Health inspection·August 27, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the ampicillin (drug used to prevent and treat several bacterial infections) six (6) grams (gm - unit of measurement) every 12 hours intravenous piggyback (IVPB- a way to give a patient a dose of medicine directly into the vein through the existing line) was reconciled (formal process of creating the most accurate and complete list of resident's current medications from the previous health care facility or from home, and comparing that the list with the medications being prescribed by the physician of the receiving healthcare facility) and administered for one (1) of two (2) sampled residents (Resident 1) in accordance with the facility's policy and procedure. This deficient practice resulted in Resident 1 not receiving the ampicillin for the scheduled time frame while the resident is in the facility which potentially resulted in delayed healing of the resident's right knee periprosthetic joint infection (PJI- an infection that affects the artificial joint and the surrounding tissues). Findings:During a review of Resident 1's admission record, the admission record indicated the resident was initially admitted to the facility on [DATE] with diagnoses that included presence of bilateral artificial knee joint and an open wound on right knee. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 7/2/2025, indicated Resident 1 had an intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 1 required substantial assistance (helper does more than half the effort) with toileting, shower, lower body dressing and putting on/taking off footwear and required partial/moderate assistance (helper does less than half the effort) with eating, oral and personal hygiene, and upper body dressing. During a review of Resident 1's order summary dated 8/1/2025, the order summary indicated admit Resident 1 to the facility under Medical Doctor 1 (MD 1). During a review of Resident 1's Admission/Discharge report dated 8/1/2025 to 8/27/2025, the Admission/Discharge report indicated Resident 1 was discharged to General Acute Care Hospital (GACH 1) on 8/20/2025. The Admission/Discharge report also indicated Resident 1 was readmitted to the facility on [DATE]. During a review of Resident 1's progress notes from GACH 1 dated 8/21/2025, the progress notes indicated Resident 1 was admitted to GACH 1 on 8/13/25 with a diagnosis of right knee PJI with E faecalis (Enterococcus faecalis - a type of bacteria that typically lives harmlessly in your gut but can cause serious, hard to treat infections if it spreads to other parts of the body). The progress notes also indicated Resident 1 was previously hospitalized from [DATE] to 8/1/2025 at GACH 1 for infected prosthetic knee joint and discharged to the facility on a 6-week course of ampicillin and had undergone a desensitization (the process of becoming less sensitive to something over time because of repeated exposure) protocol for history of penicillin allergy during stay in GACH 1 from 7/2/2025 to 8/1/2025. The progress notes further indicated, GACH 1 confirmed that Resident 1 did not receive ampicillin while the resident is at the facility 8/2/2025 to 8/12/2025 (11 days). During an interview on 8/25/2025 at Page 1 of 3 056080 056080 08/27/2025 The Bellefontaine Healthcare Center 150 Bellefontaine St Pasadena, CA 91105

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3:23 PM, Social Worker (SW) from GACH 1, the SW stated Resident 1 went back to the facility from GACH 1 on 8/1/2025 with orders for 2 antibiotics but for some reason 1 of the antibiotics which is the ampicillin was not reconciled by the facility and was not given to the resident which could have contributed to the reinfection of the resident's right leg and subsequent readmission to GACH 1 on 8/13/25. During a concurrent observation and interview on 8/27/2025 at 11:15 AM, Resident 1 was lying in bed with right leg elevated with pillows above heart level and wrapped with an elastic bandage (a stretchy strip of cloth that is used to wrap snuggly around an injured joint or muscle) resting on top of a soft layered material. Resident 1 stated when she was transferred back to the facility on 8/1/2025, she was supposed to receive 2 different antibiotics but did not realize that the ampicillin was not given during the resident's stay in the facility from 8/2/2025 to 8/12/2025. Resident 1 also stated she already went through desensitization at GACH 1 to ensure the resident can receive ampicillin due to Resident 1's history of PCN allergy. Resident 1 also stated, the resident