antifungals (medicines that kills or stop the growth of fungi)). Further review of the facility's policy under implementation of enhanced barrier precautions showed to wear gowns and gloves while performing the following tasks associated with the greatest risk for multidrug-resistant organism contamination of healthcare personnel hands, clothes, and the environment: any care activity involving contact with environmental surfaces likely contaminated by the resident. Review of Resident 295's medical record was initiated on 4/4/23. Resident 295 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of the Order Summary Report showed an order dated 4/3/23, for enhanced barrier precautions for high contact care activities related to medical device care: foley catheter (a soft, plastic or rubber tube that is inserted into the bladder to drain urine); to perform hand hygiene and apply personal protective equipment (PPE) gloves, gown and/or goggles/face shield if at risk for splash/spray; to remove PPE and perform hand hygiene prior to exiting the room; every shift to prevent transmission of multidrug-resistant organisms; and remains in place or until resolution of wound or discontinuation of medical device. Review of the MAR for April 2023 showed an order dated 4/3/23, for enhanced barrier precautions for high contact care activities related to medical device care: foley catheter; to perform hand 055518 Page 26 of 31 055518 04/07/2023 Newport Nursing and Rehabilitation Center 1555 Superior Avenue Newport Beach, CA 92663

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hygiene and apply personal protective equipment (PPE) gloves, gown and/or goggles/face shield if at risk for splash/spray; to remove PPE and perform hand hygiene prior to exiting the room; every shift to prevent transmission of multidrug-resistant organisms; and remains in place or until resolution of wound or discontinuation of medical device. On 4/4/23 at 0801 hours, medication administration observation for Room A was conducted. Room A was observed with a stop sign posted which read Enhanced Barrier Precautions at the entry of Room A. CNA 3 was observed entering Room A and proceeded to Bed B without wearing a gown. On 4/4/23 at 0805 hours, an interview was conducted with CNA 3. When asked about the Enhanced Barrier Precautions signage posted outside Room A, CNA 3 stated the precaution signage was for the resident in Bed B. CNA 3 stated the resident in Bed B was not on contact isolation and the precaution signage was for when staff performing care to the resident. CNA 3 further stated he asked for assistance from another staff to pull the resident in Bed B up in bed, and did not wear a gown. On 4/5/23 at 1534 hours, an interview was conducted with the IP. The IP was informed of the above findings. The IP stated hand hygiene should be performed between changing of gloves and proper PPE should be worn when in contact with the resident on enhanced barrier precautions. The IP further stated assisting to pull up the resident in bed was considered high contact care activity because the staff was touching the resident's linens. b. On 4/4/23 at 0937 hours, an observation was conducted with CNA 1. CNA 1 was passing new water pitcher to the residents, from one room to another room. CNA 1 was observed going to Room B and taking Resident 495's old water pitcher and replacing it with a new water pitcher. Resident 495 requested CNA 1 to clean up her bedside table. CNA 1 removed soiled tissues from the bedside table to the trash can and picked up a wet, soiled, small, white hand towel. CNA 1 then stepped out of Room B and grabbed the soiled linen barrel from the hallway closed to Room B and placed the soiled wet cloth. Then, CNA 1 grabbed another new water pitcher and delivered it to Resident 496's bedside table without performing hand hygiene. On 4/4/23 at 0942 hours, an interview was conducted with CNA 1. CNA 1 confirmed the above findings and stated she did not perform hand hygiene when she should have had. 055518 Page 27 of 31 055518 04/07/2023 Newport Nursing and Rehabilitation Center 1555 Superior Avenue Newport Beach, CA 92663

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to ensure the freezer compartment inside the residents' refrigerator was free of ice buildup. This had the potential for the refrigerators not being maintained in safe operating condition. Residents Affected - Few Findings: On 4/4/23 at 0753 hours, an inspection of the residents' refrigerator was conducted with the DSS. The surrounding of the freezer compartment of the residents' refrigerator was observed with a build-up of ice. The DSS verified the above findings. The DSS stated the dietary staff was responsible to check the temperature of the refrigerator and make sure the food items inside the refrigerator were not expired. The DSS stated the maintenance department was responsible to check the build-up of ice inside the resident's refrigerator. On 4/6/23 at 0735 hours, an interview was conducted with the Maintenance Director. The Maintenance Director stated the dietary staff was responsible to check the resident's refrigerator daily and to inform the maintenance department if the refrigerator needed to be fixed such as if there was a build-up of ice. 055518 Page 28 of 31 055518 04/07/2023 Newport Nursing and Rehabilitation Center 1555 Superior Avenue Newport Beach, CA 92663

