Health inspection·April 12, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 ensure Certified Nurse Assistant (CNA) 3 was seated during meals times while assisting feeding for three of three sampled residents (Residents 25, 33, and 388). This failure had the potential for Residents 25, 33 and 388 to experience loss of dignity, self-esteem and respect. Findings: 1. During a meal observation on 4/9/2024 at 12:42 pm at Resident 25's bedside, Resident 25 was observed sitting in bed while CNA 3 was observed standing on the left side of the bed (right side of the resident), feeding lunch to Resident 25. A review of Resident 25's admission Record indicated Resident 25 was readmitted to the facility on [DATE], with diagnoses that include dementia (a condition characterized by progressive or persistent loss of intellectual functioning), dysphagia (difficulty swallowing), aphasia (an impairment of language affecting the ability to express or understand speech), hemiplegia (paralysis of one side of the body) and hemiparesis (inability to move one side of the body). A review of Resident 25's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 3/7/2024, indicated Resident 25 with a severe impairment to make decisions, learn and/or remember things. The MDS also indicated Resident 25 required supervision or touch assistance (helper may need to help throughout activity) for eating, oral and personal hygiene. A review of Resident 25's History & Physical (H&P) dated 11/7/2023, indicated Resident 25 does not have the capacity to understand and make decisions. 2. During a meal observation on 4/9/2024 at 12:38 pm at Resident 33's bedside, Resident 33 was observed sitting in bed while CNA 3 was observed standing on the right side of the bed (left side of the resident), feeding lunch to Resident 33. A review of Resident 33's admission Record indicated Resident 33 was readmitted to the facility on [DATE], with diagnoses that include dementia (a condition characterized by progressive or persistent loss of intellectual functioning), moderate protein-calorie malnutrition, type 2 diabetes (DM2 - condition that results in too much sugar circulating in the blood) and metabolic encephalopathy (occurs when problems with your metabolism cause brain dysfunction). Page 1 of 51 055989 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 33's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 2/20/2024, indicated Resident 33 is rarely/never understood with a severe impairment to make daily decisions. The MDS also indicated Resident 33 as dependent (helper does all effort) for eating, toileting, oral and personal hygiene. A review of Resident 33's H&P dated 12/31/2023, indicated Resident 33 does not have the capacity to understand and make decisions. A review of Resident 33's Risk for Nutritional Problem Care Plan revised on 2/5/2024, indicated staff are to provide assistance at meals as needed. 3. During a meal observation on 4/9/2024 at 12:34 pm at Resident 388's bedside, Resident 388 observed sitting in bed while CNA 3 was observed standing on the left side of the bed (right side of the resident), feeding lunch to Resident 388. A review of Resident 388's admission Record indicated Resident 388 was admitted to the facility on [DATE], with diagnoses that include dementia (a condition characterized by progressive or persistent loss of intellectual functioning), dysphagia (difficulty swallowing), moderate protein-calorie malnutrition and adult failure to thrive (a state of decline and may be caused by chronic diseases and functional impairments; manifestations include weight loss, decreased appetite, poor nutrition, and inactivity). A review of Resident 388's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 4/5/2024, indicated Resident 388 with a severe impairment to make decisions, learn and/or remember things. The MDS also indicated Resident 388 as dependent (helper does all effort) for eating, toileting, oral and personal hygiene. A review of Resident 388's H&P dated 4/2/2024, indicated Resident 388 does not have the capacity to understand and make decisions. A review of Resident 388's Risk for Nutritional Problem Care Plan revised on 4/8/2024, indicated staff are to provide assistance at meals as needed. During an interview on 4/9/2024 at 2:48 pm with CNA 2, CNA 2 stated according to the facility policy, when residents were being fed by staff, staff were to sit at eye level with the residents. CNA 2 stated the importance of sitting while feeding the residents was to prevent giving the residents too much food at once, so they [the resident ' s] don ' t choke. During an interview on 4/9/2024 at 2:53 pm with CNA 3, CNA 3 stated she could not find a chair to use while feeding Resident 388 and she preferred to stand while feeding Resident 25. CNA 3 stated according to the facility protocol, she should have been seated while feeding Residents 25, 33 and 388. During an interview on 4/9/2024 at 3:31 pm with Director of Staff Development (DSD), DSD stated staff should be seated while feeding residents and should not stand. DSD stated sitting with the residents' during mealtime was important because it maintained the resident ' s dignity, and standing would create the feeling of being rushed, causing the resident to feel emotional as to why it is happening to them and create self-blame for being the reason the staff are in a hurry. The DSD also stated standing while assisting feeding can cause a safety risk of choking for the residents. 055989 Page 2 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the facility's policies and procedures (P&P) titled, Promoting/Maintaining Resident Dignity During Mealtimes, revised 12/19/2022, indicated it is the practice of the facility to treat each resident with respect and dignity and care in a manner and environment that maintains or enhances their quality of life and protects their rights. The P&P also indicated staff are to be seated (if possible) while feeding a resident. A review of the facility's P&P titled, Meal Supervision and Assistance revised 12/19/2022, indicated residents are to be provided adequate supervision and assistance during meals to prevent accidents [any unexpected or unintentional incident, which may result in injury or illness to] and assure an enjoyable event. 055989 Page 3 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0558 Reasonably accommodate the needs and preferences of each resident. 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: provide reasonable accommodation of needs for two of two residents (Resident 30 and 81). Residents Affected - Few 1. Provide reasonable accommodation of needs for one of two sampled residents (Resident 30) by failing to ensure to place resident's call light within reach. 2. Use a communication board, tool or ask assistance from a translator when communicating to one of one sampled resident (Resident 81), who speaks a foreign language. These deficient practices had the potential for Resident 30 not to receive or have a delay in provision of care and necessary services for the resident's well-being, and resulted in Resident 81's verbalized feeling confused and frustrated when the staff communicated in a language that she did not understand. These deficient practices also had the potential for Resiednt 81 not to receive immediate or appropriate care and necessary interventions for her well-being. Findings: 1. A review of Resident 30's admission Record (Face Sheet) indicated the facility originally admitted Resident 30 on 12/01/2023 and readmitted on [DATE] with diagnoses including diffuse traumatic brain injury (sudden trauma that causes damage to the brain) without loss of consciousness (state of being awake and aware of one's self and surroundings), stage 3 chronic kidney disease (mild to moderate loss of kidney function), and benign prostatic hyperplasia (non-cancerous overgrowth of prostate tissue pushing against the bladder and urethra) with lower urinary tract symptoms (blocking the flow of urine out of the body). A review of Resident 30's History and Physical (H&P, a comprehensive physician's note regarding the assessment of the resident ' s health status), dated 1/23/2024, indicated Resident 30 does not have the mental capacity to understand and make medical decisions. A review of Resident 30's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 03/10/2024 indicated the cognitive (ability to think and process information) skills for daily decision making was moderately impaired, required a substantial amount of assistance for general mobility (ability to use joints and muscles easily and comfortably), and required complete staff assistance and supervision for activities of daily living with toileting hygiene, shower/bath self, upper/lower body dressing and putting on/taking off footwear. During a concurrent observation and interview on 4/9/2024, at 8:40 am, with Resident 30 in Resident 30's room, observed Resident 30 lying in bed. Resident 30's call light observed hanging on the intravenous pole (IV pole, medical device that provides a secure place to hang bags of medicine or fluid to infuse into the resident). Resident 30 stated he could not find his call light. When Resident 30 found the call light hanging on the IV pole, Resident 30 stated the inability to reach the call light as it was too far. During an interview on 4/9/2024, at 8:43 am with Certified Nurse Assistant (CNA) 1, CNA 1 stated, she stripped (removed) Resident 30's bed this morning, placed the call light on top of the IV pole, and forgot to return the call light light to Resident 30's bedside. CNA 1 stated the call light 055989 Page 4 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few should have been next to the resident. CNA 1 stated the out of reach call light has a negative impact on the resident due to the resident inability to call the staff for help. During an interview on 04/12/2024, at 3:23 pm with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the call light should be within reach of the resident. LVN 1 stated the call light was a way for the resident to communicate assistance from the staff. During an interview on 04/12/2024, at 4:27 pm with the Director of Nursing (DON), the DON stated the call light should always be within reach of the resident. The DON stated the resident cannot ask for assistance if call light not within reach. During a review of Resident 30's Care Plan (a plan that outlines resident-specific interventions used to guide a resident's care for a given area) titled ADL (Activity of Daily Living) Function Rehabilitation Potential, last revised 02/18/2024, the care plan indicated to keep call light within easy reach. A review of the facility's Policy and Procedure (P&P) titled Call Lights: Accessibility and Timely Response, last revised 12/19/2022, indicated that staff will ensure the call light is within reach of resident and secured, as needed. The P&P also indicated that the call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room. 2. A review of Resident 81's admission Record, dated 4/11/24, indicated Resident 81 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus (a disease when blood sugar is too high) with hyperglycemia (high blood sugar), urinary tract infection (a condition in which bacteria invade and grow in the urinary tract [the organs that make urine and remove it from the body]), most common in the bladder or urethra (a tube through which urine leave the body)], sepsis (severe infection in the blood), immunodeficiency (the decreased ability of the body to fight infections and other diseases), adult failure to thrive (condition when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal), mild cognitive impairment (trouble remembering, concentrating, or making decisions that affect everyday life), and pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time). A review of Resident 81's History and Physical (H&P), dated 2/8/24, indicated Resident 81 has the capacity to understand and make decisions. A review of Resident 81's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 2/11/24, the MDS indicated, Resident 81 was cognitively intact (able to think, remember and reason) and was dependent (helper does all of the effort, resident does none of the effort to complete the activity and required the assistance of two or more helpers is required for the resident to complete the activity) in shower/bathe self, needed substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) in toilet hygiene (the ability to maintain perineal hygiene) and personal hygiene. A review of Resident 81's Care plan, dated 2/27/24, indicated Resident 81 had a communication problem related to mild cognitive impairment and the interventions included to use alternative communication tools as needed. During an observation on 4/10/24 at 9:59 am in Resident 81's room, Certified Nurse Assistant (CNA 055989 Page 5 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 6) asked Resident 81 if she wanted to go the activity ' s room. Resident 81 was observed shaking her hands, stating I don ' t understand, and was observed getting frustrated. CNA 6 did not assist Resident 81 to ensure the resident understood what she was telling the resident, instead CNA 6 was observed walking out of the room. During an interview on 4/10/24 at 10:15 am with Resident 81 in Resident 81's room, Resident 81 stated, Resident 81 could speak little English and two other languages including her native language. Resident 81 stated, the charge nurses usually does not communicate with her in her native language, but she could understand the other languages. Resident 81 stated, CNA 6 spoke to her in English, which she could not understand most of the time. Resident 81 stated, the CNAs never used any communication tool or board to help her understand the staffs when they communicated with her in a language that she does not understand too well. Resident 81 stated she gets confused most of the time when the staff communicated with her which makes her feel frustrated. During a concurrent interview and observation on 4/10/24 at 10:18 am in Resident 81's room, a communication board was observed pinned on a board just below the head light. Resident 81 stated, she did not know there was a communication board in her room, and it was never used by the staffs to communicate with her ever since her admission to the facility. During an interview on 4/10/24 at 10:30 am with CNA 6 outside of Resident 81's room, CNA 6 stated, there was no communication board in the facility that she was aware of. CNA 6 stated, she guessed if Resident 81 understood what she said by Resident 81's keeping silent or getting mean. During an interview on 4/12/24 at 3 pm with Director of Nurses (DON), the DON stated, when a Resident 81 did not understand what CNA 6 told her. The DON stated she expected CNA 6 to ask another staff that spoke the Resident 81's native language for translation. If the staff was busy, she expected CNA 6 to use the communication board located at the head of the resident's bed to make sure the resident could understand her. The DON stated, if a resident could not understand, the resident could get confused, frustrated, and became noncompliant with care, which could cause their health to decline. A review of the facility's policy and procedure titled, Effective Communication, revised 7/17/23, indicated the following: - Effective communication ensure that information provided to the resident is provided in a form and manner that the resident can access and understand, including in a language that the resident can understand. - Alternative technique include using communication boards or writing materials (i.e., write legibly, in plain terms) 055989 Page 6 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the physician and responsible party was notified for one of one resident (Resident 81) with significant change of condition (COC) related to severe MASD (damage of the skin caused by