was given ampicillin from GACH 1, so ampicillin is safe for the resident to take and just need to continue the ampicillin doses in the facility. During a concurrent interview and record review with the Assistant Director of Nursing (ADON) on 8/27/2025 at 1:41 PM, Resident 1's medication reconciliation form from GACH 1, order summary report from the facility, and Medication Administration Record (MAR) from the facility dated from 8/1/2025 to 8/19/2025 were reviewed. The medication reconciliation form from GACH 1 dated 8/1/2025 indicated an active medication order for 2 antibiotics, one of which is ampicillin 6 gm IVPB every 12 hours to be resumed with no change. The medication reconciliation form also indicated the antibiotics regimen was to be continued until 8/19/2025 for history of PJI. The medication reconciliation form further indicated, first dose of ampicillin was to start at the facility on 8/2/2025. Resident 1's order summary report and MAR did not indicate an order for ampicillin 6 gm IVPB every 12 hours from 8/2/2025 to 8/19/2025. ADON stated the ampicillin was not added to the readmission orders for Resident 1 on 8/1/2025 and the resident's MAR did not indicate an ampicillin antibiotic was administered meaning, the ampicillin was not given to the resident from 8/2/2025 to 8/12/2025 (total of 11 days which is equivalent to 22 doses). During an interview on 8/27/2025 at 2 PM, MD 1 stated the Licensed Vocational Nurse 1 (LVN 1) reached out to him on 8/1/2025 regarding Resident 1's medication list form GACH 1. MD 1 stated, MD 1 instructed LVN 1 to continue the ampicillin antibiotic for Resident 1 and that he was not and should have been informed that the resident has not received the antibiotic from 8/2/2025 to 8/12/2025. MD 1 also stated LVN 1 should have followed up and attempted to call GACH 1 to clarify the ampicillin order and answer concerns related to Resident 1's PCN allergy on the resident's electronic medical record at the facility instead of not putting in the order as instructed by MD 1. During an interview on 8/27/2025 at 2:46 PM, Registered Nurse 1 (RN 1) stated LVN 1 should have called GACH 1 if there is something that needs to be clarified from the medication reconciliation form. RN 1 also stated Resident 1's infection would not be treated effectively if the antibiotic medications for Resident 1 were not given to the resident from 8/2/2025 to 8/12/2025. During an interview on 8/27/2025 at 3 PM, LVN 1 stated he did not put the order for ampicillin after he saw the resident's electronic medical records at the facility that indicated Resident 1 is allergic to PCN. LVN 1 also stated he did not remember calling GACH 1 to clarify the order but should have called and clarified with GACH 1 if Resident 1 received ampicillin at the hospital and if there had been any reaction from the medication. LVN 1 further stated Resident 1's ampicillin should have been added in the resident's admission order as instructed by MD 1 and should have been given to Resident 1 to help resolve the resident's ongoing infection. During an interview on 8/27/2025 at 3:29 PM, the Director of Nursing (DON), the DON stated LVN 1 should have clarified the order for 056080 Page 2 of 3 056080 08/27/2025 The Bellefontaine Healthcare Center 150 Bellefontaine St Pasadena, CA 91105

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ampicillin with GACH 1 after finding out Resident 1 had a history of PCN allergy instead of not putting the order in. The DON also stated the ampicillin order should have been reconciled accurately/ completely and continued when Resident 1 was admitted back at the facility on 8/1/2025 to make sure that Resident 1 received appropriate treatment for the resident's infection During a review of the facility's P&P titled, Reconciliation of Medications on Admission, revised July 2017, the P&P indicated its purpose was to ensure medication safety by accurately accounting for the resident's medication, routes and dosages upon admission to the facility. The P&P also indicated its guidelines was to compare pre-discharge medications to post -discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care. The P&P further indicated that medication reconciliation reduces medication errors and enhance resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruptions, in the correct dosages and routes, during admission/transfer process. The P&P also indicated that medication reconciliation helps to ensure that medications, routes and dosages have been accurately communicated to the attending physician and care team. 056080 Page 3 of 3