F 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the regular inspection of all the bed frames, mattresses, and side rails were performed as part of the regular maintenance program to identify areas of possible entrapment. This had the potential to negatively impact the residents resulting to entrapment, serious injuries, and death. Findings: Review of the facility's P&P titled Bed Safety revised March 2017 showed the facility strives to reduce hazards such as resident entrapment associated with side rails, mattresses and/ or bedrails. In an effort to reduce injuries associated with bedside rails, the DON Services/Environmental Supervisor/ designee and the community IDT shall: - Inspect all bed frames, bedside rails and mattresses according to the regular preventive safety schedule to identify potential areas of possible entrapment; - Ensure that no gap between the mattress, bedframe or side rails exceeds FDA regulations; and - Ensure that replacement mattresses and bedside rail are suitable with dimensions of the bed and in accordance with specified manufacturer instructions. According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. The seven areas in the bed system where there is a potential for entrapment are: - Zone 1: within the rail; - Zone 2: under the rail, between the rail supports or next to a single rail support; - Zone 3: between the rail and the mattress; - Zone 4: under the rail, at the ends of the rail; - Zone 5: between split bed rails; - Zone 6: between the end of the rail and the side edge of the head or foot board; and - Zone 7: between the head or foot board and the mattress end. Review of the facility's document titled Annual Facility Beds Preventive Maintenance Checklist - Electric Drive Model for June 2022 showed, N/A (not applicable) for the column for side rails. The 055518 Page 29 of 31 055518 04/07/2023 Newport Nursing and Rehabilitation Center 1555 Superior Avenue Newport Beach, CA 92663

F 0909 Level of Harm - Minimal harm or potential for actual harm document showed for side rails, to inspect for proper up, down and storage operation, inspect the locking latch for proper operation and to lubricate the mechanism if needed. Review of the facility's document titled Bed Side Rails for March 2023 showed Resident 30's side rails were installed by the Maintenance Director on 3/4/23. Residents Affected - Few Review of the facility's documents and medical records showed the residents beds in the facility were not properly inspected for possible entrapment. For example: On 4/4/23 at 0957 hours, an observation and concurrent interview was conducted with Resident 30. Resident 30 was observed in bed with bilateral ¼ (quarter) side rails elevated. Resident 30 stated he used the side rails to reposition himself. Medical record review for Resident 30 was initiated on 4/4/23. Resident 30 was readmitted to the facility on [DATE]. Review of Resident 30's MDS 2/20/23, showed Resident 30 had a moderate cognitive impairment. Resident 30 required one-person assist for bed mobility and two-person assist for transfer. Review of Resident 30's Order Summary Report showed a physician's order dated 3/3/23, for bilateral ¼ side rails to promote bed mobility and transfer and as an enabler with diagnosis of bilateral AKA (above the knee amputation). Review of Resident 30's Bedrail Use and Entrapment Risk Evaluation dated 2/21/23, showed Resident 30 needed to use the bed rails due to weakness, balance deficit, and bilateral AKA. On 4/5/23 at 0936 hours, and 4/6/23 at 1453 hours, Resident 30 was observed in bed with bilateral ¼ side rails elevated. On 4/6/23 at 0818 hours, an interview and medical record review for Resident 30 was conducted with the DON. The DON verified the above findings. The DON stated Resident 30 was the only resident in the facility with the side rails. When asked about the entrapment assessment, the DON stated the facility used the form titled Bedrail Use and Entrapment Risk Evaluation, and Resident 30 was assessed for entrapment risk. When asked if Resident 30 was assessed in the seven areas/zones of the bed where there was a potential for entrapment are, the DON stated she was not familiar with the different zones of the bed for possible entrapment. When asked about the bed inspection, the DON stated the beds were being inspected on rounds, and the defects would be reported to the maintenance department. When asked if the gaps between the mattress, bedframe or side rails were inspected during the bed inspection, the DON stated the gaps were not inspected because the facility only used bilateral ¼ side rails. On 4/6/23 at 1524 hours, an interview and facility document review for Resident 30 was conducted with the Maintenance Director. The Maintenance verified the above findings. When asked about the bed inspection process, the Maintenance Director stated he checked the beds annually and as need. The Maintenance Director stated he checked the remote control, power cord, and up and down function of the bed during bed inspection. The Maintenance Director stated he installed Resident 30's side rails. When asked if Resident 30's bed was inspected in the seven areas/zones of the bed where there was a potential for entrapment are, the Maintenance Director answered no and stated he was not familiar with the different zones of the bed for possible areas of entrapment. The Maintenance Director stated he 055518 Page 30 of 31 055518 04/07/2023 Newport Nursing and Rehabilitation Center 1555 Superior Avenue Newport Beach, CA 92663

F 0909 was not informed that he had to inspect the bed for possible entrapment. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055518 Page 31 of 31