prolonged exposure to various sources of moisture) and fungal skin infection (skin disease irritation, swellingness caused by an overgrowth of a fungus) in the perineal (the area extending from the anus to the vulva in the female and to the scrotum in the male) and perianal (the tissues surrounding the anus) area. This deficient practice Resident 81 developed worsened skin breakdown, fungal infection that led to more pain, discomfort and recurrent sepsis (a life threatning infection of the blood). Crossed reference with F684 and F697. Findings: A review of Resident 81's admission Record, indicated Resident 81 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus (a disease when blood sugar is too high) with hyperglycemia (high blood sugar), urinary tract infection (presence of disease causing organism in the urinary tract [the organs that make urine and remove it from the body]), most common in the bladder or urethra (a tube through which urine leave the body), sepsis (blood poisoning by bacteria), immunodeficiency (the decreased ability of the body to fight infections and other diseases), adult failure to thrive (condition when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal), and pressure ulcer (skin damage caused by constant unrelieved pressure or friction) on the area for a long time). A review of Resident 81's History and Physical (H&P), dated 2/8/24, indicated Resident 81 has the capacity to understand and make decisions. A review of Resident 81's Minimum Data Set (MDS - a comprehensive assessment and screening tool) dated 2/11/24, the MDS indicated, Resident 81 was cognitively intact (able to think, remember and reason), dependent (helper does all of the effort with the assistance of two or more helpers to complete the activity) in shower/bathe self, and needed substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) in toilet hygiene (the ability to maintain perineal hygiene) and personal hygiene. During an interview on 4/9/24 at 2:29 pm, Resident 81 stated she had redness of the buttocks when she was admitted to the facility two months ago. Resident 81 stated, she felt that her buttock wound got worst and caused her a lot more pain than before. Resident 81 stated, at nighttime, the staffs took a long time to come and change her diaper. Resident 81 stated, having the diaper on for a long period of time contributed to her wound getting worst. Resident 81 stated, she requested seeing her doctor, but she has not seen any doctor from the time she was admitted to the facility. During an interview on 4/11/24 at 10:56 am, the Treatment Nurse (TN) stated Resident 81 had severe MASD upon admission with the skin was very very red and opened around the poo poo (perianal) area. The TN stated, Resident 81 urinated often and when the resident's diaper was changed, the resident urinated again. The TN stated Resident 81's wound improved in March 2024, but the skin opened up again 055989 Page 7 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0580 in April 2014. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 4/11/24 at 11:15 am, the TN stated she informed the Primary Medical Physician (PMP) about the change in Resident 81's wound condition on 4/1/24 when the resident's wound was observed more red, opened and multiple rashes were observed around the buttock area, but she did not document in the COC or the nursing progress notes to indicate that a physician and the resident's responsible party were informed of the significant change in Resident 81's wound. The TN stated Resident 81's PMP, or a Wound Consultant (WC, a healthcare professional specialized in skin disorders) did not look at Resident 81's wound on the buttocks. The TN stated, she asked the WC for suggestion of treatment for MASD, but the WC did not assess the resident, and the PMP did not see the resident before signing the suggested treatments by the WC on 4/1/24. The TN stated, she informed the PMP regarding the WC's recommendation and the PMP signed the medication's order without assessing the wound. Residents Affected - Few A review of Resident 81's Order Summary Report, (a physician's order summary) indicated, on 4/1/24, Resident 81's PMP ordered the resident to receive perineal care to cleanse with soap and water, pat dry, apply Zinc Oxide (skin barrier medication for diaper rash) leave open to air, at bedtime until resolved due to severe MASD, and an order for Nystatin-Triamcinolone (medicine is used to treat certain fungus infections), external (outside) cream to apply to perineal topically every shift for MASD until resolved. During an interview on 4/11/24 at 4:45 pm, Resident 81's PMP stated he did not assess Resident 81's wound. The PMP explained that the facility's nurses would usually send pictures of his patients' wound to his phone to see how the wound looked and he would relay it to the WC. The PMP stated, he did not think Resident 81 had any skin problem because he did not receive any report or any picture of the wound on his phone. The PMP stated, I did not get any image or text messages on my phone about the wound. The PMP stated, he did not assess Resident 81's wound because the resident was admitted with UTI and sepsis. The PMP added, he did not assess Resident 81's wound during his most recent visit to the facility because there was no indication to assess. The PMP stated, he signed the skin treatment that was ordered for the resident on 4/1/24 without assessing the wound. During an interview in 4/12/24 at 3 pm, the Director of Nursing (DON) stated, the facility notifies the physicians for any changes of condition, and when the physicians come to visit the patients, they need to assess all residents under their care and the nurses are supposed to let the doctor know an update on the residents because it is a chance for face-to-face report with the doctor. The DON stated for resident with skin problem, upon admission, the nurses need to do assessment, they need to put it in their record, that they notified the doctor and family. The DON stated, she expected the nurses to be specific in their documentation, the admitting nurses to follow up with the TN and the TN to assess and keep an eye on the skin problem. The DON stated, the TN is in charge of weekly assessment, and it is important to do weekly assessment to make sure the wound is getting better or getting worst. The DON stated, the doctor should be notified on time to make sure the resident receives the right treatment. The DON stated, it was important to notify the doctor if the wound treatment is not effective so the doctor can adjust the treatment right away. During an interview in 4/12/24 at 3:05 pm, the DON stated, Documentation is strong evidence that you did what you say and will have a record on the resident's condition that the whole care team will know. The DON stated, if the resident's MASD was getting worse, the ID will meet to discuss for proper care. 055989 Page 8 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0580 Level of Harm - Minimal harm or potential for actual harm A review of the facility's Policy and Procedures (P&P) titled Notification of Changes, revised 12/19/22, indicated the following: - The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification. Residents Affected - Few -Circumstances requiring notification include circumstances that require a need to alter treatment. Need to alter treatment significantly means a need to commence a new form of treatment to deal with a problem. 055989 Page 9 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop comprehensive care plans (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) for three of three sampled residents (Resident 12, 2, and 31). 1. Resident 12 who had oxygen therapy in accordance with the facility's protocol for Oxygen Administration. 2. Resident 2 who was admitted with diagnoses of sepsis (a potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs) and pneumonia (a severe infection in your lungs). 3. Resident 31's preference to receieve prescribed medication at different times from the usual medication scheduled times at the facility. These deficient practices had a potential for Resident 12 not to receive or receive delayed necessary interventions during oxygen therapy, Resident 2 to have inadequate and incomplete provision of care and treatment which would put her at risk for worsening of infection and/or wellbeing, and Resident 31's frustration related to not honoring his rights to take medicatios as he preferred without proper interventions and a high risk for other residents to consume the medications from Resident 31's bedside which could result in adverse reaction undesired effect of the medications. Findings: 1. A review of Resident 12's admission Record, dated 4/11/24, indicated Resident 12 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure (a condition where there's not enough oxygen the body) with hypoxia (the state of too little oxygen), chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems) with acute exacerbation (sudden worsening in airway function and respiratory symptoms in patients with COPD), hypertension (high blood pressure), and abnormalities of gait and mobility. A review of Resident 12's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 1/29/24, the MDS indicated, Resident 12 was cognitively intact (able to think, remember and reason) and was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity) in shower/bathe self, needed substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) in personal hygiene and needed supervision with eating and oral hygiene. A review of Resident 12's Order Summary Report, dated 4/11/24, indicated Resident 12 had order for oxygen via nasal cannula (a thin, flexible tube that gives additional oxygen through the nose) at 2-3 liters (a unit for measuring the volume of a liquid or a gas) per minutes to maintain SPO2 (measures how much oxygen blood carries in comparison to its full capacity) greater or equal to 93%, as needed. During an interview on 4/10/24 at 3:18 pm with Licensed Vocational Nurse (LVN) 4, LVN 4 stated, any 055989 Page 10 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resident with oxygen therapy should have a care plan for it. In the care plan, they would put in the exact order as in how many litters per minute, what route, and interventions such as to monitor for SPO2 (oxygen blood level) every shift. LVN 4 stated, a care plan is important because it helps them know the problem, goal and interventions, what the resident needs and if the resident meets the goal so they can monitor to see if the interventions are effective or not effective. LVN 4 stated, if they don ' t have a care plan for oxygen therapy, other care members will not share the same information, the same goal and know how to monitor for the resident. During a concurrent interview and record review on 4/10/24 at 3:42 pm with Registered Nurse Supervisor (RN) 1, Resident 12's care plan from admission date (1/26/24) was reviewed. RN 1 stated, she could not find any care plan related to oxygen therapy for Resident 12. During a concurrent interview and record on 4/10/24 at 3:48 pm with LVN 4, Resident 12's care plan from admission date (1/26/24) was reviewed. LVN 4 confirmed, there was no care plan for oxygen therapy in Resident 12's care plan. During an interview on 4/12/24 at 3 pm with the Director of Nurses (DON), the DON stated, whoever received the physician's order should develop the care plan. The DON stated, in the care plan, she expected the nurses to put in the exact order, such as how many litters, what route to be delivered so everyone would know how to care for and how to monitor the resident with oxygen order such as oxygen saturation, and all interventions related to oxygen therapy. The DON stated a care plan is a form of communication with other staff so that they can know what is going on with the resident and how to care for the resident. The DON stated failure to create a care plan could lead to a decline in the resident's health. A review of the facility's policy and procedure titled, Oxygen Administration, dated 12/19/22, indicated, the resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: a. The type of oxygen delivery system. b. When to administer, such as continuous or intermittent and/or when to discontinue. c. Equipment setting for the prescribed flow rates. d. Monitoring of SpO2 levels and/or vital signs, as ordered. e. Monitoring for complications associated with the use of oxygen. 2. A review of Resident 2's admission Record indicated Resident 2 was readmitted to the facility on [DATE] with diagnoses that included sepsis (a severe body response to infection, which causes the immune system to attack tissues and leads to inflammation and potential organ damage), Chronic Obstructive Pulmonary Disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), urinary tract infection (UTI- an infection in any part of the urinary system), pneumonia (PNA- an infection that affects one or both lungs) and dementia (a condition characterized by progressive or persistent loss of intellectual functioning). A review of Resident 2's Minimum Data Set (MDS - a standardized resident assessment care screening tool) dated 2/12/2024, indicated Resident 2 had severe impairment to make decisions, learn and/or 055989 Page 11 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some remember things that required moderate assistance (helper does less than half the effort) with eating and oral hygiene and maximal assistance (helper does more than half the effort) with toileting, bathing and dressing. The MDS also indicated active diagnoses of pneumonia and septicemia (a condition when bacteria enter the bloodstream, and cause blood poisoning triggering sepsis). A review of Resident 2's History & Physical (H&P) dated 2/8/2024, indicated Resident 2 does not have the capacity to understand and make decisions. A review of Resident 2's Admitting Diagnosis Worksheet dated 2/8/24, indicated active diagnoses of sepsis and PNA for current stay at facility. A review of Resident 2's Order Summary Report dated 4/12/2024, indicated an order for two antibiotics (a medication that works by killing bacteria or preventing their growth) Ceftriaxone and Metronidazole for the treatment of PNA from 2/7/2024 - 2/14/2024. During a concurrent interview and record review on 4/12/2024 at 9:42 am with Licensed Vocational Nurse (LVN) 1, indicated Resident 2's had no care plan that address interventions in the management of sepsis or PNA. LVN 1 stated she does not see a care plan in the resident's clinical record. LVN 1 stated care plans are necessary and not having a care plan is a risk to resident's health and care when staff don't know the interventions to do, what to monitor and goal to resolve. During an interview on 4/12/24 at 10:49 am with Admissions Nurse (AN), AN stated she initiates the comprehensive care plans for the residents that was based off the resident's admitting diagnoses, MDS and admitting medications. AN stated facility did not create a care plan for Resident 2's diagnoses of PNA and sepsis because the facility did not treat the diagnoses once admitted . During a concurrent interview and record review on 4/12/24 at 11:30 am with Admissions Nurse (AN), Resident 2's Order Summary and Nursing Progress Notes for 2/2024. The documents collectively indicated Resident 2 was being monitored and treated for PNA, sepsis and UTI once readmitted to the facility on [DATE]. AN stated the following: a. There should have been care plans created for Resident 2's sepsis and PNA diagnoses. b. A care plan is a systemic process for the well-being of the resident that identifies measurable goals and interventions that will be followed and evaluated to determine if the care is effective. c. The risks for not having a care plan that included resident's symptoms will not be treated or resolved and resident may have to go back to the hospital. 