Health inspection·February 4, 2025

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, and record review, the facility failed to ensure one of three sampled residents was free from unnecessary drugs when 1) Resident 1 did not have an appropriate diagnosis for a psychotropic medication. 2) An anti-anxiety medication was administered to Resident 1 past the 14 day limit without reassessment from the physician. These failures had the potential to harm Resident 1 when an unnecessary psychotropic medications was administered. Findings: 1. According to the Face Sheet, Resident 1 was admitted on [DATE] with diagnoses which included respiratory failure and cerebral palsy (a disorder that affects movement, balance, and posture) . According to the Minimum Data Set (MDS-an assessment tool) dated 8/11/21, Resident 1 was never or rarely understood, and was severely cognitively impaired. The MDS also indicated, Resident 1 had No speech- absence of spoken words, was Rarely/never understood and Rarely/never understands others. During a record review on 12/26/24, Resident 1's Physician's Orders dated 8/24/21 indicated, quetiapine (an antipsychotic medication) 25 mg (milligrams) 1 tablet .for schizophrenia . A record review of Resident 1's Progress Notes dated 8/24/21 indicated, .[Medical Doctor (MD)] gave an order to clarify quetiapine to schizophrenia as manifested by restlessness . There was no documentation from MD that indicated Resident 1 was assessed for or met the criteria for schizophrenia. On 1/10/25 at 8:46 A.M. an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated she was familiar with Resident 1. LN 1 stated Resident 1 did not have any behaviors that suggested hallucinations or delusions, symptoms of schizophrenia. LN 1 stated, He makes noises once in a while .he's not a difficult patient . LN 1 stated Resident 1 never appeared to be in emotional distress and, We would talk to him, and he smiles . On 1/22/25 at 2:12 P.M. a telephone interview was conducted with Resident 1's Family Member (FM) 1. FM 1 stated, He didn't have [schizophrenia]! Who said he had that? He couldn't even talk! Page 1 of 4 055873 055873 02/04/2025 Community Care Center 8665 LA Mesa Blvd. LA Mesa, CA 91942

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 1/24/25 at 1:08 P.M. a telephone interview was conducted with the Psychiatrist (PSYCH) 1 who stated, When [Resident 1] came in [to the facility] based on my recollection, he took [quetiapine]. It seemed to be helping him. I put unspecified schizophrenia .when we use the diagnosis [unspecified schizophrenia] we're trying to justify the continued use of the medication .we don't want to call someone schizophrenic when they might not be . PSYCH 1 stated, In [Resident 1]'s case, its not a confirmed diagnosis .its impossible to diagnose [Resident 1] because he's nonverbal . PSYCH 1 stated he did not discontinue the medication because it helped Resident 1 remain calm. A review of the facility's policy titled Antipsychotic Medication Use revised 7/22 indicated, Residents will not receive medications that are not clinically indicated to treat a specific condition . 2. A review of Resident 1's Physician's Orders dated 10/26/21 indicated, Xanax (alprazolam-a medication used to treat anxiety) 1 tablet PRN (as needed) every 6 hours. For 14 days . On 1/10/25 at 8:56 A.M. a joint interview and record review was conducted with LN 1. LN 1 acknowledged alprazolam was administered to Resident 1 multiple times from 10/26/21 until 12/9/21 and according to the physician order it should only have been given for 14 days. LN 1 stated, the doctor should have given a new order if he wanted to continue to give it .[nursing] probably just forgot to put a stop date . LN 1 stated it was important to reassess the resident to see if he still needed the medication, .because it could sedate him . A review of the facility's policy titled Antipsychotic Medication Use revised 7/22 indicated, .16. PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication and documented the rational for continued use . 055873 Page 2 of 4 055873 02/04/2025 Community Care Center 8665 LA Mesa Blvd. LA Mesa, CA 91942

