Health inspection·April 8, 2022

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure one of 40 sampled residents (Resident 12) was not provided grooming of fingernails. Residents Affected - Few This deficient practice had the potential to result in Resident 12 being predisposes to microorganisms that can cause infection and a decrease self-esteem. Findings: On 4/7/2022 at 11:00 a.m., a review of the electronic medical record indicated that Resident 12 was admitted at the facility on 7/28/2012 with the diagnosis of Osteomyelitis (inflammation of the bone or bone marrow due to infection) of the Lumbar (lower part of the back) region of the Vertebra (series of small bones forming the backbone); Malignant Neoplasm (a disease in which abnormal cells divide uncontrollably and destroy body tissue) of the Prostate; Unspecified Anemia ( a condition in which the blood does not have enough healthy red blood cells); Chronic Obstructive Pulmonary Disease ( a group of diseases that cause airflow blockage and breathing related problems) with Acute Lower Respiratory Infection; Hypertension (blood pressure higher than normal); Atrial Fibrillation (irregular and very rapid heart rhythm); Localized Edema (swelling caused by excess fluid trapped in body tissues); Asthma (a respiratory condition marked by spasms in the bronchi {any major passages of the lungs}of the lungs, causing difficulty breathing); Congestive Heart Failure (a serious condition in which the heart does not pump blood as efficiently as it should); Recurrent Major Depressive Disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities); Dysphagia (difficulty in swallowing); Cognitive Communication Deficit; Hyperlipidemia (abnormally high concentration of fats in the blood); Idiopathic neuropathy (damage of the peripheral nerves where cause is undetermined); Gastroesophageal Reflux (a condition in which the gastric fluid flows backward into the esophagus {a canal that connects the throat to the stomach}); Generalized Muscle Weakness and Lack of Coordination. A concurrent review of the Minimum Data Set (MDS) a standardized assessment and care screening tool, dated 1/10/2022, indicated Resident 12's cognition is mildly impaired and need cuing on recall of date and time orientation, however, the resident was able to make his needs and preferences known. On 4/7/2022 at 10:38 a.m., during a concurrent observation and interview, Resident 12's fingernails on both hands were observed appropriately ¼ inch long and with brown substance underneath. Resident 12 stated he had a shower last week and the activity personnel who trim his fingernails had not been in lately. When asked when was the last time his nails were trimmed, Resident 12 stated he had nail care about 2 to 3 weeks ago. On 4/7/2022 at 10:42 a.m., during an interview with CNA 1, CNA 1 stated grooming of the residents Page 1 of 30 056104 056104 04/08/2022 Rose Villa Health Care Center 9028 Rose Street Bellflower, CA 90706

F 0677 include bed bath, showers, shaving for males, tooth brushing and care/ trimming of fingernails. Level of Harm - Minimal harm or potential for actual harm On 4/8/2022 at 9:49 a.m., during an interview with LVN 1, LVN stated grooming and hygiene is part of the daily activities of living provided by the nursing assistants to the residents. LVN 1 further stated that if residents are not assisted with the activities of daily living, the residents will get sick due to possibility of infection and can have skin concerns such as skin tears/ abrasions due to scratching. Residents Affected - Few On 4/8/2022 at 10:08 a.m., during a concurrent observation and interview, observed Resident 12 awake in bed and watching TV. While Resident 12 was holding the TV's remote control, observed fingernails to both hands still dirty (brown substance under the nails) and untrimmed. Resident 12 verbalized, while looking at his fingernails, They look dirty and it is concerning. On 4/8/2022 at 11:11 a.m., during a record review of the facility's document log titled CNA Skin Observation Binder confirmed with LVN 1 that Resident 12's last documented shower and nail care was 12/6/2021. A concurrent review of the facility's policy titled, Quality of Care- ADL Care dated and revised 11/2007, indicated residents are given treatment and services to maintain or improve his/ her abilities. This policy also indicated under procedures: (2) residents who are unable to carry out activities of daily living (ADL) will receive assistance as needed. 056104 Page 2 of 30 056104 04/08/2022 Rose Villa Health Care Center 9028 Rose Street Bellflower, CA 90706

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to develop a care plan for activities for one of 40 sampled residents (Resident 12). Residents Affected - Few This deficient practice had the potential to negatively impact the resident's physical, cognitive and emotional health. Findings: On 4/5/2022 at 1:00 p.m., a review of the electronic medical record indicated that Resident 12 was admitted at the facility on 7/28/12 with the diagnosis of Osteomyelitis (inflammation of the bone or bone marrow due to infection) of the Lumbar (lower part of the back) region of the Vertebra (series of small bones forming the backbone); Malignant Neoplasm (a disease in which abnormal cells divide uncontrollably and destroy body tissue) of the Prostate; Unspecified Anemia ( a condition in which the blood does not have enough healthy red blood cells); Chronic Obstructive Pulmonary Disease ( a group of diseases that cause airflow blockage and breathing related problems) with Acute Lower Respiratory Infection; Hypertension (blood pressure higher than normal); Atrial Fibrillation (irregular and very rapid heart rhythm); Localized Edema (swelling caused by excess fluid trapped in body tissues); Asthma (a respiratory condition marked by spasms in the bronchi {any major passages of the lungs}of the lungs, causing difficulty breathing); Congestive Heart Failure (a serious condition in which the heart does not pump blood as efficiently as it should); Recurrent Major Depressive Disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities); Dysphagia (difficulty in swallowing); Cognitive Communication Deficit; Hyperlipidemia (abnormally high concentration of fats in the blood); Idiopathic neuropathy (damage of the peripheral nerves where cause is undetermined); Gastroesophageal Reflux (a condition in which the gastric fluid flows backward into the esophagus {a canal that connects the throat to the stomach}); Generalized Muscle Weakness and Lack of Coordination. A concurrent review of the Minimum Data Set (MDS) a standardized assessment and care screening tool, dated 1/10/2022, indicated Resident 12's cognition is moderately impaired and need cuing on recall of date and time orientation, however, the resident is able to make his needs and preferences known. The Minimum Data Set indicated the resident loves to be around animals and pets. It is important to the resident to do his favorite activities and do things with groups of people. During an observation and concurrent interview on 4/5/2022 at 10:12 a.m., Resident 12 was observed in bed with eyes closed. Resident 12 opened his eyes when greeted. The resident stated, I have been in this facility for 3 years and I have not been out of bed for a while. Resident 12 stated, with a sad facial expression, he only watch movies in his room and verbalized That is all I have for now. Resident 12 concluded the interview and stated he would like to get out of bed and join Bingo in the dining room. During an observation on 4/6/2022 at 8:00 a.m., and 1:00 p.m., Resident 12 observed in bed asleep and no activity staff at the bedside. During an observation on 4/7/2022 at 8:00 a.m., and 2:46 p.m., Resident 12 observed in bed asleep and no activity staff in the room. On 4/7/2022 at 10:26 a.m., during an interview with CNA 1, CNA 1 stated Resident 12 only watches TV 056104 Page 3 of 30 056104 04/08/2022 Rose Villa Health Care Center 9028 Rose Street Bellflower, CA 90706