3. A review of Resident 31's admission Records (Face Sheet) indicated the facility originally admitted Resident 31 on 5/1/2023 and readmitted on [DATE] with diagnoses including hypoxemia (low level of oxygen in the blood), chronic obstructive pulmonary disease (lung disease that causes restricted airflow and breathing problems) with acute exacerbation (sudden flare up of symptoms), and lack of coordination. A review of the Resident 31's History and Physical (H&P), a comprehensive physician's note regarding the assessment of the resident's health status), dated 5/2/2023, indicated Resident 31 had the 055989 Page 12 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0656 mental capacity to understand and make medical decisions. Level of Harm - Minimal harm or potential for actual harm A review of Resident 31's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 02/08/2023 indicated the cognitive (the ability to think and process information) skills for daily decision making was moderately impaired and required supervision/ assistance with personal hygiene, and partial staff assistance with supervision for activities of daily living such as shower/bathing self and upper/lower body dressing. Residents Affected - Some During a concurrent observation and interview on 4/9/2024 at 9:50 am in Resident 31's room, a a plastic medicine cup with five medication pills was on top of Resident 31's bedside table. Resident 31 stated he takes some morning pills with breakfast and leaves the rest of the pills in the cup on the bedside table to be taken at a later time. During an interview on 4/9/2024, at 9:55 am with Licensed Vocational Nurse (LVN) 2, LVN 2 stated the correct process to give medications was pulling out medications from medication cart, putting it in a medicine cup, passing the medicine cup to the resident, and making sure resident takes the medications. LVN 2 stated she could not identify the five medication pills in medicine cup that was left on Resident 31's bedside table. A review of Resident 31's clinical recod indicated the resident did not have a person-centered comprehensive care plan to address goals and interventons for resident's preference to recieve prescribed medication at a different time from the usual medication schedule times at the facility. During a review of Resident 31's Physician Order Summary, there were no physician order for Resident 31's preference to take medication at a later time than the usual scheduled time at facility. During a concurrent interview and record review on 4/9/2024 at 10 am with LVN 2, Resident 31's care plan and physician order from 5/1/2023 to April 2024 were reviewed. LVN 2 stated Resident 31 does not have care plan or physician's order that addressed Resident 31's preference to take medication at a later time. LVN 2 stated there should be a care plan implemented and the physician should be aware of Resident 31's medication administration preferences. During an interview on 4/10/2024, at 3:20 pm with the Director of Nursing (DON), the DON stated all residents should not be left on resident's bedside table. The DON stated the medication given past scheduled time reduced the effectiveness of the medication. The DON stated the care plans should help guide licensed nurses what to do. The DON stated Resident 31 did not have a care plan to address Resident 31's preference to take medication at a later time and the physician was not notified of the resident's preference. A review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plan revised 12/19/2022, indicated: a. It is the policy of the facility to develop and implement a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychological needs identified in the comprehensive assessment. b. The care plan will describe services to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. 055989 Page 13 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0656 Level of Harm - Minimal harm or potential for actual harm c. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. The facility's P&P also indicated the comprehensive care plan will describe resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity. Residents Affected - Some 055989 Page 14 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

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 record review, the facility failed to ensure one of three residents (Resident 81) was assessed, monitored, and evaluated for skin breakdown related to MASD (Moisture-associated skin damage caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, mucus, saliva, and their contents. MASD is characterized by inflammation of the skin, occurring with or without erosion [gradual destruction of tissue] or skin infection) and fungal infection (irritation or swelling of the skin cause by overgrowth of fungus) in accordance with the facility's policy and procedure and resident's plan of care. Residents Affected - Some The facility failed to ensure: 1. Resident 81's plan of care was implemented to assess and document status of wound perimeter; wound bed and healing progress and report improvements and declines to medical doctor and resident. 2. The Treatment Nurse (TN) assessed, monitored and evaluated Resident 81 ' s skin weekly for as needed for size, appearance, presence of infection, drainage and presence of new skin breakdown. 3. Resident 81's name was not listed in the Assessment History for Skin Only Evaluation in the facility ' s computerized charting system to prompt the TN to assess the resident ' s skin condition. 4. The TN informed the physician and documented on a Change of Condition report (COC) when Resident 81 ' s wound worsened in size, new rashes and fungal infection was noted. 5. The TN consulted the primary physician before consulting the Wound Consultant (WC- specialist in wound management) for Resident 81 ' s skin and wound treatment. The WC was not assigned to the resident to be assessed. 6. The physician order was implemented for Resident 81 to leave perineal area open to air, at bedtime until resolved due to severe MASD. 7. The Primary Physician did not physically assess and evaluated Resident 81 ' s skin to ensure the skin treatment ordered was adequate and effective. This failure resulted in Resident 81 ' s wound to delay healing or worsened by having unrelieved severe pain and verbalized feeling sad that the facility allowed her to suffer from pain, which prevented her from moving around and attending activities that can potentially cause a decline in the resident's physical health and quality of life. Crossed reference with F697, F711 and F580 Findings: A review of Resident 81 ' s admission Record indicated Resident 81 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus (a disease when blood sugar is too high) with hyperglycemia (high blood sugar), urinary tract infection (presence of disease causing organism in the urinary tract [the organs that make urine and remove it from the body]), most common in the bladder or urethra (a tube through which urine leave the body), sepsis (blood poisoning by 055989 Page 15 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some bacteria), immunodeficiency (the decreased ability of the body to fight infections and other diseases), adult failure to thrive (condition when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal), and pressure ulcer (skin damage caused by constant unrelieved pressure or friction on one area for a long time). A review of Resident 81's History and Physical (H&P), dated 2/8/24, indicated Resident 81 has the capacity to understand and make decisions. A review of Resident 81's Minimum Data Set (MDS- a comprehensive assessment and screening tool), dated 2/11/24, the MDS indicated, Resident 81 was cognitively intact (able to think, remember and reason) and was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity) in shower/bathe self, needed substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) in toilet hygiene (the ability to maintain perineal hygiene) and personal hygiene. A review of Resident 81's Care plan, dated 2/8/24, indicated Resident 81 had a rash of the perineal (body area between the anus and vaginal area) extending to perianal (body area near the anus) redness relate to severe MASD. The plan of care indicated a goal to prevent no complications from rash. To prevent signs and symptoms of infection of the rash the interventions included to monitor for skin rashes for increased spread or signs of infection. A review of Resident 81's Care plan, dated 2/27/24, indicated Resident 81 was at risk for skin break down related to impaired mobility, cognitive impairment, and diabetes mellitus and the goal was that the resident risk for skin breakdown/pressure ulcer will be minimized daily. The interventions included to administer treatment/medication as ordered and monitor for effectiveness and delayed healing. A review of Resident 81's Care plan, dated 3/1/24, indicated Resident 81 had a potential to develop pressure ulcer, and the interventions included to assess/record/monitor wound healing on a weekly basis and as needed; assess and document status of wound perimeter; wound bed and healing progress; report improvements and declines to medical doctor and resident/resident representative. The interventions also included to follow facility polices/protocols for the prevention/treatment of skin breakdown and inform the resident/family/care givers of any new area of skin breakdown. A review of Resident 81's Order Summary Report, (a physician's order summary) for April 2024, indicated on 4/1/24 Resident 81 ' s physician ordered the resident to receive perineal care to cleanse with soap and water, pat dry, apply Zinc Oxide(skin barrier medication for diaper rash) leave open to air, at bedtime until resolved due to severe MASD, and an order for an external (outside) cream named Nystatin-Triamcinolone (a medicine used to treat certain fungus infections) to apply to perineal are topically every day shift for MASD until resolved. During an interview on 4/9/24 at 2:29 pm, Resident 81 stated she was admitted to the facility two months ago with skin redness on her buttock. Resident 81 stated she feels the skin redness to the buttocks, got worst and now caused the worst pain she ever experienced. Resident 81 stated, she believed wearing diaper for a long period of time contributed to her worsened wound condition that is causing her severe pain. During an observation in Resident 81's room on 4/10/24 at 9:45 a.m. Certified Nurse Assistant (CNA) 055989 Page 16 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 6 was assisting Resident 81 to change brief. While being assisted by CNA 6, Resident 81 was observed moaning saying Ahhh ahhh. Resident 81 ' s perineal and perianal skin area was observed with left buttock (close to the perianal area) maroon colored skin discoloration approximately measure 5 cm x 7 cm with multiple open lesions (area of abnormal or damaged tissue caused by injury, infection, or disease), scattered redness and dry skin peeling off and rashes covering the buttock area extending to the back of bilateral (both sides) upper thigh. CNA 6 was observed continuing to clean Resident 81 while the resident was moaning and saying Ahhhh and without stopping or asking why Resident 81 was screaming while telling Resident 81 It's ok, it's ok. During an interview on 4/10/24 at 9:59 AM, Resident 81 stated, she had to keep her brief on at all times because she was incontinent (no control) and the staffs does not come to change her often and she can not control urination and she does not want to lay on a wet bed constantly. During an interview on 4/11/24 at 10:56 am with the TN, the TN stated, she was aware that Resident 81 was admitted with severe MASD in the private area up to the anal area on 2/8/24. The TN stated, Resident 81 ' s skin was very red when the resident was admitted which improved in March but got worse again in April. The TN stated she does not know why Resident 81 ' s wound was worsened. TN stated there was no process to ensure the CNAs were monitored how Resident 81 with MASD was kept clean and dry. During a concurrent interview and record review on 4/11/24 at 11:05 am with the TN, Resident 81's Skin assessment records and Assessment History were reviewed. The TN stated, she documented on 2/8/24 that Resident 81's wound was maceration. TN stated, maceration means swollen, very bad condition but skin was not open. The TN stated, she was supposed to assess, monitor Resident 81 ' s skin weekly for healing, but she was not able to do so because Resident 81 ' s name was not included in the list for the resident ' s to be assessed using the skin Assessment History. TN stated, the report shows the status of the wound and completed resident's skin assessment for each resident that are on the list. The TN stated, she would do the resident's skin assessment when the report indicated incomplete. The TN showed the surveyor the Assessment History record and TN stated, Resident 81 was not listed in the report. TN stated I have so many residents for skin assessment, so I forgot to do it. During an interview on 4/11/24 at 11:15 am with the TN, the TN stated, the Wound Consult (WC medical personnel specialized in recommending wound management) was not ordered by the physician to assess Resident 81 ' s wound. The TN stated, I classified it (Resident 81's wound) as MASD because it was in the pee-pee and poo-poo area (referring to the perineal and perianal area). The TN stated, on 4/1/24, she put in an order for Nystatin-Triamcinolone external cream as a treatment for severe MASD after she speaking to the Wound Consultant (WC) about MASD treatment. The TN stated, she then called the primary physician for Resident 81 about the treatment and the doctor ordered the Nystatin-Triamcinolone cream without assessing the wound. The TN stated, the WC did not see Resident 81's wound on 4/1/24 when the order for resident's wound was placed on 4/1/24 or at any time. During an interview on 4/11/24 at 1:49 pm with the Registered Nurse Supervisor (RNS) 3, RN 3 stated, when she admitted Resident 81 on 2/8/24. she did not notify the primary medical doctor (PMD) about the presence of MASD, pressure injury, rashes, because she usually relays the resident's skin problem to the TN. The TN consults with the WC for treatment and recommendations. RN 3 stated, it's important to notify the doctor about the resident's skin issue for immediate treatment and interventions. During a concurrent interview and record review on 4/11/24 at 2 pm, Resident 81 ' s N Adv-Clinical 055989 Page 17 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Admission (a record of the facility ' s admission assessment) was reviewed. RNS 3 stated, she did not thoroughly assess Resident 81 ' s skin condition on admission. RN 3 stated, Resident 81 was admitted on [DATE], with perineal skin redness and the skin was not opened. RN 3 stated, I saw it today and the rashes looked worst, and the wound had a few openings. During a concurrent interview and record review of Resident 81 ' s H&P, Change of Condition (COC), report, Progress Notes, and Skin assessment notes from admission date (2/8/24), on 4/11/24 at 2:10 p.m. with RNS 3, RN 3 stated, she could not find any documented evidence Resident 81 ' s MASD in the perineal and perianal area was assessed and reassessed by the licensed staffs and the physicians to identify if the wound was improved or worst. RN 3 explained, if Resident 81's perineal wound condition became worse, there should be a COC report indicating the physician ' s notification and physician ' s orders or skin treatment to be carried out. RN 3 stated, she could not find any documented COC report or nurses' progress notes regarding Resident 81's perineal and perianal skin condition in the resident's medical record. RN 3 stated, she was responsible for weekly skin assessment of Resident 81, but she could not find in Resident 81's medical record that a weekly