Health inspection·January 17, 2024

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident, who was in severe back pain and was at the facility for pain management, received Hydrocodone-Acetaminophen ([Norco] a combination medication used to relieve moderate to severe pain) 10/325 milligram ([mg] a unit of weight measurement), for severe pain, for one of three sampled residents (Resident 1). The facility failed to: Residents Affected - Few 1. Ensure licensed nurses ordered a refill of Norco 10/325 mg for Resident 1's moderate to severe pain management before its quantity was depleted, leaving Resident 1 in severe pain. 2. Ensure Registered Nurse Supervisor (RNS 1) contacted Resident 1's physician or the facility's Medical Director for authorization to take Norco 10/325 mg from the facility's emergency kit ([E-Kit] a kit that contains a small quantity of medications that can be dispensed when pharmacy service is not available) where six Norco 10/325 mg tablets were available, to administer to Resident 1 for severe back pain. 3. Ensure Resident 1 was medicated to control her severe pain as ordered by the physician and care planned. 4. Ensure licensed nurses followed the facility's Policy and Procedure (P&P) titled, Medication Orders, Controlled Substance Prescriptions, to refill Norco and send the request form to the pharmacy five (5) days in advance to assure an adequate supply of Norco was on hand for administration to Resident 1. These deficient practices resulted in Resident 1 experiencing uncontrolled severe back pain for approximately 22 hours without a relief. Resident 1 was eventually transferred to a General Acute Care Hospital (GACH) on 12/25/2023 at 10 a.m., for evaluation of uncontrolled back pain where she was administered intravenous ([IV] in the vein) Morphine (a medication used for severe pain) to relieve her uncontrolled severe pain. Findings: A review of Resident 1's admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included orthopedic (a medical specialty that deals with the treatment of bones that did not grow correctly or sustained damaged) aftercare (care provided following a surgical procedure), arthrodesis status (orthopedic surgery in which two or more bones in a joint are fused (joined together) to become one larger bone), and difficulty in walking. Page 1 of 8 056125 056125 01/17/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0697 Level of Harm - Actual harm A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care planning tool), dated 12/19/2023, indicated Resident 1 was able to make independent decisions that were reasonable and consistent and was able to understand and be understood by others. The MDS indicated Resident 1 experienced severe pain frequently over the last five days making it hard to sleep. Residents Affected - Few A review of Resident 1's Care Plan, dated 12/14/2023, indicated Resident 1 had acute/chronic pain related to lumbar stenosis (a narrowing of the spinal canal in the lower part of the back) with five prior lumbar surgeries with misplaced plates, rods, and screws, removal of hardware decompression (a release of physical pressure from plates, rods, and screws used to keep spine stable), laminectomy (a surgical procedure to relieve pressure on the nerves by removing the arched back piece of the vertebrae [backbone]) and fusion (surgery to connect two or more bones together) of the thoracic 11 (the middle section of the spine) vertebrae through the sacrum bone 1 (a triangle shaped bony structure at the base of the lumbar vertebrae). The care plan goal for Resident 1 was to verbalize adequate pain relief or the ability to cope with incompletely relieved pain. The Care Plan interventions included to anticipate Resident 1's need for pain relief and respond immediately to any complaint of pain and administer analgesics (pain medications) as ordered by the physician. A review of Resident 1's Physician's Orders indicated the following: 1. On 12/14/2023 - an order for Tylenol 325 mg, give two tablets by mouth every four hours as needed for mild pain (from 1 to 3) rated on a zero to 10 pain rating scale (a subjective [personal view] measure in which individuals rate their pain on an 11 point scale; 0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain, and 10=worst imaginable pain). 2. On 12/24/2023 - Norco 10/325 mg one tablet every four hours as needed for moderate pain (4-6) to severe pain (7-10). A review of Resident 1's Progress Note, dated 12/14/2023 and timed at 12:52 p.m., indicated Resident 1 was admitted to the facility from a GACH after an elective surgery to remove misplaced back hardware with severe stenosis, had hardware decompression with a history of multiple back surgeries. The Progress Note indicated Resident 1 was transferred to the facility (12/14/2023) for observation and management of physical condition/symptoms, and medication management for pain. A review of Resident 1's Controlled Medication Count Sheet, dated 12/23/2023 and timed at 9:20 a.m., indicated Resident 1 had one tablet of Norco 10/325 mg left. A review of Resident 1's Pharmacy Medication Order form, dated 12/23/2023 indicated, Resident 1's refill order for Norco 10/325 mg was faxed to the pharmacy on 12/23/2023 at 11:56 p.m., when Resident 1 had only one tablet (for one time dose) of Norco remaining available. A review of Resident 1's Medication Administration Record (MAR), dated 12/2023 indicated Resident 1's last (available at the facility) dose of Norco10/325 mg was administered at 1:01 p.m., on 12/24/2023. The MAR indicated Resident 1's pain level was a 10 on a pain scale of 1 to 10 and was administered Tylenol 650 mg (usually given for mild pain rating 1-3) on 12/25/2023, at 8:36 a.m. A review of Resident 1's Change in Condition Evaluation (COC), dated 12/25/2023 and timed at 10:05 a.m., indicated at 9:30 a.m., Resident 1 had an uncontrolled severe pain rated at 10. The COC indicated Resident 1 was tearful and had decreased mobility. The COC indicated there was no pain medication available, and the facility was waiting for Resident 1's pain medication (Norco 10/325 