F 0679 and the Activities personnel sometimes come and play cards with the resident 12. Level of Harm - Minimal harm or potential for actual harm On 4/7/2022 at 2:57 p.m., during an interview with the Activity Director (AD), the AD stated the Activity Assistant (AA) perform activity rounds in the morning between 9:00 a.m. to 10:30 a.m. with the residents confined in bed and residents in the yellow zone. AD further stated the activities offered for these residents are nail care, reading materials, radio/TV, sensory stimulation but she does not know how long the Activity Assistant spend time with each resident. Residents Affected - Few On 4/7/2022 at 3:14 p.m., during an interview with the AA, the AA stated she provides radio listening, reading materials, coloring and crosswords to residents confined in bed and residents in the yellow zone. AA further stated there are 18 residents in this group and she spends 10 minutes with each resident from 9:00 a.m. to 10:00 a.m., which is the daily activity routine. AA concluded the interview and stated activity log is not updated in the electronic medical record and she is unable to provide a log for the residents' activities. On 4/8/2022 at 9:16 a.m., during an interview with the Director of Nurses (DON), the DON stated there is no excuse that residents are not offered activities. The DON further stated all residents must be provided activities consistently while acknowledging their choice of activity. The DON concluded the interview by stating if residents are not provided activities, they can decline in general and will feel left out. On 4/8/2022 at 11:51 a.m., during an interview and concurrent record review with the AD, she stated that she has records of all the residents activities. The AD showed the Task Section, through the electronic medical record, and it indicated an Independent and a one on one activity for Resident 12. Resident 12 response and tolerance to the activity was not documented. On 4/8/2022 at 12:30 p.m., a review of the facility's electronic medical record was conducted and a specific and individualized care plan of activities for Resident 12 was not documented. 056104 Page 4 of 30 056104 04/08/2022 Rose Villa Health Care Center 9028 Rose Street Bellflower, CA 90706

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatment and services to maintain or prevent further decrease in joint range of motion (ROM, full movement potential of a joint) and/or mobility for one of 12 sampled residents (Resident 6). The facility failed to ensure that Resident 6 received Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and joint mobility) treatment five times a week as ordered. This deficient practice had the potential for Resident 6 to have an avoidable decline in range of motion and mobility. Findings: A review of Resident 6's admission Record indicated the resident was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses including chronic pain syndrome (persistent pain that lasts over three months), hypertensive heart disease without heart failure (heart disease that occurs due to long periods of high blood pressure), and morbid obesity (health condition involving excessive body mass). A review of Resident 6's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 01/05/2022 indicated the resident had intact cognitive skills for daily decision making and required extensive assistance (resident involved in activity with staff assistance for weight bearing support) from staff for bed mobility (moving in bed to and from different positions such as side to side), transfers (moving from one surface to another such as bed to chair), dressing, toileting, and personal hygiene. MDS indicated Resident 6 was totally dependent (full staff performance) on staff for bathing and did not walk during the assessment period. The MDS further indicated that Resident 6 had functional limitations in ROM on one upper extremity (shoulder, elbow, wrist, hand) and one lower extremity (hip, knee, ankle, foot). A review of Resident 6's undated care plan titled ADL Self Care Performance Deficit indicated the resident was at high risk for further decline in ROM. The care plan indicated for RNA to assist wit active range of motion (AAROM, movement at a given joint with a person's own effort and assistance from an external force or another person) for bilateral (both) lower extremity (LE) as tolerated once a day, five times a week. A review of the Resident 6's physician's order dated 5/12/2021, the order indicated for RNA for perform AAROM exercises for bilateral lower extremities as tolerated once a day, five times a week. On 04/06/2022 at 03:27 p.m., a review of the RNA treatment Flow Sheets for December 2021, January 2022, February 2022, March 2022, and April 2022, treatment notes indicated the following: 1. December 2021: X noted on 12/4, 12/5, 12/6, 12/7, 12/11, 12/12, 12/13, 12/14, 12/18, 12/19, 12/20, 12/21, 12/25, 12/26, 12/27, 12/28. Blank boxes noted on 12/3, 12/17, and 12/29. RNA treatment not completed for 11 days. 2. January 2022: X noted on 1/1, 1/2, 1/3, 1/4, 1/8, 1/9, 1/10, 1/11, 1/15, 1/16, 1/17, 1/18, 1/22, 1/23, 1/24, 1/25, 1/29, 1/30, and 1/31. RNA treatment not completed for 9 days. 056104 Page 5 of 30 056104 04/08/2022 Rose Villa Health Care Center 9028 Rose Street Bellflower, CA 90706

F 0688 Level of Harm - Minimal harm or potential for actual harm 3. February 2022: X's noted on 2/1, 2/5, 2/6, 2/7, 2/8, 2/12, 2/13, 2/14, 2/15, 2/17, 2/19, 2/20, 2/21, 2/22, 2/26, 2/27, and 2/28. RNA treatment not completed for 9 days. 4. March 2022: X's on 3/1, 3/5, 3/6, 3/7, 3/8, 3/12, 3/13, 3/14, 3/15, 3/19, 3/20, 3/21, 3/22, 3/26, 3/27, 3/28, and 3/29. RNA treatment not completed for 9 days. Residents Affected - Few During an interview and record review on 04/07/2022 at 01:52 p.m., Restorative Nursing Aide 1 (RNA 1) reviewed Resident 6's physician's orders and confirmed an order for RNA to conduct BLE AAROM as tolerated once a day five days a week. RNA 1 reviewed Resident 6's RNA treatment flow sheets for December 2021, January 2022, February 2022, March 2022, and April 2022 and stated an X in the box or a blank box meant that the RNA treatment was not completed that day. RNA 1 stated that staff initials in a box indicated that RNA treatment was completed that day. RNA 1 stated that the X in all the Monday and Tuesday boxes were incorrect and should instead be on Saturday and Sunday because RNA treatments were not provided on Saturday or Sunday. RNA 1 confirmed that Resident 6 did not receive RNA treatment five days a week as ordered. RNA 1 stated that if a resident did not receive RNA treatments ordered by the physician, the resident was at risk for pressure sores (Injury to skin and underlying tissue resulting from prolonged pressure on the skin) and contractures (loss of motion of a joint). During an interview with the Director of Rehab (DOR) on 04/07/2022 03:15 p.m., the DOR stated that potential outcomes of a resident not receiving RNA services as ordered would put the resident at risk for a change in a resident's condition and a decline in function. During an interview with the Director of Nursing (DON) on 04/08/2022 at 1:39 p.m., the DON stated that the facility did not have a policy regarding following physician's orders as prescribed. 056104 Page 6 of 30 056104 04/08/2022 Rose Villa Health Care Center 9028 Rose Street Bellflower, CA 90706