skin assessment was conducted since resident ' s admission on [DATE]. During a phone interview on 4/11/24 at 4:45 pm with Resident 81's PMD, the PMD stated, he was not aware that Resident 81 had any skin problem. The PMD stated, the nurses would text him to his phone and send him the picture of the resident ' s wound and would replay it to treatment nurse and the wound doctor would take care of it. The PMD stated, he checked his phone and confirmed that he did not receive any image regarding Resident 81's perineal and perianal wound. The PMD stated, he was not notified and did not assess any wound from Resident 81. The PMD stated, he usually rounded on his patients, but he would not see or assess them if there was no change and no indication for assessment that was reported to him about the residents. During an interview on 4/11/24 at 6:45 pm, LVN 5 ( worked from 11pm to 7am) stated she was not aware that Resident 81 had a physician order to keep wound open to air at bedtime until MASD was resolved. LVN 5 stated Resident 81 uses brief at all times during the night. A review of Resident 81's Surgical Consult, notes, dated 4/11/24, indicated, Resident 81 had a skin lesion located on the perineum extending to perianal that was consistent with severe MASD/Fungal dermatitis. The record also indicated, Resident 81 was at risk for developing a pressure injury because of resident ' s risk factors that included diabetes, cognitive impairment, and limited mobility. During an interview on 4/12/24 at 9 am, Resident 81 stated, she has been having a lot of pain in her perineal and perianal area for the last two months. Resident 81 stated, her wound was never better, it is worst that is causing her a lot of negative effect in her mental health because she had been constantly sad and does not know why the facility allowed her to suffer from her wound. Resident 81 stated, she could not move around because of the wound pain. During an interview on 4/12/24 at 11:31 am with Licensed Vocational Nurse (LVN) 3, LVN 3 stated, she had been taking care of Resident 81 since admission on [DATE]. LVN 3 stated, upon admission, Resident 81's perineal and perianal area was very red. LVN 3 stated, she did not see any open skin around Resident 81 ' s perianal area and the MASD was not too much. LVN 3 stated, Resident 81 had some rashes but was minimal. During a concurrent interview and record review on 4/12/24 at 11:50 am with the TN in the conference room, Resident 81's Electronic Health Record was reviewed. The TN confirmed that there was no 055989 Page 18 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some record of skin assessment, COC report, and no nurse ' s progress note that indicated Resident 81's perineal/perianal skin condition was assessed and evaluated if the treatment provided was effective. The TN stated, there was also no record that the PMD was informed when Resident 81's perineal/perianal wound became worst on 4/1/24 that required the addition of another skin treatment and there was no record that the PMD assessed and evaluated Resident 81's wound condition to ensure the skin treatment orders were effective. During an interview on 4/12/24 at 3 pm with the Director of Nurses (DON), the DON stated she expected her nurses to conduct skin assessment for any resident with skin problem upon admission and document in the resident's medical record if the doctor and/or responsible party were notified. The DON stated the TN was expected to assess and keep an eye on the resident ' s identified skin problem on admission and weekly. The DON stated the nurses needed be specific in their documentation for what problem that was reported to the physician and document the physician ' s orders or recommendations. The DON stated, the admission Nurse was expected to assess the resident ' s skin condition upon admission and the treatment nurse was expected to recheck, monitor for wound healing and complete the weekly skin assessments. The DON stated, it was important to do weekly assessment because it was a tool to know if the wound was getting better or getting worse so that the nurses could notify the doctor on time to make sure the right treatment was given immediately, for the well-being of the resident. The DON stated, it was important to monitor for wound healing to make sure if the treatment was effective or ineffective and notify the doctor as soon as possible so the treatment could be adjusted. The DON stated, when a resident ' s skin condition became worst, she expected her nurses to notify the physician and document it in the COC report, the skin assessment, and Nurses ' Progress notes. The DON stated if you don't document it, you did no do it. You need to document so that everyone else will know because when you're not there, they don't know. The documentation is a strong proof that you did what you said and will have a record on the resident's condition that the whole care team will know. A review of the facility ' s policy and procedure (P&P) titled, Skin Assessment, dated 12/19/2022, indicated the following: -A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. - Documentation of skin assessment: Include date and time of the assessment, your name, and position title; Document observations (e.g. skin conditions, how the resident tolerated the procedure, etc.); Document type of wound; Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain). b. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). A review of the facility ' s P&P titled, Skin Integrity - Incontinence Associated Dermatitis (IAD), dated 12/19/2022, indicated the following: - Residents who are incontinent will receive appropriate treatment and services for the prevention and management of incontinence-associated dermatitis (IAD). IAD refers to skin damage caused by prolonged or recurrent contact with stool and/or urine. Affected skin areas involve the perineum, and 055989 Page 19 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0684 may extend to involve the buttocks, hips, and sacrum. Level of Harm - Minimal harm or potential for actual harm - Monitoring and Modification of Interventions: Monitor response to interventions for managing incontinence and to skin care regimen; Notify the physician of the presence and severity of IAD; Notify the physician of the presence and severity of any skin loss or presence of fungal or bacterial skin infection. Residents Affected - Some A review of the facility ' s P&P titled, Notification of Changes, dated 12/19/2022, indicated the following: - The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification. -Circumstances requiring notification include circumstances that require a need to alter treatment. Need to alter treatment significantly means a need to commence a new form of treatment to deal with a problem. 055989 Page 20 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **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 (Resident 76) receives appropriate care and services to prevent urine in the Foley catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) from entering back into the bladder and cause urinary tract infections (an infection due to a disease causing organisms that enters the bladder and the kidney). Resident 76 was observed with Foley catheter tubing kinked (sharp twist or bent) on the bedrail and causing the urine to flow back to the bladder and not flow freely into the drainage bag as indicated in the facility's policy and procedure and Resident 76's plan of care. This deficient practice had the potential for Resident 76 to experience recurrent urinary tract infection and negatively affect Resident 76s quality of life. Findings: During a review of Resident 76's admission Record (AR), dated 4/11/2024, indicated Resident 76 was admitted on [DATE], and readmitted on [DATE], with diagnoses including urinary tract infection, respiratory failure (a condition in which the lungs have a hard time loading the blood with oxygen or removing carbon dioxide) and heart failure (heart doesn't pump enough blood for your body's needs). During a review of Resident 76's History and Physical (H&P) Assessment, dated 2/28/2024, indicated Resident 76 did not have the capacity to understand and make decisions. The H&P also indicated Resident 76 was diagnosed of sepsis (a life-threatening infection in the blood) secondary to urinary tract infection (UTI). During a review of Resident 76's Minimum Data Set (MDS) -a standardized assessment and screening tool dated 3/19/2024, the MDS indicated Resident 76's cognitive status (ability to process and comprehend information) was severely impaired and was dependent (helper does all the effort) with all ADLs (activities of daily living). During a concurrent observation and interview on 4/9/2024, at 4:12 pm with Registered Nurse (RN) 2 in Resident 76's room, Resident 76's foley catheter was kinked on the bedrail positioned above Resident 76's bladder. The urine from the foley catheter was not flowing freely and was flowing back up towards Resident 76's bladder. RN 2 stated, the Foley catheter should not be kinked, and the backflow of urine could cause the resident to have recurrent UTI. During an interview on 4/9/2024 at 4:15 pm with the Infection Preventionist (IP) nurse, IP nurse stated, the urine in Resident 76's Foley catheter should be flowing freely because the urine can backflow to the bladder and cause the resident to experience recurrent UTI. During an interview on 4/11/2024 at 9:10 am with the Director of Nurses (DON), the DON stated, Resident 76s urine in the Foley catheter should be free flowing and the catheter was not kinked to prevent the urine to backflow into the bladder and prevent further UTI. A review of Resident 76's care plan (CP), initiated 2/28/2024, indicated Resident 76's Foley catheter bag and tubing should be positioned below the level of the bladder. 055989 Page 21 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0690 A review of Resident 76's order Summary Report dated 4/11/2024, indicated: Level of Harm - Minimal harm or potential for actual harm a. Physician order date 3/4/2024, Resident 76 had a Foley catheter for neurogenic bladder (lacks bladder control due to a brain, spinal cord, or nerve condition) distention (swelling and becoming large by pressure from inside) management. Residents Affected - Few b. Physician order date 4/2/2024, Cipro (used to treat bacterial infections) 500 mg (milligrams-unit of measurement) twice a day for 10 days for abnormal urinalysis (UA) (a test for urine that determines presence of infection). A review of the facility's policy and procedure (P&P) titled, Catheter Care, revised on 12/19/2022, the P&P indicated the facility will a) ensure drainage bag is located below the level of the bladder to discouraged backflow of the urine, b) check drainage tubing and bag to ensure that the catheter is draining properly. A review of the facility's P&P titled, Infection Prevention and Control Program, revised 12/19/2022, the P&P indicated, the facility will establish, maintain infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of communicable diseases an infection as per accepted national standards and guidelines. 055989 Page 22 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

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 implement the facility's policy and procedure on Care and Treatment of Feeding Tubes, for one of one sampled resident (Resident 72). The facility failed to ensure: 1. Resident 72's gastrostomy tube (tube inserted through the belly that brings nutrition directly to the stomach) was labeled with the date when the tubing will be changed and/or the last time it was changed. This failure had the potential to cause complications to Resident 72's gastrostomy tube. Findings: During a review of Resident 72's admission Record (AR), dated 4/11/2024, indicated Resident 72 was admitted on [DATE], and readmitted on [DATE], with diagnoses including gastrostomy ( (an opening into the stomach from the abdominal wall, made surgically for the introduction of food) infection, other complication of gastrostomy, sepsis (potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), and atherosclerosis of aorta (material called plaque (fat and calcium) has built up in the inside wall of a large blood vessel called the aorta). During a review of Resident 72's History and Physical (H&P) Assessment, dated 10/16/2023, indicated Resident 72 did not have the capacity to understand and make decisions. During a review of Resident 72's Minimum Data Set (MDS) -a standardized assessment and screening tool, dated 3/13/2024, the MDS indicated Resident 72's cognitive status (ability to process and comprehend information) was severely impaired. The MDS indicated Resident 72 was dependent (helper does all the effort) with all ADLs (Activities of Daily Living). During a concurrent observation and interview on 4/9/2024, at 10:10 am with Registered Nurse (RN) 1 in Resident 72's room, Resident 72 gastrostomy tubing did not have a date on when the GT will be changed or last changed. RN 1 stated, gastrostomy tubing should have been dated to have determination the last time it was changed. RN 1 stated, if the gastrostomy tubing was not dated, it is an infection control issue because no one can tell when it was changed. RN 1 stated, old tubing could cause bacteria build up, and potentially cause infection. During an interview on 4/9/2024 at 12:30 pm with the Infection Preventionist (IP) nurse, IP nurse stated, tubing for the gastrostomy feeding formula should be dated so the nurses would know the last time it was changed. IP nurse stated, old tubing's can harbor bacteria and affect patients' health. During an interview on 4/11/2024 at 9:09 am with the Director of Nurses (DON), DON stated, the facility does not have the policy for gastrostomy feeding tubing to be changed, but it should have been labeled and dated so the nurses would know the last time it was changed. DON stated, if the tubing did not have a date, it should be changed right away. DON stated, old tubing can harbor bacteria and be an infection control issue. 055989 Page 23 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the facility's policy and procedure (P&P) titled, Care and Treatment of Feeding Tubes, revised on 12/19/2022, the P&P indicated; a) the facility to utilize feeding tubes in accordance with current clinical standards of practice with interventions to prevent complications to the extent possible, b) use of infection control precautions and related techniques to minimize the risk of contamination. A review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, revised 12/19/2022, the P&P indicated, the facility to establish and maintains and infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of communicable diseases an infection as per accepted national standards and guidelines. 055989 Page 24 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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: Residents Affected - Few 1. Ensure one of three sampled residents (Resident 12) had nasal canula and humidifier bottle dated and changed weekly in accordance with the facility's protocol for Oxygen Administration. 