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 implement infection control measure when three of nine Subacute resident rooms were reviewed. Residents Affected - Few 1) A housekeeper was observed removing Personal Based onProtective Equipment (PPE-gown, gloves, masks) in the hallway outside of an Enhanced Barrier Precaution (EBP--a type of infection control strategy where PPE is worn when providing high-contact care to residents) resident room. 2) A visitor was in an Enhanced Barrier Precaution room providing care without wearing PPE. These failures had the potential to spread infection among staff and visitors. Findings: 1. During a tour of the facility on 1/8/25 at 11:15 A.M. Housekeeper (HK) 1 was observed exiting an Enhanced Barrier Precaution room [resident room [ROOM NUMBER]] wearing PPE. HK 1 was observed removing the PPE in the hallway and discarding it in the housekeeping cart outside the room. On 1/8/25 Resident 1's record was reviewed. According to the Face Sheet, Resident 1 was admitted on [DATE] with diagnosis which included chronic respiratory failure with hypoxia and traumatic brain injury. On 1/8/25 at 11:30 A.M., a joint observation and interview was conducted with the Infection Preventionist (IP). HK 1 was observed exiting [resident room [ROOM NUMBER]] wearing full PPE. room [ROOM NUMBER] had an EBP sign posted on the wall, outside the room. HK 1 was then observed handling a stack of wash cloths, placing it into a clean plastic bag, and placing the bag in the housekeeping cart. HK 1 then doffed (removed) her PPE and discarded it in the housekeeping cart, outside [resident room [ROOM NUMBER]]. On 1/8/25 Resident 2's record was reviewed. According to the Face Sheet, Resident 2 was admitted on [DATE] with diagnosis which included acute and chronic respiratory failure with hypoxia, dependence on a ventilator. The IP stated, [HK 1] should never wear her gown and gloves in the hallway-ever, especially after leaving an EBP room. You don't know what she touched with the dirty gloves . The IP stated HK 1's PPE was considered dirty after she entered the room, and the PPE should have been removed before she exited. The IP stated it was her expectation that PPE be doffed (removed) and discarded prior to exiting the room, to prevent the spread of infection. A review of the facility policy titled Infection Prevention and Control Program dated 10/28 indicated, 11 .a. Important facets of infection prevention include .educating staff and ensuring that they adhere to proper techniques and procedures . 2. According to the Face Sheet, Resident 3 was admitted on [DATE] with diagnoses which included respiratory failure and CRAB (carbapenem resistant Acinetobacter baumannii-a bacteria which is often resistant to nearly all antibiotics). 055873 Page 3 of 4 055873 02/04/2025 Community Care Center 8665 LA Mesa Blvd. LA Mesa, CA 91942

F 0880 Level of Harm - Minimal harm or potential for actual harm During an observation in the Subacute Unit on 1/10/25 at 10 A.M., room [ROOM NUMBER] was observed with an Enhanced Barrier Precautions sign posted outside the door. A visitor (VIS) 1 was observed inside room [ROOM NUMBER] wearing a surgical mask, but no other PPE. Vis 1 used a white gauze to clean Resident 3's skin around the tracheostomy (an opening in the neck made for tube insertion to allow the patient to breathe) site. Residents Affected - Few On 1/10/25 at 11:40 A.M. an interview was conducted with VIS 1. VIS 1 stated he was not aware that he needed to wear a gown and gloves when providing care to Resident 3. VIS 1 stated, I have a pregnant [family member] at home. I don't want to bring anything home to her. VIS 1 stated he would have donned (put on) PPE if he had known prior to entering the room. On 1/20/25 at 11:56 A.M. an interview was conducted with the IP. The IP stated it was important for anybody entering the room to don (put on) PPE, especially if there was going to be high-contact activities. The IP stated, .we should educate them as much as we can . to keep infection from spreading. A review of the facility policy titled Infection Prevention and Control Program dated 10/28 indicated, 13 .a. The facility has established policies and procedures regarding infection control among employees .visitors .precautions to prevent these individuals from contracting infections . 055873 Page 4 of 4