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to clarify physician orders for an accurate dose of MiraLAX AX (medication used to treat occasional constipation) for one of three residents (Resident 38). This deficient practice had the potential to result in Resident 38 having unintended complications related to bowel patterns that can lead to constipation. Findings: During an observation on 4/7/2022 at 8:46 a.m., in front of resident 38's room, Licensed Vocational Nurse (LVN) 5 was observed preparing MiraLAX for administration to Resident 38. LVN 5 poured 1 cap full in a cup of 6 ounces of water. During a review of Resident 38's Order Summary Report (OSR), dated 6/30/2021, the OS indicated, MiraLAX Powder (Polyethylene Glycol 3350) Give 25 gram (gm) by mouth two times a day for bowel management dissolve with 6-8 ounces of water or juice. During a concurrent observation and interview on 4/7/2022, at 11:27 a.m., with LVN 5 in front of medication cart, MiraLAX bottle directions printed as, 1 cap full equal to 17 mg. LVN 5 stated order for MiraLAX is 25 mg, only gave one cap full which equaled to 17 mg, if given two cap fulls then it would equal to 34 mg. LVN 5 stated, When the dose is different than what is on the bottle the doctor or pharmacist need to be called to verify the dosage. During a review of Resident 38's admission Record AR, AR indicated Resident 38 was admitted to the facility on [DATE] with diagnosis including hypothyroidism (condition in which your thyroid gland doesn't produce enough of certain crucial hormones), type 2 diabetes mellitus (disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), major depressive disorder (mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts), bilateral primary osteoarthritis (degeneration of joint cartilage and the underlying bone) of knee. During a review of the Minimum Data Set Assessment (MDS), a standardized assessment and care screening tool, dated 2/17/2022, indicated Resident 38 was cognitively intact. During an interview on 4/7/2022, at 12:07 p.m., with LVN 5, LVN 5 stated, Staff should have caught the discrepancy since 6/21/2022. Pharmacy said MiraLAX is not available in 25 gm. During a review of Resident 38's Medication Administration Record (MAR), dated March 2022, the MAR indicated, Resident 38 was administered 25 gm of MiraLAX. During an interview on 4/8/2022, at 6:14 p.m., with the Director if Nursing (DON), the DON stated, MiraLAX is not effective if the dosage is not given per physician order. During a review of the facility's policy and procedure (P&P) titled Medication Administration 056104 Page 7 of 30 056104 04/08/2022 Rose Villa Health Care Center 9028 Rose Street Bellflower, CA 90706

F 0726 Level of Harm - Minimal harm or potential for actual harm revised 5/2007, the P&P indicated prior to administering the resident's medication, the nurse should compare the drug and dosage schedule on the resident's MAR with the drug label. NOTE: If there is any reason to question the dosage or the schedule, the nurse should check the physician's orders. Residents Affected - Few 056104 Page 8 of 30 056104 04/08/2022 Rose Villa Health Care Center 9028 Rose Street Bellflower, CA 90706

F 0755 Level of Harm - Minimal harm or potential for actual harm 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: Residents Affected - Few 1. Administer two medications necessary to treat Resident 12's anemia. The deficient practice had the potential to result in a delay of alleviating of or worsening of Resident 12's anemia. 2. Replace inhalation (INH) solution medication in the Emergency Kit ([E-kit] medications needed immediately) in a timely manner, taken for Resident 202 for Nurses Station (Station 1). The deficient practice had the potential to result in a delay in administration of necessary emergency medication for the residents. 3. Properly document resident names on E-kit slips at one of two Nurses Stations (Station 1). The deficient practice had the potential to result in unclear communication which could have led to issues with follow-up evaluations and treatment. Findings: 1. During a concurrent observation and interview on 4/6/2022, at 1:46 p.m., at Station 1, with Director of Nursing (DON), there was a full dose syringe of Epogen (medication used to treat low red blood cell levels) and a full dose of Procrit (medication used to treat low red blood cell levels) for Resident 12 was found. One bottle had a dispensed date of 3/15/2022, and the other of 3/28/2022. DON stated she was not sure if medications were given and will check 3/2022 Medication Administration Record (MAR). During a review of Resident 12's admission Record (AR), the AR indicated, Resident 12 was admitted to the facility on [DATE], with diagnoses not limited to anemia (condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues), heart failure (a serious condition in which the heart doesn't pump blood as efficiently as it should), and osteomyelitis (inflammation or swelling that occurs in the bone). During a review of Resident 12's Minimum Data Set ([MDS] a standardized comprehensive assessment and care screening tool), dated on 1/10/2022, the MDS indicated Resident 12 was cognitively(ability to make decisions of daily living) moderately impaired. During a review of Resident 12's Order Summary (OS), OS indicated, Resident 12 had an order for Procrit Solution 40000 Unit (U)/Milliliter (ML) (Epoetin Alfa) Inject 40000 unit subcutaneously ([SQ]beneath, or under, all the layers of the skin) one time a day every Monday for ANEMIA. During a concurrent interview and record review, on 4/07/2022, at 10:55 a.m., with DON, DON presented copies of pharmacy delivery receipts for Resident 12's Procrit (Epogen) since order date 3/15/2022. The order indicated Procrit 40,000 U every Monday. DON stated the pharmacy delivered a total of 3 doses of Procrit (dates: 3/16/22 x 1 dose, 3/21/22 x 1 dose, and 3/28/22 x 1 dose). DON 056104 Page 9 of 30 056104 04/08/2022 Rose Villa Health Care Center 9028 Rose Street Bellflower, CA 90706

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few acknowledged that there were 2 doses of Procrit in the medication room refrigerator during observation of 4/6/2022. During a concurrent interview and record review, on 4/7/2022, at 10:55 a.m., with DON, DON presented a copy of Resident 12's Medication Administration Record (MAR), DON stated the nurses documented that Resident 12 received one dose each on 3/21/2022, 3/28/2022, & on 4/4/2022. DON stated there should not have been two doses remaining when the facility received three doses total and MAR indicated three doses had been given. DON stated Procrit was not in the E-kit medications and the facility had no other resident on the same medication during the same period. During a review of Resident 12's Lab Results Report (LRR), LRR for hemoglobin ([HGB]a protein in the red blood cells) and hematocrit, (reflects the percentage of blood volume that is composed of red blood cells) related to total blood cell count. Resident 12's levels were all below the normal reference range. LRR indicated reference range indicated hemoglobin 13.5- 17.5 gram (gm) per deciliter (dl), and hematocrit 40.0- 51.0 percent (%). Resident 12's LRR indicated the following: 3/1/2022: Hemoglobin: 11.0 gm/dl Hematocrit: 33.8 % 3/21/2022: Hemoglobin: 9.2 gm/dl Hematocrit: 28.3 % 3/28/2022: Hemoglobin: 9.2 gm/dl Hematocrit: 28.3 % 4/6/2022: Hemoglobin: 9.2 gm/dl Hematocrit: 28.9 % 4/7/2022: Hemoglobin: 9.2 gm/dl Hematocrit: 28.6 % During a review of Resident 12's Care Plan (CP), no date, the CP indicated, Resident 12's goals, will maintain lab values within acceptable parameters per MD (medical doctor) through review date, will remain free if signs and symptoms or complications related to anemia through review date. The CP 056104 Page 10 of 30 056104 04/08/2022 Rose Villa Health Care Center 9028 Rose Street Bellflower, CA 90706