2. Ensure one of three residents (Resident 59) had a plastic storage bag for oxygen equipment changed weekly per facility's standard of practice. This failure had a potential to result in Resident 12 and Resident 59 using contaminated (the presence of an infectious agents- bacteria, viruses, microbes) oxygen equipment leading to a possible respiratory infection (an infection of parts of the body involved in breathing, such as the sinuses, throat, airways or lungs), sepsis (severe infection in the blood) including pneumonia (an infection that affects one or both lungs). Findings: 1. A review of Resident 12's admission Record, dated 4/11/24, indicated Resident 12 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure (a condition where there's not enough oxygen the body) with hypoxia (the state of too little oxygen), chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems) with acute exacerbation (sudden worsening in airway function and respiratory symptoms in patients with COPD), hypertension (high blood pressure), and abnormalities of gait and mobility. A review of Resident 12's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 1/29/24, the MDS indicated, Resident 12 was cognitively intact (able to think, remember and reason) and was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity) in shower/bathe self, needed substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) in personal hygiene and needed supervision with eating and oral hygiene. A review of Resident 12's Order Summary Report, dated 4/11/24, indicated Resident 12 had a physician order to receive oxygen via nasal cannula (a thin, flexible tube that gives additional oxygen through the nose) at 2-3 liters (a unit for measuring the volume of a liquid or a gas) per minutes to maintain SPO2 (measures how much oxygen blood carries in comparison to its full capacity) greater or equal to 93%, as needed. During an observation with Registered Nurse Supervisor (RN) 1 on 4/9/24 at 10:30 am in Resident 12's room. Resident 12 was observed receiving oxygen via nasal cannula tubing without a dated attached to a prefilled humidifier bottle with handwritten label dated 3/31/24 to 4/6/24. On a concurrent interview Registered Nurse Supervisor (RN) 1 stated, the nasal cannula was supposed to be dated with the date that cannula was changed and the date that it supposed to be used by and the prefilled humidifier (a device for increasing the amount of water vapor) bottle was supposed to be change weekly because of infection control issue. RN 1 stated, we already passed three days. During an interview with the Director of Nurses (DON) on 4/12/24 at 3:00 pm, the DON stated, per 055989 Page 25 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility protocol, the nasal cannula and the humidifier bottle should be dated and changed weekly. The DON stated, the resident would breathe in the oxygen via nasal cannula and humidifier so changing them weekly would prevent lung infection. A review of the facility's policy and procedure titled, Oxygen Administration, dated 12/19/22, indicated, infection control measures include: a. Follow manufacturer recommendations for the frequency of cleaning equipment filters. b. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. c. Change humidifier bottle when empty, weekly or per facility policy. 2. A review of Resident 59's admission Record indicated Resident 59 was admitted to the facility on [DATE] with diagnoses that include acute respiratory failure (a sudden condition in which not enough oxygen passes from the lungs into the blood), Chronic Obstructive Pulmonary Disease (COPD -a lung disease characterized by long-term poor airflow), emphysema (a chronic disease in which the small air sacs in the lungs become damaged; characterized by difficulty breathing), dementia (a gradual decline in mental ability) and quadriplegia (paralysis from the neck down, affecting all arms and legs). A review of Resident 59's Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated 2/12/2024, indicated Resident 59 with a severe impairment to make decisions, learn and/or remember things. The MDS also indicated Resident 59 as dependent (helper does all effort) for eating, toileting and personal hygiene. A review of Resident 59's History & Physical (H&P) dated 2/8/2024, indicated Resident 59 does not have the capacity to understand and make decisions. A review of Resident 59's Order Summary Report, dated 4/10/2024, indicated the following active orders: a. Oxygen via nasal cannula (NC- a device that delivers extra oxygen through a tube and into your nose) at two to three liters per minute. b. Albuterol Sulfate Inhalation Nebulization Solution 1.25 milligram (mg) inhale orally via nebulizer every four hours as needed for respiratory failure. During an observation on 4/9/2024 at 9:07 am at Resident 59's bedside, a plastic storage bag dated 3/30/2024, labeled with Resident 59's name and room number was observed attached to Resident 59's oxygen concentrator machine (a medical device that takes air from the surrounding to filter it into purified breathable oxygen) with a nebulizer (small machine that turns liquid medicine into a mist that can be easily inhaled) mask inside. During an interview on 4/9/2024 at 10:50 am with Registered Nurse (RN) 2, RN 2 stated facility's standard of practice was to change the plastic storage bags every seven days and to label the bag with the date the bag was to be replaced. RN 2 stated both the bag and equipment stored inside can become contaminated (come in contact with disease causing organism) if the plastic bag was not changed, 055989 Page 26 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few causing an infection control issue. RN 2 also stated using contaminated equipment can cause symptoms such as coughing, fever congestion and shortness of breath (SOB) or difficulty breathing. During an interview on 4/12/24 at 3:51 pm with Infection Preventionist (IP), IP stated the facility's infection control protocol was to change the plastic storage bag weekly every Sunday and the bag was to be labeled and dated. IP stated if staff were not changing the plastic storage bag weekly, the bag can store bacteria and cause the resident to have SOB, altered consciousness, respiratory infection, decline in their function, mobility and eventually sepsis. A review of facility's policy and procedure (P&P) titled, Oxygen Administration revised on 2/23/2024, indicated that oxygen equipment is kept in a plastic bag when not in use and the cleaning and care of equipment will be in accordance with facility policy. 055989 Page 27 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 81), was assessed, provided pain management and interventions to relieve severe pain in the perianal (body area near the anus), perineal (body area between the anus and vaginal area) area due to severe MASD (Moisture Associated Skin Damage characterized by skin inflammation and damage of the outer layer of the skin resulting from prolong exposure moisture from to feces, urines and perspiration) and fungal dermatitis (irritation or swelling of the skin due to overgrowth of fungus) during wound care, hygiene care or when sitting on the chair for a long period of time as indicated in the facility's policy and procedure and as ordered by the physician. Residents Affected - Some This failure resulted in Resident 81's having unrelieved severe pain and verbalized feeling sad that the facility allowed her to suffer from pain, which prevented her from moving around and attending activities and potentially caused a decline in the resident's overall health and quality of life. Crossed reference with F684 , F711 and F580 Findings: A review of Resident 81 ' s admission Record, dated 4/11/24, indicated Resident 81 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus (a disease when blood sugar is too high) with hyperglycemia (high blood sugar), urinary tract infection (a condition in which bacteria invade and grow in the urinary tract [the organs that make urine and remove it from the body]), sepsis (severe infection in the blood or poisoning by bacteria), immunodeficiency (the decreased ability of the body to fight infections and other diseases), adult failure to thrive (condition when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal),and pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time). A review of Resident 81's History and Physical (H&P), dated 2/8/24, indicated Resident 81 has the capacity to understand and make decisions. A review of Resident 81's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 2/11/24, the MDS indicated, Resident 81 was cognitively intact (able to process information, remember and reason) and was dependent (helper does all of the effort to complete the activity and the assistance of two or more helpers is required for the resident to complete the activity) in shower/bathing self, needed substantial/maximal assistance (helper does more than half of the effort, lifts or holds trunk or limbs) in toilet hygiene (the ability to maintain perineal hygiene) and personal hygiene. A review of Resident 81's Care plan, dated 2/11/24, indicated Resident 81 ' s pain experience related to her perineal and perianal skin breakdown indicated no specific intervention to manage resident's pain in the perineal and perianal area. A review of Resident 81's Order Summary Report, (a physician's order summary) indicated on 4/1/24 Resident 81's physician ordered the resident to receive perineal care to cleanse with soap and water, pat dry, apply Zinc Oxide (skin barrier medication for diaper rash) leave open to air, at bedtime until resolved due to severe MASD, and an order for Nystatin-Triamcinolone (medicine is used to treat 055989 Page 28 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some certain fungus infections,) external (outside) cream to apply to perineal topically every shift for MASD until resolved. During an interview on 4/9/24 at 2:29 pm, Resident 81 stated she was admitted to the facility two months ago with skin redness on her buttock. Resident 81 stated she feels the skin redness to the buttocks, got worst and now caused the worst pain she ever experienced. Resident 81 stated, she believed wearing diaper for a long period of time contributed to her worsened wound condition that is causing her severe pain. During an observation in Resident 81's room on 4/10/24 at 9:45 a.m. Certified Nurse Assistant (CNA) 6 was assisting Resident 81 to change brief. While being assisted by CNA 6, Resident 81 was observed moaning saying Ahhh ahhh. Resident 81 ' s perineal and perianal skin area was observed with left buttock (close to the perianal area) maroon colored skin discoloration approximately measure 5 cm x 7 cm with multiple open lesions (area of abnormal or damaged tissue caused by injury, infection, or disease), scattered redness and dry skin peeling off and rashes covering the buttock area extending to the back of bilateral (both sides) upper thigh. CNA 6 was observed continuing to clean Resident 81 while the resident was moaning and saying Ahhhh and without stopping or asking why Resident 81 was moaning while telling Resident 81 It's ok, it's ok. During an interview on 4/10/24 at 9:59 am with Resident 81, Resident 81 stated, she was screaming because she had severe pain on her wound in the perineal and perianal area. Resident 81 stated, she always had pain from her wound when she is being cleaned by the CNAs. Resident 81 described her pain level as around eight (8) to ten (10) on a pain scale (0 for no pain and 10 for severe pain) and the worst pain she ever experienced. Resident 81 stated, she used to ask to pain medication in the past and they would sometimes bring Tylenol (a pain relieved medication) to her, but she was not given any pain medications in the last few weeks. During an interview on 4/10/24 at 10:30 am with CNA 6, CNA 6 stated, Resident 81 always had pain while being cleaned and brief change. CNA 6 was asked if she reported to the charge nurse that Resident 81 had pain every time she was being changed and cleaned, CNA 6 replied No, the charge nurse should already be aware of it. A review of the physician order, for the month of April 2024, indicated starting 2/29/24, to monitor Resident 81 for pain very shift. A review of the physician's order for April 2024 indicated, no pain medication was ordered for Resident 81. A review of Resident 81's Progress Notes titled N Adv Skilled Evaluation, dated 4/9/24 to 4/11/24 at 8:56 am, indicated the resident had no pain. On 4/9/24 to 4/11/24 was observed by the surveyor and reported by Resident 81 to have severe pain on the perineal and perianal area. A review of Resident 81's Medication Administration Record (MAR) for April 2024 indicated no record that resident receive pain medication prior to wound treatment and at anytime from 4/1/24 to 4/11/24. The MAR did not have a section in the record to indicate the pain assessment and level of pain of Resident 81. During an interview on 4/11/24 at 1:29 pm with CNA 5, CNA 5 stated, CNA 5 had been taking care of Resident 81 since the resident was admitted to the facility. CNA 5 stated, Resident 81 always had 055989 Page 29 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some pain in her perineal area during brief change and when sitting on the shower chair to shower, and during wound treatment on the buttocks. CNA 5 stated, CNA 5 always let the charge nurse know after providing care to the resident when she observed the resident complain of pain. A review of Resident 81's Surgical Consult, notes, dated 4/11/24, indicated, Resident 81 had a skin lesion located on the perineum extending to perianal that was consistent with severe MASD/Fungal dermatitis. The record also indicated, Resident 81 was at risk for developing a pressure injury because of resident ' s risk factors that included diabetes, cognitive impairment, and limited mobility. During an interview on 4/12/24 at 9 am, Resident 81 stated, she had been having a lot of pain because of her perineal wound for the last two months, which prevented her from moving around and sitting up for a long period of time to attend activities. Resident 81 stated, the pain caused her a lot of negative effect in her mental health because she is currently very upset with the wound care that she receives. Resident 81 stated, she was constantly sad because she did not understand why the facility let her suffer from pain. During a concurrent interview and record review of the MAR on 4/12/24 at 11:31 am with Licensed Vocational Nurse (LVN) 3, Resident 81's physician orders for April was reviewed. LVN 3 stated, she could not find a pain medication for Resident 81 that was ordered by the physician. LVN 3 was informed that Resident 81 was observed with pain while the resident was being cleaned by CNA. Resident 81 and stated, the CNAs has never reported to her that Resident 81's had pain. During an interview on 4/12/24 at 12:18 pm with the Treatment Nurse (TN), the TN stated she usually asked the charge nurse if the Resident 81's was given pain medication, but she did not check or confirm that Resident 81 ' s pain medication was given prior to starting her wound treatment. The TN stated, she was not aware if Resident 81 had any pain medication ordered because she was not responsible for passing medications. During an interview on 4/12/24 at 1 pm with Resident 81, Resident 81 stated, when the CNAs changed her brief or the TN gave her wound treatment, she always had the highest pain level that she had ever experienced because they were touching her wound. Resident 81 stated, the staffs never stopped and asked her if she had pain or offered pain medications. During an interview on 4/12/24 at 1:22 pm with CNA 4, CNA 4 stated, she observed Resident 81 had a lot of pain and itching around her perineal and anal area since her admission to the facility. CNA 4 stated, she observed Resident 81 moaning and saying, it hurts it hurts whenever she put A&D ointment (skin protective barrier cream) during brief change and her body was fidgeting (making small movements with the body, which often reflects discomfort and restlessness) which indicates she was in pain. CNA 4 added, she observed Resident 81 yelling and saying, don't put it fast. CNA 4 stated, she told Resident 81 that she had to do it fast so it would be less painful. CNA 4 stated, she told Resident 81 that It had to hurt, so Resident 81 should understand that. CNA 4 stated, she reported Resident 81 to the charge nurse that the resident had pain after she provided care, and she does not know if the charge nurse offered any pain interventions to the resident. During an interview on 4/12/24 at 3 pm with the Director of Nurses (DON), the DON stated, if the resident was screaming while the CNA was providing care, the resident was most likely experiencing pain. The DON stated, she expected the CNA to stop and notify the charge nurse right away so the charge nurse could assess why the resident was in pain, what cause the pain to provide interventions or pain medications. The DON stated, it was not acceptable for the CNA to continue providing care and 055989 Page 30 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some tell the resident to bare the pain because the resident would be irritated, would not want to eat, to move and their health could decline. The DON added, Resident 81 should never suffer from pain and should have pain interventions or pain reliever timely. A review of the facility's policy and procedure (P&P) titled, Pain Management, dated 12/19/22, indicated the following: In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will: Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. 055989 Page 31 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the attending physician failed to take an active role in supervising the total program of care, including medications and treatments, and a decision about the continued appropriateness of the resident's current medical regimen for one of one sample resident (Resident 81), in accordance with the facility policy and procedure on Physician Visits and Physician Delegation. The facility failed to ensure Resident 81's attending physician: 1. Physically assess, evaluate and document the resident's skin condition during admission and during other physician ' s visits for Resident 81 with severe MASD (damage of the skin caused by prolonged exposure to various sources of moisture), fungal infection (skin disease caused by an overgrowth of a fungus) and dermatitis (irritation or swelling of the skin). 2. Assess and evaluate Resident 81 ' s skin condition before ordering a skin treatment to ensure the accurate diagnosis. 3. Assess and provide a medication regimen for Resident 81 with pain due to severe MASD. These deficient practices had the potential for the resident not to receive appropriate care and/or delayed care or wrong treatment for skin disorders and other clinical condition. Crossed references with F684 and F697. Findings: A review of Resident 81's admission Record, dated 4/11/24, indicated Resident 81 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus (a disease when blood sugar is too high) with hyperglycemia (high blood sugar), urinary tract infection (a condition in which bacteria invade and grow in the urinary tract [the organs that make urine and remove it from the body]), sepsis (severe infection in the blood or poisoning by bacteria), immunodeficiency (the decreased ability of the body to fight infections and other diseases), adult failure to thrive (condition when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal),and pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time). A review of Resident 81's History and Physical (H&P- a record of a physician ' s assessment and resident ' s diagnoses), dated 2/8/24, indicated Resident 81 has the capacity to understand and make decisions. The H&P indicated Resident 81 did not have a skin issue. A review of Resident 81's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 2/11/24, the MDS indicated, Resident 81 was cognitively intact (able to process information, remember and reason) and was dependent (helper does all of the effort to complete the activity and the assistance of two or more helpers is required for the resident to complete the activity) in shower/bathing self, needed substantial/maximal assistance (helper does more than half of the effort, lifts or holds trunk or limbs) in toilet hygiene (the ability to maintain perineal hygiene) and personal hygiene. 055989 Page 32 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 81's Physician's Progress Notes, dated 3/24/24, no documented evidence that the resident had MASD, and skin rashes related to fungal infection and dermatitis. During an interview on 4/9/24 at 2:29 pm, Resident 81 stated she had redness of the buttocks when she was admitted to the facility two months ago. Resident 81 stated, she felt that her buttock wound got worst and caused her a lot more pain than before. Resident 81 stated, at nighttime, the staffs took a long time to come and change her diaper. Resident 81 stated, having the diaper on for a long period of time contributed to her wound getting worst. Resident 81 stated, she requested seeing her doctor, but she has not seen any doctor from the time she was admitted to the facility. During a concurrent observation in Resident 81's room on 4/10/24 at 9:45 a.m. Certified Nurse Assistant (CNA) 6 was assisting Resident 81 change brief. While being assisted by CNA 6, Resident 81 was observed moaning saying Ahhh ahhh. Resident 81 ' s perineal and perianal skin area were observed with multiple opened lesions (area of abnormal or damaged tissue caused by injury, infection, or disease) and scattered redness and dry skin peeling off and rashes covering the buttock area extending to the back of bilateral (both sides) upper thigh. During an interview on 4/10/24 at 9:59 am with Resident 81, Resident 81 stated, she was screaming because she had severe pain on her wound in the perineal and perianal area. Resident 81 described her pain level was at around eight (8) to ten (10) on a pain scale (0 for no pain and 10 for severe pain) and the worst pain she ever experienced. Resident 81 stated, she used to ask to pain medication in the past and they would sometimes bring Tylenol (a pain relieved medication) to her, but she was not given any pain medications in the last few weeks. During an interview on 4/11/24 at 4:45 pm, Resident 81's Primary Medical Physician (PMP) stated he did not assess Resident 81's wound. The PMP explained that the facility's nurses usually send pictures of the resident's wound to his phone to see how the wound looked, and he would relay it to the WC (Wound Consultant- a healthcare worker specialized in wound care). The PMP stated, he did not think Resident 81 had any skin problem because he did not receive any report or any picture of the wound on his phone. The PMP stated, I did not get an image or text messages on my phone about the wound. The PMP stated, he did not assess Resident 81's wound because the resident was admitted with UTI and sepsis. The PMP added, he did not assess Resident 81's wound during his most recent visit to the facility because there was no indication to assess. The PMP stated, he signed the skin treatment that was ordered for the resident on 4/1/24 without assessing the wound. A review of the physician ' s order for April 2024 indicated, no pain medication was ordered for Resident 81. During an interview in 4/12/24 at 3 pm, the Director of Nursing (DON) stated, the facility notifies the physicians for any changes of condition, and when the physicians come to visit the patients, they need to assess all residents under their care and the nurses are supposed to let the doctor know an update on the residents because it is a chance for face-to-face report with the doctor. The DON also stated, Resident 81 should never be suffered from pain and should have pain interventions or pain reliever timely. A review of the facility ' s Policy and Procedure titled Physician Visits and Physician Delegation, revised 12/19/22, indicated the following: - It is the policy of this facility to ensure the physician takes an active role in supervising the 055989 Page 33 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0711 care of residents. Level of Harm - Minimal harm or potential for actual harm - The facility should gather medical records and other documents for review by the physician during the visit and provide records such as weight and vital sign records, accident reports, risk assessments, etc. for physician review. Residents Affected - Few - The Physician should see resident within 30 days of initial admission to the facility and the resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission. 055989 Page 34 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review, the facility failed to complete a performance review for eight of nine (9) Certified Nurse Assistants (CNAs) based on the outcome of the review for each of the CNAs. The CNAs did not have a completed Annual Core Clinical Competencies (ACCC, an assessment and training on the CNAs the ability to perform clinical nursing care). Residents Affected - Some This failure had a potential to result in the facility ' s CNAs not able to provide quality care to the resident ' s population based on the Facility Assessment (an assessment to make decisions about direct care staff needs, as well capabilities to provide services to the residents). Findings: During an interview on 4/11/24 at 9:19 am with the Director of Staff Development (DSD), the DSD stated, all CNAs were supposed to have yearly clinical skills competency check to assess for their competency and to refresh their knowledge on how to provide appropriate care to the residents. The DSD stated, she just started the DSD position three months ago and the previous DSD did not use CNA Core Clinical Competencies checklist for any of 2023 competency skills check, so all the facility's CNAs' skills' check were either incomplete or not done. During a concurrent interview and record review on 4/11/24 at 10:13 am with the DSD, a binder with all the staffs' annual competency check list was reviewed. The record indicated, there were nine full-time CNAs with no ACCC done since 2022. The DSD stated, she spoke with the previous DSD and confirmed that the previous DSD did not conduct any ACCC with all nine CNAs. The DSD stated, it should be in their policy that they needed to follow the CNA Core Clinical Competencies checklist to assess and make sure the CNAs was competent with all their clinical skills in order to provide quality care to the facility ' s residents. A review of the facility's CNA Hiring Date Summary, undated, provided by the DSD and the ADM, nine CNAs with undone ACCC were listed with hiring dates as followed: 1. CNA 6 hired on 4/5/2012 2. CNA 7 hired on 1/8/2019 3. CNA 8 hired on 1/22/2007 4. CNA 9 hired on 1/9/2010 5. CNA 10 hired on 2/7/2018 6. CNA 11 hired on 3/10/2004 7. CNA 12 hired on 4/25/1997 8. CNA 13 hired on 5/10/2010 9. CNA 14 hired on 9/14/2018 055989 Page 35 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0730 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 4/12/24 at 3:54 pm with the Administrator (ADM), the ADM confirmed that there had been an issue with the previous DSD not keeping up with all staffs' annual competency skills check. The ADM stated, it was not acceptable that the CNAs not having their annual competency skills check since 2022 because their skills needed to be refreshed yearly to take care of the facility's residents. A review of the facility's policy and procedure (P&P) titled, Training Requirements, revised 12/19/22, indicated the following: - Competencies and skills set for all new and existing staff must be consistent with their expected roles. - Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. 055989 Page 36 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that two of two sampled residents (Residents 2 and 50), who were at risk for bleeding and bruising were free of unnecessary medication while receiving blood thinners by failing to ensure: Residents Affected - Few 1. Resident 2 had adequate monitoring for bleeding and bruising while receiving Plavix (a medication that prevents platelets [a type of blood cell] in your blood from clumping together to form unwanted blood clots). 2. Resident 50 had routine laboratory test ordered to monitor the resident for complications of Aspirin (used to prevent blood cells called platelets from clumping together to form unwanted blood clots) and Eliquis (medication that decreases the clotting ability of the blood and helps to prevent harmful clots from forming) such as bleeding. These failures had the potential for Resident 2 and Resident 50 to experience side effects or adverse effects (undesired harmful effects) related to anticoagulant such as bleeding and/or bruising that were undetected and cause a decline in the resident's health and wellbeing. Findings: 1. A review of Resident 2's admission Record indicated Resident 2 was readmitted to the facility on [DATE] with diagnoses that include hemiplegia (paralysis of one side of the body) and hemiparesis (inability to move one side of the body) following cerebral infarction (also known as a stroke; refers to damage to the tissues in the brain due to a loss of oxygen to the area), paraplegia (paralysis of the lower part of the body, including the legs), dementia (a condition characterized by progressive or persistent loss of intellectual functioning), Chronic Obstructive Pulmonary Disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), type 2 diabetes mellitus (DM2 - condition that results in too much sugar circulating in the blood). A review of Resident 2's Minimum Data Set (MDS - a standardized resident assessment care screening tool) dated 2/12/2024, indicated Resident 2 with a severe impairment to make decisions, learn and/or remember things and requires moderate assistance (helper does less than half the effort) with eating and oral hygiene and maximal assistance (helper does more than half the effort) with toileting, bathing and dressing. A review of Resident 2's History & Physical (H&P) dated 2/8/2024, indicated Resident 2 does not have the capacity to understand and make decisions. During a concurrent interview and record review of Resident 2's clinical records on 4/10/2024 at 3:20 pm with the Director of Nursing (DON), indicated the physician ordered Resident 2 to receive Plavix 75 milligrams (mg) every morning that started on 2/28/2024.The DON stated there was no physician order to monitor Resident 2 for bleeding and/or bruising and other side effects of anticoagulant. DON stated Resident 2's clinical records indicated no entry or documentation that Resident 2 was monitored for bleeding and/or bruising and other side effects/or adverse reaction to anticoagulant or antiplatelet as indicated in the resident ' s care plan. DON stated possible side effects of anticoagulants/antiplatelets included blood in the urine, stool (feces), hematoma (a solid swelling of clotted blood within the tissues) and change in level of consciousness. risks of not monitoring the 055989 Page 37 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0757 resident include increased bleeding anywhere in the body and health decline. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/11/2024 at 2:38 pm with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 2 was receiving Plavix and staff need to monitor Resident 2 for bleeding, bruising, blood in the stool and/or gums every shift and document on the MAR. LVN 1 stated if there was no physician order to monitor the resident for bleeding, staff are to call the doctor to get an order to monitor the resident for bleeding and bruising every shift. Residents Affected - Few 2. A review of Resident 50's admission Record indicated Resident 50 was readmitted to the facility on [DATE] with diagnoses that include end stage renal disease (ESRD - a stage where the kidneys can no longer support the body's needs for waste removal and fluid balance), dependence on renal dialysis (clinical purification of blood as a substitute for the normal function of the kidney), acute respiratory failure (a sudden condition in which not enough oxygen passes from the lungs into the blood) with hypoxia (low levels of oxygen in your body tissues), pulmonary edema (a condition caused by too much fluid in the lungs), anemia (not having enough healthy red blood cells to carry oxygen to the body's tissues), and cardiomegaly (an enlarged heart). A review of Resident 50's MDS, dated [DATE], indicated Resident 50 had a severe impairment to make decisions, learn and/or remember things and requires setup assistance with eating, oral hygiene and maximal assistance (helper does more than half the effort) with toileting and bathing. The MDS also indicated Resident 50 was receiving anticoagulant and antiplatelet therapy. A review of Resident 50's History & Physical (H&P) dated 1/29/2024, indicated Resident 50 has the capacity to understand and make decisions. A review of Resident 50's Order Summary Report dated 4/12/2024, indicated an order for Aspirin 81 mg once a day started 2/25/2024 and Eliquis 2.5mg twice a day started on 2/9/2024. A review of Resident 50's Anticoagulant Therapy (Aspirin, Eliquis) Care Plan revised 4/5/2024, indicated staff will monitor for adverse side effects of anticoagulant therapy every shift. During a concurrent interview and record review on 4/11/2024 at 5:04 pm with DON, Resident 50's Order Summary Report dated 4/12/2024 indicated no physician's order for routine laboratory test and blood draws. DON stated there were no routine labs ordered for Resident 50 as indicated in the facility policy for anticoagulant therapy. DON stated the importance of routine laboratory test was to make sure the resident was not bleeding. The DON stated not having a routine laboratory test could result in the resident have bleeding, such as internal bleeding (bleeding from blood vessels that collects inside the body instead of bleeding out through an open wound) and external bleeding (occurs when blood exits through a break in the skin or a natural opening in the body) that could not be detected sooner. A review of the facility's policy and procedure (P&P) titled High Risk Medications - Anticoagulants revised 12/19/2022, indicated compliance guidelines including routine lab orders for each resident requiring anticoagulant medication and monitoring for adverse consequences including bleeding and hemorrhage (bleeding gums, nosebleed, unusual bruising, blood in urine or stool). 055989 Page 38 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