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few interventions indicated, give medications as ordered. Procrit Solution 40000 u/ml (Epoetin Alfa) inject 40000 U SQ one time a day every Monday for anemia, hold of HGB level more than 10. During a review of the facility's policy and procedure (P&P) titled Medication Administration revised 5/07, the P&P indicated, Medications must be administered in accordance with the written orders of the attending physician. Unless otherwise specified by the residents attending physician, routine medications should be administered as scheduled. Should a drug be withheld, refused, or given other than at the scheduled time, the nurse must initial and circle the MAR space provided for that particular drug. The nurse must enter an explanatory note on the reverse side of the MAR when drugs are withheld, refused, or given other than at scheduled times. 2. During a concurrent observation and interview on 4/6/2022, at 1:46 p.m., with DON, in the nurse's station one medication room, there was a cabinet under the sink labeled E-kit. From inside the cabinet, DON pulled out a stack of E- kits. One of them labeled as sub- acute E-kit, had a green zip tie as all the other ones had red zip tie. DON stated green zip tie indicated it was opened prior. DON opened the E-kit with green zip tie and there was an E-kit Usage Kit Slip dated 3/23/2022 for Resident 202, Ipratropium 0.5/2.5 ml x 1 and abutter x 1. DON confirmed it had been nine days, since the medication was used from the E-Kit. DON confirmed the mediations should have been replaced in the E-Kit but was not. DON stated there was a potential for a delay in resident's care when E- kits are not replenished as soon as possible. During a review of Resident 202's admission record, the record indicated, Resident 202 was admitted to the facility on [DATE], with diagnoses not limited to pulmonary hypertension (a type of high blood pressure that affects the arteries in the lungs and the right side of the heart), sepsis (body's extreme response to an infection), kidney failure (condition in which the kidneys stop working and are not able to remove waste and extra water from the blood or keep body chemicals in balance), and heart failure (condition in which the heart can't pump enough blood to meet the body's needs). During a review of the facility's P&P titled Medication Ordering and Receiving From Pharmacy Provider dated 9/10, the P&P indicated, Inform the pharmacy of items used from the emergency kit. This can be done immediately by fax or telephone during normal pharmacy hours. This will signal the pharmacy to replace the E-kit or item, within 72 hours as applicable per state law. 3. During a concurrent interview and record review, on 4/6/2022, at 1:46 p.m., with DON, in nurse's station one medication room, there was an E-kit Usage folder. DON confirmed that four out of 84 E-kit Usage slips were incomplete such as missing resident names. During a review of the facility's P&P titled Medication Ordering and Receiving from Pharmacy Provider dated 9/10, the P&P indicated, Upon removal of any medication or supply item from the emergency kit, the nurse documents the medication or item used on an emergency kit log. Items to be documented include: Resident's name. 056104 Page 11 of 30 056104 04/08/2022 Rose Villa Health Care Center 9028 Rose Street Bellflower, CA 90706

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to communicate the consultant pharmacist's recommendation in the Medication Regime Review (MRR), (a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) to the physician for one of five residents (Resident 16) for unnecessary medications. This deficient practice resulted in a recommended gradual dose reduction not performed for Resident 16, with a potential for adverse drug reaction for the resident. Findings: a. During a review of the admission face sheet, the face sheet indicated Resident 16 was admitted to the facility on [DATE], with diagnoses not limited to diverticulitis (infection or inflammation of pouches that can form in your intestines), depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (feeling of fear, dread, and uneasiness). During a review of Resident 16's Minimum Data Set ([MDS] a comprehensive assessment and care screening tool), dated 2/11/2022, MDS indicated Resident 16 was moderately cognitively (ability to make decisions of daily living) impaired. During a review of Resident 16's physicians' orders, dated 2/6/2019, the order indicated, Lexapro Tablet 10 milligrams (gm) (Escitalopram Oxalate) Give one tablet (tb) by mouth (PO) one time a day for depression manifested by verbalization of sadness. During a concurrent interview and record review on 4/8/2021, at 12:41 p.m., with Director of Nursing (DON), Resident 16's MRR, a review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy), dated 2/2/2022 was reviewed. The MRR indicated, Please evaluate the continuous use of Lexapro 10 milligrams PO daily for depression since 7/2021. Facility must attempt a gradual dose reduction (GDR) in two separate quarters (with at least one month in between attempts), unless clinically contraindicated. Please check one of the following below to keep the facility in compliance. Upon further review, no checks were marked to indicate disagree or agreeance of GDR. DON stated, Couldn't find doctor's response to pharmacist recommendation for resident's GDR attempt 2/2/2022 for Lexapro 10 mg for MRR. DON stated that no GDR performed. During a review of the facility policy and procedure (P&P), titled Consultant Pharmacist Reports, dated 11/2017, indicated the MRR was conducted to evaluate a resident's response to medication therapy in order to prevent or minimize adverse consequences related to medication therapy. The policy and procedure indicated that the consultant pharmacist's recommendations are acted upon and documented by the facility staff and/or the prescriber. During a review of the facility's P&P titled, Medication Regimen Review and Reporting, dated 9/10, the P&P indicated The consultant pharmacist and the care center follow up on the recommendations to verify that appropriate action has been taken. Recommendation shall be acted upon within a 056104 Page 12 of 30 056104 04/08/2022 Rose Villa Health Care Center 9028 Rose Street Bellflower, CA 90706

F 0756 reasonable timeframe. Physician may accept or act on recommendation or reject recommendation and provide an explanation for disagreement. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 056104 Page 13 of 30 056104 04/08/2022 Rose Villa Health Care Center 9028 Rose Street Bellflower, CA 90706

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Do a Gradual Dose Reduction ([GDR] an attempt to decrease or discontinue psychotropic [medications that act on the mind] medication after three months of starting on the psychotropic medication, unless clinically contraindicated) for two of three residents (Resident 16 and Resident 36). This deficient practice resulted in Resident 16 receiving Escitalopram (brand name Lexapro, a medication to treat depression), and Resident 36 receiving Aripiprazole (brand name Abilify, a medication to treat depression) and Fluoxetine (brand name Prozac, an antidepressant medication that works in the brain) without clinical justification for use. 2. Ensure a proper physician consultation evaluation for Aripiprazole for one of three residents (Resident 36). This deficient practice had the potential for Resident 36 to take medications and experience side effects and adverse effects without being evaluated by a mental health proffesional for appropriateness, before administering psychotropic medications. 3. Ensure a physician order for an, 'as needed' anti-psychotic drug was not renewed unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of that medication for one of three residents (Resident 37). This deficient practice had the potential to result in the use of unnecessary psychotropic drugs, Lorazepam (brand name Ativan, a medication to treat anxiety) for Resident 37 and could lead to side effect and adverse consequence such as a decline in quality of life and functional capacity. Findings: 1. During a review of the admission face sheet, the face sheet indicated Resident 16 was admitted to the facility on [DATE], with diagnoses not limited to diverticulitis (infection or inflammation of pouches that can form in your intestines), depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (feeling of fear, dread, and uneasiness). During a review of Resident 16's Minimum Data Set ([MDS] a comprehensive assessment and care screening tool), dated 2/11/2022, MDS indicated Resident 16 was moderately cognitively (ability to make decisions of daily living) impaired. During a review of Resident 16's physicans order, dated 2/6/2019, the order indicated, Lexapro Tablet 5 milligrams (gm) (Escitalopram Oxalate) Give one tablet (tb) by mouth (PO) one time a day for depression manifested by irritable mood. During a review of Resident 16's Medication Regimen Review ([MRR] a review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate 056104 Page 14 of 30 056104 04/08/2022 Rose Villa Health Care Center 9028 Rose Street Bellflower, CA 90706