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 interview, observation, and record review, the facility failed to ensure that medication error rate was less than five percent (%). Residents Affected - Few During the medication administration observation, four medications out of 30 total medications administered and opportunities contributed to an overall medication error rate of 13.33 % affecting three of eight residents observed for medication administration (Resident 37, 28, and 69). The medication errors noted were as follows: 1. The medication nurse attempted to administer Calcitriol (medication to treats low calcium level) and Folic Acid (medication is used to treat low blood level) without checking the expiration date on the bottle for Resident 37. 2. The medication nurse administered Metoprolol Tartrate (medication used to lower blood pressure) without offering food as ordered by the physician for Resident 28. 3. The medication nurse administered Metoprolol Succinate (medication to lower the blood pressure) without offering food as order by the physician for Resident 69. These deficient practices had the potential to develop adverse reaction or undesired effect to the medications that could affect the resident's wellbeing. Findings: 1. A review of Resident 37's admission Record (a document containing a resident's demographic and diagnostic information) indicated the resident was admitted to the facility on [DATE] with diagnoses that included hypokalemia (low level of potassium in the blood) and hyperlipidemia (a condition in which there are high levels of fat particles (lipids) in the blood). A review of Resident 37's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 1/30/24 indicated the resident was cognitive skill (mental action or process of acquiring knowledge and understanding for daily decision-making) was moderately impaired. The MDS indicated Resident 37 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower/bathe hygiene, and personal hygiene. A review of Resident 37's order Summary Report (a physician orders), dated 2/25/24, indicated Resident 37 was scheduled to receive the following medication during the 9AM medication pass. One tablet of Calcitriol Oral Capsule 0.25 microgram (mcg-unit of measurement of mass). One tablet of Folic Acid Oral Tablet 1 milligram (mg-unit of measurement of mass) During a concurrent observation of medication administration and interview with the Licensed Vocational Nurse (LVN 1) in the Nursing Station 1 on 4/10/24 at 8:07 am, LVN 1 was observed preparing one tablet of Calcitriol Oral Capsule 0.25 mcg and one tablet of Folic Acid Oral Tablet 1 mg medications for Resident 37. Prior to administration of the medication LVN 1 did not check the expiration dates 055989 Page 39 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of the medications to be administered and was asked by the surveyor to check the expiration dates before administration. During the same interview on 4/10/24 at 8:07 am, LVN 1 stated there were four total medications to administer for Resident 37 this morning. LVN 1 stated she forgot to check expiration date which was printed onto the bottles for calcitriol and folic acid. LVN 1 stated it was importance to check the expiration date on the medications because using expired medications is risky and possibly harmful to residents' health. 2. A review of Resident 28's admission Record, indicated she was initiate admitted to the facility on [DATE] and re-admitted to facility on 3/7/24 with diagnoses including osteoarthritis (degeneration of joint cartilage) left and right hip. A review of Resident 28's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 3/11/24 indicated the resident had severe impairment in cognitive skills (mental action or process of acquiring knowledge and understanding for daily decision-making). The MDS indicated the resident is totally dependent on staff for activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 28's order Summary Report, dated 4/11/24, indicated Resident 28 was scheduled to receive Metoprolol Tartrate by mouth one time a day for hypertension, hold if SBP (systolic blood pressurethe pressure in your arteries when your heart rests between beats) < 100 or Heart rate < 60 and to administer Metoprolol Tartrate with food. During medication pass observation with the LVN 1 in the nursing station on 4/10/24 at 8:46 am, LVN 1 was observed administering Metoprolol Tartrate for Resident 28 without offering food as indicated as in the physician order. 3. A review of Resident 69's admission Record, indicated the resident was admitted to the facility on [DATE] with diagnoses that included and hyperlipidemia (a condition in which there are high levels of fat particles (lipids) in the blood). A review of Resident 69's MDS dated [DATE], indicated the resident had cognitive skill (mental action or process of acquiring knowledge and understanding for daily decision-making) was moderately impaired. The MDS indicated the resident required partial/moderate assistance (helper does more than half the effort) with toileting hygiene and personal hygiene. A review of Resident 69's order Summary Report, dated 4/11/24, indicated Resident 69 was scheduled to receive Metoprolol Succinate by mouth in the morning for hypertension, hold if SBP < 100 or Heart rate < 60. Physician order to administer Metoprolol Succinate with food. During a concurrent observation of medication administration with the LVN 1 in the Nursing Station 1 on 4/10/24 at 8:57 am, LVN 1 administered Metoprolol Succinate to Resident 69 without food. After medication pass on 4/10/24 at 11:10 am, LVN 1 confirmed the physician order for Resident 28 to administer Metoprolol Tartrate and Resident 69's to receive Metoprolol Succinate with food. LVN 1 confirmed she did not offer snack or food to Resident 28 and Resident 69 before administration of Metoprolol. LVN 1 stated it was important to take Metoprolol with food to reduce the risk of serious side effects such as nausea vomiting, or diarrhea. 055989 Page 40 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with the Director of Nursing (DON) on 4/11/24 at 11:34 am, the DON stated it was important to check the expiration date of the medications and taking expired medications can have serious health consequences. The DON stated licensed nurse should have offered some snacks before administering Metoprolol to the resident to prevent stomach irritation. A review of the facility's revised policy, dated 5/15/23, titled Provision of physician Ordered Service indicated that qualified nursing personnel will administer medications as ordered by the physician, physician assistant, nurse practitioner, or clinical nurse specialist. Medication will be administered following facility protocol, dosage guidelines, and documentation procedures. A review of the facility's revised policy, dated 12/19/22, titled Administering Medications, indicated that medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by physician and in accordance with professional standards of practice. The policy also indicated that licensed nurse should identify expiration date. If expired, notify nurse manager. 055989 Page 41 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview and record review the facility failed to implement the facility's policy and procedure on food storage and in accordance with professional standards of practice for food service safety by failing to: 1. Label and date of when it was opened or used by a brown powder in a clear plastic container, the chicken bouillon (ingredients used for seasoning). 2. Label a clear plastic container containing rice found in the refrigerator, with the use-by-date (the date the food product could be safely consumed). 3. Label a clear plastic container containing sliced peaches found in the refrigerator with the use-by date. 4. Label a clear plastic container containing tofu found in the refrigerator with the use-by-date. 5. Label a clear plastic container containing green peas found in the refrigerator with the use-by date. These deficient practices had the potential to result in food contamination or growth of microorganisms (disease causing organism) that could cause foodborne illness (food poisoning or food illness due to pathogens (organism that cause illness such as bacteria, viruses, or parasites) and toxins that contaminate food that could negatively affect the facility resident's wellbeing. Findings: During an initial kitchen observation conducted with DSS (Dietary Service Supervisor) on 4/9/2024 at 8:40 AM, the kitchen shelf had a brown powdery substance in a clear plastic container without a label or date of when it was opened and/or used by. In a concurrent interview, the DSS stated, the brown powder was a chicken bouillon used for seasoning residents' food. The DSS stated, the chicken bouillon seasoning should have been labeled and dated to ensure that it is still fresh and safe for residents' consumption. During a concurrent observation and interview on 4/9/2024 at 8:50 am with the DSS, the facility's refrigerator had rice in a clear plastic container, sliced peaches in a clear plastic container, tofu in a clear plastic container, and green peas in a clear plastic container all without a use-by date or when the food was prepared. DSS stated, all those items should have a used-by date to ensure it is still fresh for consumption. DSS stated, food that were not labeled with the date, or did not have a use-by date had a potential to be consumed spoiled or expired that could harm residents. During an interview on 4/11/2024 at 8:57 am with Director of Nurses (DON), the DON stated, the food in the kitchen should be labeled and dated and had a use-by date to ensure it is not spoiled because that can affect resident's health. A review of the facility's policy and procedure (P&P) titled, Food Storage, date revised 8/29/2023, the P&P indicated; a) all food products should be inspected for safety and quality and be dated upon receipt, when open, and when prepared, b) Use use-by dates on all food stored in refrigerators and 055989 Page 42 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some use dates according to the timetable in dry, refrigerated, and freezer storage charts. c) Leftover should be dated according to refrigerated leftover storage chart, and d) remember to cover, label and date. A review of the Food Code 2022, indicated 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking indicated Ready-to-Eat, Time/Temperature Control for Safety Food prepared and held in a food estabishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Ready-to-Eat, Time/Temperature Control for Safety Food prepared and packaged by a Food Processing Plant shall be clearly marked, at the time the original container is opened in a food estabishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises. 055989 Page 43 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: Residents Affected - Some 1. Complete the facility's Surveillance Data Collection Form (SDC - a form used by the facility to indicate if the resident met the criteria for the use of antibiotic [medication used to treat infection]), a part of the facility's Antibiotic Stewardship Program (protocols and a system in the facility to monitor antibiotic use) prior to the administration of antibiotic for one of three sampled residents (Resident 30). 2. Implement the facility's Antibiotic Stewardship Program (a facility policy that uses protocols and a monitoring system for antibiotic [medication used to kill bacteria and to treat infections]) use by not conducting a surveillance (close observation) and monitoring prior to antibiotic use. for one of three sampled residents (Resident 2). These deficient practices had the potential for Residents 30 and Resident 2 to receive unneccessary or inappropriate antibiotics, incomplete monitoring during antibiotic therapy, and to develop infection that is resistant (organism that is not able to be killed and continued to grow) to antibiotics or multiple drug resistant organism (MDRO, are define as microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents) that is difficult to treat. Findings: 1. A review of Resident 30's admission Record indicated the resident was admitted to the facility on original admitted to facility on 12/1/23 and re-admitted on [DATE] with diagnosis that included Gastro-esophageal reflux disease (GERD- stomach acid repeatedly flow back into the tube connecting mouth and stomach) and benign prostatic hyperplasia (BPH- is a condition in men in which the urinary stream may be weak or stop and start). A review of the History and Physical Examination (H&P) dated 1/23/24, indicated Resident 30 does not have the capacity to understand and make decisions. A review of Resident 30's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 3/10/24, indicated Resident 30 had moderate cognitive impairment (ability to think, understand, and reason). The MDS indicated Resident 30 required supervision or touching assistance (helper provides verbal cues and/or touching/steady and/or contact guard assistance as resident completes activity) from staff for eating and oral care. A review of Resident 30's physician's order, dated 3/28/24, indicated to administer Ciprofloxacin (medication used to treat infection caused by bacteria) 500 milligrams (mg - unit of measurement of mass) by mouth (PO), two times a day (BID) for until 4/2/24, for Urinated Tract Infection (UTI- an infection in any part of the urinary system, the kidney, bladder, or urethra). A review of the SDC form indicated both criteria 1 and 2 must be present for medication use. SDC form indicated to mark at least one of the signs and symptoms on Signs & Symptoms Selection to support criteria 1 and to mark the lab result at least 100,000 cfu/ml (colony forming unit/milligram) to support criteria 2 for medication use. The SDC form had no documented evidence that criteria 1 and 2 were marked for Resident 30's to indicate if the prescribed antibiotic were adequate to treat the 055989 Page 44 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0881 infection. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 4/12/24 at 4:36 pm, the Infection Preventionist Nurse (IPN) stated she filled out the SDC form and reviewed the resident's lab results. If the process indicated that the resident did not have an infection, then she would notify the physician. Residents Affected - Some During an interview on 4/12/24 at 4:43 pm, IPN stated there was no evidence SDC form was completed to indicate that Resident 30 had signs and symptoms of infection and the no lab result for Resident 30 to indicate if the resident met the criteria for the use of antibiotics. The IPN also stated, it was important to complete the SDC form accurately so physician could use this information to prescribe the appropriate antibiotic to target specific infection. A review of facility policy and procedure titled, Antibiotic Stewardship Program dated 12/19/22, indicated that it is the policy of the facility to implement an Antibiotic Stewardship Program is to optimize the treatment of infections while reducing the adverse events associate with antibiotic use. The policy also indicated that Infection Preventionist who coordinates all antibiotic stewardship activities, maintains documentation, and serves as a resource for all clinical staff. 2. A review of Resident 2's admission Record indicated Resident 2 was readmitted to the facility on [DATE] with diagnoses that include sepsis (a severe body response to infection, which causes the immune system to attack tissues and leads to inflammation and potential organ damage), Chronic Obstructive Pulmonary Disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), urinary tract infection (UTI- an infection in any part of the urinary system), pneumonia (PNA- an infection that affects one or both lungs) and dementia (a condition characterized by progressive or persistent loss of intellectual functioning). A review of Resident 2's Minimum Data Set (MDS - a standardized resident assessment care screening tool) dated 2/12/2024, indicated Resident 2 with a severe impairment to make decisions, learn and/or remember things and Resident 2 needs moderate assistance (helper does less than half the effort) with eating and oral hygiene and maximal assistance (helper does more than half the effort) with toileting, bathing and dressing. A review of Resident 2's History & Physical (H&P) dated 2/8/2024, indicated Resident 2 does not have the capacity to understand and make decisions. A review of Resident 2's Order Summary Report dated 4/12/2024, indicated an order for two antibiotics, Ceftriaxone and Metronidazole for the treatment of PNA and UTI from 2/7/2024-2/14/2024. During a review of Resident 2's Medication Administration Record dated 2/1/2024- 2/29/2024, indicated Resident 2 was given Metronidazole 500 milligrams (mg) three times a day from 2/8/2024-2/14/2024, and Ceftriaxone 1 gram once a day from 2/11/2024-2/14/2024. During a concurrent interview and record review on 4/12/2024 at 3:51 pm with Infection Preventionist, the facility's Antibiotic Stewardship Binder and Resident 2 ' s medical chart was reviewed. The stewardship binder had no documentation to indicate Resident 2 was screened prior to the use of Metronidazole and Ceftriaxone that specified the symptoms or monitoring for adverse reaction (undesired effect) of antibiotic. Resident 2 ' s clinical record did not have an Antibiotic Time Out (an assessment of an antibiotic prescription that occurs 48-72 hours after first administration) completed for the use of Ceftriaxone or Metronidazole. IP stated the antibiotic surveillance, documentation and 055989 Page 45 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0881 monitoring was not per facility protocol for Resident 2 and should have been. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure (P&P) titled Antibiotic Stewardship Program revised 12/19/2022, indicated the purpose to optimize the treatment of infections while reducing the adverse events (harmful and negative outcomes) related to antibiotic use. The P&P also indicated: Residents Affected - Some a. The IP will coordinate all antibiotic stewardship activities, maintain documentation and serves as a resource for all clinical staff. b. Antibiotic use protocols includes (but not limited to) the facility using surveillance tools to define infections and determine whether to treat an infection with antibiotics. c. Monitoring of antibiotics includes (but not limited to) the response to antibiotics to determine if the antibiotic is still needed or if adjustments should be made (e.g antibiotic time out). 055989 Page 46 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed provide documented evidence that two of three sampled residents (Residents 53 and 390) were offered or declined (refused) the influenza (flu- results in severe infection of the lungs) vaccine (a substance used to stimulate immunity to a particular infectious disease administered via injection) annually (every year). Residents Affected - Few This deficient practice placed Residents 53 and 390 at a higher risk of acquiring and transmitting the flu to other residents and staffs that could result in a widespread infection in the facility. Findings: A review of the facility's Resident Immunization Record dated 2/6/2024, indicated Resident 53 and Resident 390 declined the flu vaccine for the flu season of 2023-2024 (October to March). 1. A review of Resident 53's admission Record indicated Resident 53 was admitted to the facility on [DATE] with diagnoses of hyperthyroidism (when the thyroid gland makes too much thyroid hormone, resulting in a rapid heartbeat and an increased rate of metabolism), anemia (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin to carry oxygen all through the body) and abnormalities of gait (manner of walking or moving on foot) and mobility (ability to move). A review of Resident 53's Minimum Data Set (MDS - a comprehensive standardized assessment and screening tool) dated 3/8/2024, indicated Resident 53 is usually able to express ideas and wants as well as the ability to usually understand others. The MDS also indicated Resident 59 is varied assistance levels from setup/cleanup to supervision with eating, oral and personal hygiene, toileting and bathing. A review of Resident 53's History & Physical (H&P) dated 12/20/2023, indicated Resident 53 has the capacity to understand and make decisions. A review of Resident 53's medical charts (paper and electronic) indicated no documented evidence that the resident was administered, offered or declined the flu vaccine for 2023-2024 flu season. 2. A review of Resident 390's admission Record indicated Resident 390 was admitted to the facility on [DATE] with the diagnoses that included acute respiratory failure (a sudden condition in which not enough oxygen passes from the lungs into the blood), congestive heart failure (CHF - a chronic condition in which a weakness of the heart leads to a buildup of fluid in the lungs), type 2 diabetes mellitus (DM2 - condition that results in too much sugar circulating in the blood) and immunodeficiency (failure of the immune system to protect the body adequately from infection). A review of Resident 390's MDS, dated [DATE], indicated Resident 390 was usually able to express ideas and wants as well as the ability to usually understand others. The MDS also indicated Resident 390 required partial assistance (helper does less than half the effort) for eating and hygiene, and dependent (helper does all the effort) for toileting and bathing. A review of Resident 390's H&P dated 1/20/2024, indicated Resident 390 has the capacity to understand and make decisions. 055989 Page 47 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 390's medical charts (paper and electronic) indicated no record of administration or declination of the flu vaccine or any documentation for the 2023-2024 flu season. During an interview on 4/12/2024 at 1:09 pm with Infection Preventionist (IP), IP stated residents are offered the flu vaccine every year and explained the risks and benefits to the resident and if the resident declines, the resident signs a declination letter that is kept in the medical chart. IP also stated if a resident declines the flu vaccine, staff are to document (in the medical chart) that the vaccine was offered three times, and the risks and benefits of the vaccination were explained to the resident. During a concurrent interview and record review on 4/12/2024 at 1:47 pm with IP, Resident 53 and Resident 390's medical charts (paper and electronic) were reviewed. Resident 390 ' s and Resident 53's medical chart indicated no documentation and/or declination forms for 2023-2024 flu season. IP stated there should have been documentation indicating administration or declination records in the charts of Resident 53 and Resident 390 for the 2023-2024 flu season. IP stated she was unable to provide documented evidence that the flu vaccines were offered or administered to Residents 53 and 390 for the 2023-2024 flu season. IP also stated it was important to offer the flu vaccine to residents annually because it prevents the residents from getting and spreading the flu to other residents. The IPN stated not offering the residents the Flu vaccine increases the resident's risk of getting the flu, and experience coughing, nasal congestion (stuffy nose), fever, loss of appetite and decline in mobility. A review of the facility's policy and procedure (P&P) titled Infection Prevention and Control Program (IPCP)Influenza and Pneumococcal Immunization revised 12/19/2022, indicated residents will be offered the flu vaccine each year between October 1st and March 31st unless contraindicated or received elsewhere during that year. The P&P also indicated documentation will reflect the education provided and details regarding whether the resident received or did not receive the immunizations. The P&P also indicated the IPCP was designed to help prevent the development and transmission of communicable diseases and infections as per national standards and guidelines. 055989 Page 48 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: Residents Affected - Few 1. Ensure that employee's personal item was not stored in the one of two medication rooms (Med room [ROOM NUMBER]) at Nursing Station 2. 2. Ensure one of three sampled residents (Resident 6), was maintained with sanitary environment by failing to timely clean up Resident 6's bedside commode with feces and urine. These deficient practices had the potential for cross contamination leading to infection and had a potential to result in a negative effect on Resident 6's overall well-being. Findings: 1. During the inspection of the medication room in Nursing Station 2 with a Registered Nurse 1 (RN 1), on 4/10/24 at 12:23 PM, a black colored jacket was observed hanging on the back of door of the medication room. RN 1 stated the jacket should not be there. RN 1 further stated that employees have a lounge to store their personal belongings. During an interview with the Director of Nursing (DON) on 4/10/24 at 3:28 pm, the DON stated that personal belongings should not be stored in medication room because there was a risk for infection. A review of facility's policy and procedure titled, Medication Storage, dated 12/19/22, indicated that facility to ensure all medications housed on the premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation . and security. A review of facility's policy and procedure titled, Infection Prevention and Control Program, dated 12/19/22, indicated that facility had established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. 2. A review of Resident 6's admission Record indicated Resident 6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), asthma [a chronic lung disease caused by inflammation (the body's immune system's response to an irritant) and muscle tightening around the airways, which makes it harder to breathe], dementia (the loss of cognitive functioning and thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), and lack of coordination (not able to move different parts of the body together well or easily). A review of Resident 6's History and Physical (H&P), dated 1/24/23, indicated Resident 6 does not have the capacity to understand and make decisions. A review of Resident 6's Minimum Data Set (MDS- a comprehensive assessment and screening tool) 055989 Page 49 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dated 2/11/24, the MDS indicated, Resident 6 was cognitively impaired (ability to think, remember and reason) and needed partial/moderate assistance (helper does less than half the effort. Helper lifts or holds, or supports trunk or limbs, but provides less than half the effort) in toilet hygiene (the ability to maintain perineal hygiene), and toilet transfer (the ability to get in and off a toilet or commode). During an observation on 4/9/24 at 9:35 am in Resident 6's room, a bedside commode with feces and urine was observed on the left side of Resident 6's bed, a smell of urine was also noted. During a concurrent observation and interview on 4/9/24 at 10:27 am with Registered Nurse (RN) 1 in Resident 6's room, RN 1 stated, Resident 6's room smelt like urine and feces because her bedside commode was full of feces and urine, which was not acceptable and should be cleaned right after the resident had finished using it. During an interview on 4/9/24 at 10:29 am with Certified Nurse Assistant (CNA) 5, CNA 5 stated, she assisted Resident 6 to the bedside commode to have a bowel movement but forgot to clean and empty the commode since 8 am (two and a half hour with no cleaning). During an interview on 4/9/24 at 10:31 am with RN 1, RN 1 stated, when the bedside commode was not cleaned timely, it could cause a bad smell and spread infection, which could affect the resident's health. During a phone interview on 4/10/24 at 11:15 am with Resident 6's family member (FAM) 1, FAM 1 stated, he usually visits Resident 6 every other day. FAM 1 stated, at least four times when he came to visit Resident 6 that he found the bedside commode full of feces and urine that he could smell them right away when he entered the resident's room. FAM 1 stated, the unsanitary environment could potentially cause a decline in Resident 6's overall well-being and not a comfortable environment to be in. During an interview on 4/12/24 at 2:56 pm with Infection Control Nurse (IPN), the IPN stated, uncleaned bedside commode with feces and urine was not acceptable because it could be a start of infection, it could spread bacteria because they would not know what kind of bacteria in the urine or stool. During an interview on 4/12/24 at 3 pm with the Director of Nurses (DON), the DON stated, when a resident pooped the CNA should have cleaned it right away, especially when the bedside commode was located close to the resident's bed. The DON stated the poop ' s smell is an unsanitary environment that could negatively affect the resident's well-being. A review of the facility's policy and procedure (P&P) titled, Safe and Homelike Environment, revised 12/19/22, indicated the following information: - In accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike Environment. - Environment refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas. 055989 Page 50 of 51 055989 04/12/2024 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0921 Level of Harm - Minimal harm or potential for actual harm - Sanitary includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes, but is not limited to, equipment used in the completion of the activities of daily living. Residents Affected - Few 055989 Page 51 of 51