F 0758 Level of Harm - Minimal harm or potential for actual harm drug therapy, and noncompliance with drug therapy), dated 2/2/2022, the MAR indicated, Please evaluate the continuous use of Lexapro 10 milligrams PO daily for depression since 7/2021. Facility must attempt a gradual dose reduction in two separate quarters (with at least one month in between attempts), unless clinically contraindicated. Please check one of the following below; Agree or Disagree : Upon further review, no checks were marked to indicate the ordering physician agreed or disagreed trying a GDR. Residents Affected - Some During an interview with Director of Nursing (DON), on 4/8/2022, at 12:41 9 a.m., DON acknowledged the doctor did not respond to the pharmacist recommendation dated 2/2/2022 for resident 36's GDR attempt for Lexapro 10 mg for MRR. DON stated that no GDR was performed. 1 a. During a review of the admission face sheet, the face sheet indicated Resident 36 was readmitted on [DATE], with diagnoses not limited to Postprocedural Status (the condition of a patient in the period following a surgical operation), psychosis (condition that affects the way your brain processes information), depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (feeling of fear, dread, and uneasiness). During a review of Resident 36's Minimum Data Set MDS, dated [DATE], the MDS indicated Resident 36 was moderately cognitively impaired. During a review of Resident 36's physician's orders, dated 9/9/2021, the orders indicated, Aripiprazole tablet 20 MG give one tablet by mouth one time a day for psychosis manifested by striking out. Fluoxetine HCL (hydrochloric acid) capsule 20 milligrams give one capsule by mouth two times a day for depression manifested by verbalization of sadness. During an interview with Director of Nursing (DON), on 4/8/2022, at 8:48 a.m., DON stated, there was no record of a GDR trial for Abilify and Prozac for Resident 36. During a review of the facility's policies and procedures (P&P) titled, Psychotropic Drug Use, revised 8/17, the P&P indicated Based on a comprehensive assessment of a resident, the facility will ensure that: Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Upon initial comprehensive assessment, the Social Services designee shall review new admissions for any psychiatric, mood or behavior disorders, mental and psychosocial difficulties, and/or physicians orders for psychotropic medications. These residents will be referred to the facility's Psychotropic Drug Review Committee and/or the Psychiatrist to ensure: Attempt/consider a GDR, if appropriate. 2. During a review of Resident 36's Order Summary (OS), dated 5/31/2021, the OS indicated, Aripiprazole tablet 20 MG give one tablet by mouth one time a day for schizophrenia manifested by striking out. On 9/9/2021 the diagnosis was changed, Aripiprazole tablet 20 MG give one tablet by mouth one time a day for psychosis manifested by striking out. During an interview with Director of Nursing (DON), on 4/8/2022, at 8:48 a.m., DON confirmed there was no psychiatric evaluation performed for Resident 36 since 5/2021 even though the diagnose that was originally schizophrenia, was later changed to psychosis without a psychiatric evaluation. During a review of the facility's policies and procedures (P&P) titled, Psychotropic Drug Use, revised 8/17, the P&P indicated It is the policy of this facility to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a 056104 Page 15 of 30 056104 04/08/2022 Rose Villa Health Care Center 9028 Rose Street Bellflower, CA 90706

F 0758 specific condition as diagnosed and documented in the clinical record. Level of Harm - Minimal harm or potential for actual harm 3. During a review of Resident 37's Psychotherapy Note, dated 3/2022, the Psychotherapy Note indicated, Resident 37's Psychiatric Diagnose was: Acute Psychiatric Disorder. Lorazepam (brand name Ativan 1 milligram every eight hours as needed. Residents Affected - Some During a review of the admission face sheet indicated Resident 37 was admitted to the facility on [DATE] and 6/4/2021, with diagnoses not limited to sepsis (body's extreme response to an infection), depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (feeling of fear, dread, and uneasiness). During a review of Resident 37's Minimum Data Set ([MDS] a comprehensive assessment and care screening tool), dated 3/6/2022, indicated Resident 36 was moderately cognitively impaired. During a review of Resident 37's Order Summary Report (OSR), dated 4/8/2022, the OSR indicated, Resident 37 had an order for Ativan tablet 1 milligram give one tablet via G- Tube every eight hours as needed for anxiety manifested by restlessness. Ativan had an order date of 3/22/2022. During a concurrent interview and record review on 4/8/2022 at 9:00 a.m., with Director of Staff Development (DSD), of Resident 37's Medication Administration Record (MAR), dated 4/2022, the MAR indicated Ativan was administered on 4/6/2022 at 1:57 p.m. DSD stated Resident 37 has an order for Ativan as needed ordered 3/22/2022. DSD confirmed last time Resident 37 received Ativan was on 4/6/2022 at 1:57 p.m., it had been 17 days, past the revaluate and reorder date. DSD stated the process for antipsychotic 'as needed' prescriptions needed to be reevaluated and renewed every 14 days. DSD acknowledged there was no noted doctor note for Ativan continuation past 14 days as needed. During an interview with Director of Nursing (DON), on 4/8/2022, at 8:48 a.m., DON stated, Psychotropic, 'as needed' medication orders are only good for 14 days so the doctor can evaluate if there was still a need to continue the medication. During a review of the facility's policies and procedures (P&P) titled, Psychotropic Drug Use, revised 8/17, the P&P indicated As needed orders for psychotropic drugs are limited to 14 days . if the attending physician or prescribing practitioner believes that it is appropriate for the as needed psychotropic medication order to be extended beyond 14 days, he or she should document their rationale in the residence medical record and indicate the duration for the as needed order. As needed orders for antipsychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. 056104 Page 16 of 30 056104 04/08/2022 Rose Villa Health Care Center 9028 Rose Street Bellflower, CA 90706

F 0760 Ensure that residents are free from significant medication errors. 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 one of seven residents (Resident 16), who had a physicans order for insulin (used to control the level of the sugar-glucose in the blood) according to a sliding scale (a dosing regimen that prescribes how much insulin to give for different levels of blood sugar) was free from significant medication error when insulin was potentially omitted. Residents Affected - Few This deficient practice placed the resident at risk of inadequate blood sugar management, which can cause hyperglycemia (high blood sugar), or hypoglycemia (abnormal low blood sugar) which untreated can lead to complications, such as eye, kidney, or heart disease, nerve damage, loss of consciousness and even death. Findings: During a review of the admission face sheet, the face sheet indicated Resident 16 was admitted to the facility on [DATE], with diagnoses of type 2 diabetes mellitus ([DM] impairment in the way the body regulates and uses sugar [glucose] as a fuel), chronic kidney disease (kidneys are damaged and cannot filter blood the way they should), and hyperlipidemia (blood has too many lipids [ fats], such as cholesterol and triglycerides). During a review of Resident 16's Minimum Data Set ([MDS] a comprehensive assessment and care screening tool), dated 2/11/2022, MDS indicated Resident 16 was moderately cognitively (ability to make decisions of daily living) impaired. During a review of Resident 16's order, dated 2/23/2021, the order indicated as follows: Humulin R Solution 100 Unit/ml (Insulin Regular Human) Inject as per sliding scale: If 70 milligram (mg)/deciliter (dl)- 150 mg/dl= 0 units, Blood Sugar (BS) less than 70 mg/dl notify MD; 151 mg/dl -200 mg/dl= 2 unit 201 mg/dl-250 mg/dl= 4 units 251 mg/dl -300 mg/dl=6 units 301 mg/dl- 350 mg/dl=8 units 351 mg/dl-400 mg/dl=10 units BS more than 400 mg/dl= 12 units then notify the physician, subcutaneous (beneath, or under, all the layers of the skin) two times a day for DM. During a concurrent interview and record review, on 4/8/2022, at 9:15 a.m., with Minimum Data Set Nurse and Director of Nursing (DON), Resident 16's Medication Administration Record (MAR), dated 3/2022 was reviewed. The MAR indicated, Resident 16 had an omitted BS check on 3/27/2022 for 0630. MDS stated, There are no notes on missing blood glucose for 3/27/2022. DON stated, There shouldn't be any 056104 Page 17 of 30 056104 04/08/2022 Rose Villa Health Care Center 9028 Rose Street Bellflower, CA 90706

F 0760 Level of Harm - Minimal harm or potential for actual harm blanks and should be documented somewhere regarding resident blood glucose results. If missing nurse probably checked it but didn't document it or didn't do it. During a review of Resident 16's Plan of Care developed on 11/7/2020, the care plan interventions indicated, Fasting Serum Blood Sugar as ordered by doctor. Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled Medication Administration revised 5/07, the P&P indicated, Medications must be administered in accordance with the written orders of the attending physician. Should a drug be withheld, refused, or given other than at the scheduled time, the nurse must initial and circle the MAR [Medication Administration Record] space provided for that particular drug. The nurse must enter an explanatory note on the reverse side of the MAR when drugs are withheld, refused, or given other than at scheduled times. 056104 Page 18 of 30 056104 04/08/2022 Rose Villa Health Care Center 9028 Rose Street Bellflower, CA 90706

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review, the facility failed to maintain proper temperature controls for medications requiring storage in the medication room. This deficient practice had the potential of medication exposure to extreme temperatures in the medication storage room in station 1, potentially leading to loss of strength of the medications, causing residents to receive ineffective medication dosages. Findings: During a concurrent observation and interview on 4/6/2022, at 1:46 p.m., with Director of Nursing (DON), in station 1 medication room, the medication room did not have a room thermometer. DON stated, she did not know the temperature in the medication room because there was no thermometer as they do not monitor the inside of the medication room. During a review of the facility's policy and procedure (P&P) titled, Medication Storage dated 9/10, the P&P indicated, Medications requiring storage at 'room storage' are kept at temperatures ranging from 15°C (59°F) to 30°C (86°F). 056104 Page 19 of 30 056104 04/08/2022 Rose Villa Health Care Center 9028 Rose Street Bellflower, CA 90706

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure expired food was not stored in the kitchen and accessible to be used in preparing foods in accordance with professional standards for food service safety. This practice had the potential to result in the residents ingesting expired food and can result in foodborne illnesses and can lead to symptoms such as nausea, vomiting, stomach cramps, and diarrhea including decrease in food flavoring and taste. Findings: a). During an observation on 4/5/2022 at 8:26 a.m. of the spice shelf, there was an egg shade pure food color bottle with an open date of 2/10/2021, with no expiration date. The egg shade pure food color, was missing on the Dry food storage guidelines. There was a rum flavor liquid with an open date of 2/10/2021, with no expiration date. The rum flavor liquid was missing on the Dry food storage guidelines. There was poultry seasoning with an open date of 5/10/2021, with a best by date of 10/6/2021. During an interview on 4/6/2022 at 2:22 p.m. with DS, DS stated, for all the products we check the best by date and expiration date. We also, check the expiration sheet for manufacture recommendations and we check the expiration date four times a week. We use the FEFO system (First Expired First Out). If we use the product beyond the best by date the product is decreased in quality and the taste will not be the same. We will not serve that to the residents because it will not have a good flavor. Every time, we use a new box we label it with the date we received it and the date the bottle was open. We also check the expiration date on the bottles, but we do not make any notes for the best by date. DS stated, if we serve a resident expired food or products the resident can get sick, not only one resident but all the residents in the facility. If we do not see the expiration date on the bottle, we check the manufacturer paper and if there is no expiration date showing, we discard the product because we would not know when it was expired. DS stated, I will call the manufactures for information about the products and the expiration date. a. During an observation on 4/6/2022 at 11:51 p.m. in the dry food storage room, the surveyor observed the following: 1. Pistachio flavor pudding was opened on 7/8/2021 with a best by date of 3/10/2022. 2. Gelatin orange was opened on 12/8/2021, with no expiration date. 3. During a record review of Dry food storage guidelines dated 2017, indicated opened gelatin orange 056104 Page 20 of 30 056104 04/08/2022 Rose Villa Health Care Center 9028 Rose Street Bellflower, CA 90706

F 0812 can only be kept on the shelf for three months. Level of Harm - Minimal harm or potential for actual harm 4. Lemon pudding was opened on 4/24/21 with a best by date of 2/17/2022. Residents Affected - Few During an interview on 4/7/2022 at 2:04 p.m. with DS, DS stated, we do not have a log system to monitor products that are ready to be expired or products past the best by date. DS stated, The only thing, I do is to rotate the products. The boxes that were found with pistachio and lemon pudding with the best by date past due I would eventually find it. I think it was a mistake not checking the best by date. If the best by date was past, I will not serve those products to resident because the quality is lower, and the flavor will decrease. I do not have a proof when the last time lemon or pistachio pudding, was served but I think it was in January. DS further stated we receive new products twice a week. If I am not here the head cook receives those. DS stated, I oversee the expiration date and best by date on products. During a review of the facility's policy and procedure titled General Receiving of Delivery of Food and Supplies dated 2018, the P&P indicated food deliveries will be inspected to assure high quality food and supplies. They are to be received in proper conditions. Carefully inspect deliveries for proper labeling, temperature, and appearance. Label all items with the delivery date or a use-by date. During a review of the facility's policy and procedure titled Storage of Food and Supplies dated 2017, the P&P indicated, food and supplies will be stored properly and in a safe manner. Labels should be visible, and the arrangement should permit rotation of supplies so the oldest items will be used first. All food will be dated-month, day, year. All food products will be used per the times specified in the Dry Food Storage Guidelines No food will be kept longer than the expiration date on the product. 056104 Page 21 of 30 056104 04/08/2022 Rose Villa Health Care Center 9028 Rose Street Bellflower, CA 90706

F 0825 Provide or get specialized rehabilitative services as required for a resident. 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 provide physical therapy (PT) and occupational therapy (OT) evaluations as ordered for one of 12 sampled residents (Resident 6). Residents Affected - Few This deficient practice had the potential to prevent Resident 6 from maximizing her functional mobility (the way in which one moves in the environment to complete everyday tasks), joint range of motion (ROM, full movement potential of a joint), and activities of daily living (ADL, basic activities such as eating, dressing, toileting) while residing in the facility. Findings: A review of Resident 6's admission Record indicated the resident was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses including chronic pain syndrome (persistent pain that lasts over three months), hypertensive heart disease without heart failure (heart disease that occurs due to long periods of high blood pressure), and morbid obesity (health condition involving excessive body mass). A review of Resident 6's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 01/05/2022 indicated that the resident was cognitively intact. MDS indicated that Resident 6 required extensive assistance (resident involved in activity with staff assistance for weight bearing support) for bed mobility (moving in bed to and from different positions such as side to side), transfers (moving from one surface to another such as bed to chair), dressing, toileting, and personal hygiene. Resident 6 required total dependence (full staff performance) for bathing and did not walk during the assessment period. The MDS further indicated that the resident had functional limitations in range of motion on one upper extremity (shoulder, elbow, wrist, hand) and one lower extremity (hip, knee, ankle, foot). A review of Resident 6's undated care plan titled Activities of Daily Living (ADL) Self Care Performance Deficit indicated that the resident was at high risk for further decline in range of motion. The care plan indicated for PT and OT evaluation and treatment per physician's order under interventions/tasks. A review of Resident 6's physician's orders indicated an order dated 01/26/2022 for PT and OT evaluation and treatment. During an interview and record review on 04/06/2022 at 4:00 p.m., the Director of Rehabilitation Services (DOR) reviewed Resident 6's clinical record and confirmed physician's orders for PT and OT evaluations on 01/26/2022. The DOR stated she was not aware of PT and OT evaluation and treatment orders dated 01/26/2022. The DOR reviewed Resident 6's rehabilitation therapy records and confirmed Resident 6 was last evaluated by PT on 04/13/2021 and by OT on 04/15/2021. The DOR stated that PT and OT evaluations were not done as ordered. During an interview on 04/07/2022 at 10:54 a.m., the DOR stated if a resident did not receive PT and OT as ordered by the physician, then it put the resident at risk for a change in a resident's condition and a decline in function. During an interview with the Director of Nursing (DON) on 04/08/2022 at 1:39 p.m., the DON stated 056104 Page 22 of 30 056104 04/08/2022 Rose Villa Health Care Center 9028 Rose Street Bellflower, CA 90706

F 0825 that the facility did not have a policy regarding following physician's orders as prescribed. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 056104 Page 23 of 30 056104 04/08/2022 Rose Villa Health Care Center 9028 Rose Street Bellflower, CA 90706

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship by failing to: Residents Affected - Few 1). Ensure Resident 46 was prescribed an antibiotic drug without meeting the criteria, after being screened for a urinary tract infection UTI (common infections that happen when bacteria, often from the skin or rectum, enter the urethra, and infect the urinary tract), and failing to provide a McGeer's criteria surveillance list. 2). Provide a McGeer's criteria surveillance documentation for (Resident 198). Resident 198 was prescribed antibiotic drug without following McGeer's surveillance. These deficient practices had the potential to result in antibiotic resistance (not effective to treat infection) due to unnecessary or inappropriate antibiotic use. Findings: a). During a review of the admission record for Resident 46 dated 3/21/2022, the record indicated Resident 46 had diagnosis that included traumatic subdural hemorrhage without loss of consciousness subsequent encounter (It is caused by a traumatic head injury, such as a blow to the head or a fall. This indicates that there is significant bleeding inside the skull, and pressure against the brain), radiculopathy, lumbar region (disease involving the lumbar spinal nerve root. This can manifest as pain, numbness, or weakness of the buttock and leg), other cervical disc degeneration, unspecified cervical region (It develops when one or more of the cushioning discs in the cervical spine starts to break down due to wear and tear). During a review of Residents 46's Minimum Data Set (MDS -a resident assessment tool) dated 3/25/2022, the MDS indicated Resident 46 has the capacity to understand and to make decisions and was always continent of bladder and bowel. During a review of the Interact Change in Condition Evaluation for Resident 46 dated 4/2/2022, the evaluation indicated the resident had symptoms of a burning sensation when urinating. During a review of Resident 46's physician's order dated 4/2/2022, the order indicated to administer Macrobid (antibiotics) capsule 100 milligrams (mg) give one capsule by mouth two times a day for UTI. The physicians order further indicated Macrobid was started on 4/2/2022 and discontinued on 4/7/2022. During a review of the Infection Report Surveillance form, the Surveillance form indicated that both criteria 1 and 2 must be present for antibiotics use. 1. Acute dysuria or acute pain, swelling, or tenderness of the testes, epididymis, or prostate 2. One of the following microbiologic sub criteria a. At least 100,000 cfu/ml of no more than 2 species of microorganism in a voided urine sample b. At least 100 cfu/ml of any number of organisms in a specimen collected by in and out catheter. 056104 Page 24 of 30 056104 04/08/2022 Rose Villa Health Care Center 9028 Rose Street Bellflower, CA 90706

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 46 only had a new onset of acute dysuria, which was one sub criteria sign and symptom of a urinary tract infection. The urine culture results received on 4/4/2022 indicated No growth after 48 hours and did not meet criteria. During an interview on 4/8/2022 at 2:14 p.m. with IP/DSD, IP/DSD stated, we use McGeer's criteria whether the resident meets criteria or not. We will notify the MD. Fill out the McGeer's Criteria form for Infection Surveillance Checklist before the antibiotic start. IP stated the medications for resident 46 were stopped as of today. The start date was 4/3/2022. The resident received six doses. Before an antibiotic is initiated, staff need to make sure the resident meets the criteria. I don't have a checklist. The DSD ensures this is checked, and the backup is the DON. There is no McGeer's surveillance list for Resident 46. During an interview on 4/8/2022 at 2:29 p.m. with DON, DON stated, it is important, to have the McGeer's checklist to make sure the resident is not getting an antibiotic without an actual infection to treat, because it creates resistance and possible other infections. b). During a review of the admission record for Resident 198 dated 4/1/2022, the admission record indicated Resident 198 had diagnoses that included sepsis, unspecified organism (classified as a condition due to bacteria when it can also be due to viruses, fungi, or protozoa). Methicillin resistant staphylococcus aureus infection (MRSA) (a bacterium that causes infections in different parts of the body), cellulitis of left lower limb (a common, potentially serious bacterial skin infection). During a review of Resident 198's initial admission record dated 4/1/2022 indicated Resident 198 does not have the capacity to understand and make decisions. During a review of the physician's orders for Resident 198 dated 4/1/2022, the orders indicated to administer vancomycin HCL solution (antibiotics) 1250 milligrams (mg) intravenously one time a day for MRSA for two weeks. Vancomycin was discontinued. The orders further indicated physician's order dated 4/6/22 to administer Zyvox (antibiotic) 600 mg tablet by mouth every 12 hours for MRSA of the wound for 14 days. During an interview on 4/8/2022 at 2:29 p.m. with the DON, it was asked how many doses of vancomycin did resident 198 receive? The DON stated the antibiotic was supposed to be administered for 14 days, Resident 198 come with a midline, but it was pulled out; DON placed a peripheral line, but it was pulled out the next day. The DON stated, she notified the doctor, and was told to change to oral antibiotic. The resident was on an antibiotic from the hospital. DON stated will find the hospital record. DON further stated, If the resident is on an antibiotic usually the doctor will order to continue the medications to prevent unnecessary drugs, the McGeer's list will be checked. During a record review of a random McGeer's surveillance list for Cellulitis, Soft Tissue or Wound Infection, based on checklist, the criteria for antibiotic use is met, for resident 198, however there is no McGeer's surveillance list with Resident 198's name. During a review of the facility's policy and procedure titled, Infection Prevention and Control Program. Antibiotic Stewardship dated 9/2017, indicated that it is the policy of this facility to implement an Antibiotic Stewardship Program (ASP) that is incorporated in the overall Infection Prevention and Control Program which will promote appropriate use of antibiotics while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotics use. The Procedure indicates the following: 056104 Page 25 of 30 056104 04/08/2022 Rose Villa Health Care Center 9028 Rose Street Bellflower, CA 90706

F 0881 Level of Harm - Minimal harm or potential for actual harm 1). The facility may consider antibiotic time out (TO) practice. A time-out can be considered a stop order of antibiotic when a diagnosis test or symptoms of resident do not support the diagnosis of infection. 2). Assess residents for any infection using standardized tools and criteria. A separate report will be maintained for the number of residents on antibiotics that did not meet McGeer's criteria for active infection. Residents Affected - Few 3). Incorporate monitoring of antibiotic use, including the frequency of monitoring/review. 056104 Page 26 of 30 056104 04/08/2022 Rose Villa Health Care Center 9028 Rose Street Bellflower, CA 90706

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure the pneumonia (PNA) (an infection of the lungs) vaccinations (medication to prevent a particular disease) was administered timely (within admission)) to one of one resident (Resident 36). Residents Affected - Few This deficient practice placed Resident 36 at a higher risk of acquiring and transmitting pneumonia to other residents in the facility. During a review of the admission record for resident 36 dated 2/23/2022, the admission record indicated diagnosis that included end stage renal disease (ESRD) (kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), muscle weakness (generalized) (lack of strength in the muscles.) anemia, unspecified (a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues.) During a review of Resident 36 History and Physical (H&P), dated 2/23/2022, the H&P indicated Resident 36 has the ability to understand and make medical decisions. During a record review of California Immunization Registry (CIR) for Resident 36, the CIR indicated Pneumo Poly 23 vaccine (PV 23) (protect against many, but not all types of pneumococcal bacteria) was received on 12/27/2015. During a record review of the Pneumonia Vaccine Consent form for resident 36 dated 2/15/2022 , the consent form indicated Resident 36 refused the vaccine because Resident 36 stated she had gotten the vaccine in 8/2021. The IP/DSD stated, No I have not offered her. The charge nurses, DON can offer. During an interview on 4/8/2022 at 1:54 p.m. with IP/DSD, IP/DSD stated on 6/16/2021, Resident 36 stated she had already gotten the vaccine but did not know the date. IP stated We just go to the CIR'S, which gives us the public record on when the last vaccine was given. The resident has ESRD. It was determined her last PV 23 was given on 12/27/2015 and was uploaded in Point Click Care system (PCC) on 3/29/2022 by DON. During an interview on 4/08/2022 at 2:38 p.m. with the DON, DON stated, not sure about the criteria for PNA vaccine for those 60 and above but can find out. If there is no immunization record, we must interview the resident or family. We also need to contact the primary physician if they have the immunization. The immunization needs to be administered every five years. Resident 36 has not received the vaccine in seven years. When CIR'S does not match, we need to call the primary MD to ask if they have a record, if none we need to let the resident know she has not gotten her PNA vaccine more than five years ago. DON stated, No I haven't called the primary doctor office. [NAME] stated, Yes we will contact the MD and notify the resident and offer to her. If she refuses we will explain the risks and benefits. During a review of facility's policy and procedure title, Care and Treatment, Immunization, Influenza and Pneumococcal dated 9/2017, the P&P indicated, to minimize the risk of resident acquiring, transmitting, or experiencing complications from pneumonia by assuring that each resident, is informed about the benefits and risk of immunization. Each resident is offered a pneumococcal immunization unless the immunization is medically 056104 Page 27 of 30 056104 04/08/2022 Rose Villa Health Care Center 9028 Rose Street Bellflower, CA 90706

F 0883 contradicted, and the resident has already been immunized. Level of Harm - Minimal harm or potential for actual harm If declined, document the reason why resident did not receive the pneumococcal immunization. (Electronic Immunization Record). Residents Affected - Few Administration of the Pneumococcal vaccination will be made in accordance with current Centers for Disease Control and Prevention recommendations at time of vaccination. 056104 Page 28 of 30 056104 04/08/2022 Rose Villa Health Care Center 9028 Rose Street Bellflower, CA 90706

F 0907 Provide enough space and equipment to meet each resident's needs Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide adequate space for therapy in the rehabilitation gym as evidenced by multiple binders, cardboard boxes, plastic containers, a laptop, bags, a water bottle, and office supplies were placed on the therapy mat (an adjustable padded surface used for therapy treatment) that is used for residents during therapy. Residents Affected - Some This deficient practice had the potential to minimize equipment use and usable treatment space for residents during therapy. Findings: During an observation of the rehabilitation gym on 04/06/2022 at 3:47 p.m., six binders, two clipboards, two cardboard boxes, three plastic containers, a laptop, two bags, one water bottle, and office supplies were observed on top of therapy mat. During an observation and interview with the Director of Rehabilitation Services (DOR) on 04/06/2022 at 4:00 p.m., DOR stated that the therapy mat was used for residents who had trouble standing, sitting, and/or demonstrated decreased endurance. The DOR stated that there were multiple binders, cardboard boxes, plastic containers, a laptop, bags, and office supplies on the therapy mat. The DOR stated that there should not be any items on the therapy mat because the mat was used for therapy treatment with residents. The DOR stated that there was a storage area outside where staff should place items. During an interview with the Director of Nursing (DON) on 04/08/2022 at 1:39 p.m., the DON stated that the facility did not have a policy for maintaining rehabilitation space. 056104 Page 29 of 30 056104 04/08/2022 Rose Villa Health Care Center 9028 Rose Street Bellflower, CA 90706

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to routinely clean and remove lint from the dryer. This deficient practice had the potential to cause a fire and/or injury to all residents and staff in the facility. Residents Affected - Some Findings: During an observation, interview, and record review, with the Director of Maintenance (DM) and housekeeper/laundry aide (HKLA) on 04/07/2022 at 8:57 a.m., the dryer filter was observed to be dirty and entirely covered in lint and debris. The DM stated that the lint trap was dirty and that it needed to be cleaned. The DM proceeded to clean the dryer filter and stated that it was supposed to be cleaned after every two loads. The DM and HKLA stated that it was important to clean the filters regularly due to fire risk. The DM stated staff needed to document and initial on the dryer filter cleaning log. Upon review of the dryer filter cleaning log, the DM and HKLA stated the log was blank for today, 04/7/2022 for 6:00 a.m. and 8:00 a.m. The DM and HKLA stated if the log was not initialed and was blank, then it indicated that the task was not completed. A review of the facility's policy and procedure revised 2007 titled, Laundry, Dryer, indicated laundry employee will record the cleaning and lint removal at least every two hours while the dryer is in use. 056104 Page 30 of 30