mg) to be 056125 Page 2 of 8 056125 01/17/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0697 Level of Harm - Actual harm Residents Affected - Few delivered. The COC indicated Resident 1's physician was notified of Resident 1's pain level and an order was obtained to transfer Resident 1 to the GACH ' s emergency room (ER) for uncontrolled severe back pain. A review of Resident 1's physician order dated 12/25/2023, indicated to transfer Resident 1 to the GACH ER for uncontrolled severe back pain. A review of Resident 1's Transfer Form, dated 12/25/2024 indicated Resident 1 was transferred to the GACH on 12/25/2023 at 10 a.m. for uncontrolled severe back pain. A review of Resident 1's Narcotic Prescription Form Long Term Care Facility Patient, indicated a fax confirmation indicating the order for Norco (Hydrocodone-Acetaminophen) refill was faxed to the pharmacy on 12/25/2023 at 3:59 a.m. A review of Resident 1's GACH ER records, dated 12/25/2023 and timed at 11:13 a.m., indicated Resident 1's chief complaint was uncontrolled severe back pain that started on 12/24/2023, and radiated down Resident 1's right leg. The ER record indicated Resident 1 received IV Morphine to relief her uncontrolled severe pain. During a concurrent interview and record review, on 1/11/2024, at 3:34 p.m., with Registered Nurse Supervisor (RNS 1) Resident 1's MAR dated 12/2023 was reviewed. The MAR indicated on 12/25/2023 Tylenol 650 mg was given at 8:36 a.m., for a pain level of 10 out of 10. RNS 1 stated Tylenol 650 mg was administered to Resident 1 because Norco was not available. RNS 1 stated Norco had been ordered (12/24/2023) and was expected to be delivered to the facility at any time. RNS 1 stated there were six tablets of Norco available in the facility's E-Kit but because Resident 1 was being transferred to the GACH, she (RNS 1) did not think to call the Medical Director to obtain an order to retrieve Norco from the E-Kit and instead gave Resident 1 Tylenol 650 mg. RNS 1 stated she should have called the Medical Director to get authorization to access the Norco from the E-Kit earlier so that Resident 1's pain could have been under control sooner. During an interview on 1/11/2024 at 4:25 p.m., the Assistant Director of Nursing (ADON) stated, when medications are close to running out and get down to approximately 7-10 tablets, a medication order should be placed to refill the medication. The ADON stated in order to obtain a refill for a narcotic, the licensed nurse has to call the physician, the physician then calls the pharmacy to authorize the refill. Then ADON stated if the medication needed to be retrieved from the E-Kit, the licensed nurse has to call the physician, the physician then calls the pharmacy to authorize the medication to be taken from the E-Kit, then the pharmacy calls the facility to authorize the licensed nurse to retrieve the medication from the E-Kit. The ADON stated the nursing staff should have ordered Resident 1's pain medication before it was completely out of stock and called the physician and/or the Medical Director to get access to the Norco in the E-Kit so that Resident 1's pain could be controlled by preventing a delay in Resident 1's pain medication administration and transfer to the GACH. During an interview on 1/12/2024 at 4:24 p.m., a Certified Nurse Assistant (CNA 1) stated Resident 1 was in a lot of pain, (12/24/2023 during the night), she (Resident 1) was moaning, crying, and had shooting pain down both of her hips. CNA 1 stated he (CNA 1) approached the charge nurse (CN 1) three to four times during her shift (11 p.m.-7 a.m.) to ask if Resident 1's pain medication had been approved, and the charge nurse told him no it had not. During an interview on 1/12/2024 at 12:59 p.m., Licensed Vocational Nurse (LVN 2) stated, it was 056125 Page 3 of 8 056125 01/17/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0697 Level of Harm - Actual harm Residents Affected - Few important to order the pain medication before its quantity became too low, so they did not run out of it, leaving Resident 1 in severe pain. LVN 2 stated she did not realize Resident 1's pain medication was running out. During an interview on 1/16/2024 at 3 p.m., the Director of Nursing (DON) stated the nurse should have sent the refill order for Norco at least three days ahead, so there was no delay in Resident 1 receiving pain medication. A review of the facility's P&P, titled Medication Orders, Controlled Substance Prescriptions, dated 8/2019 indicated emergency pharmacy service is available on a 24-hour basis. Emergency needs for medication are met by using the facility's approved emergency medication supply or by special order from Med-Plus Pharmacy LTC. Med-Plus Pharmacy LTC supplies emergency medications including emergency drugs, antibiotics, controlled substances, products for infusion in limited quantities in portable, sealed containers in compliance with applicable State regulation. To access medication from the emergency kit secondary to a new order or when medication for which there is a current prescription is not readily available, the nurse confers with the prescriber to determine whether the order is a true emergency., i.e., order cannot be delayed util the scheduled pharmacy delivery. If the medication is a controlled substance, the prescriber either faxes a complete prescription to the facility and pharmacy or communicates the verbal order to both the nurse and directly to the pharmacist along with details about the situation to verify that it meets the criteria of an emergency situation. A review of the facility's P&P, titled, Medication Orders, Controlled Substance Prescriptions, dated 8/2019, indicated, if a partial fill quantity of schedule II ([CIIs] drugs that require additional care because of the potential for the patient to intentionally or unintentionally abuse the drug) medication remains, refills are written on a medication order form or ordered by peeling the top label from the label and placing it in the appropriate area on the order form provided by the pharmacy for that purpose and requested from the pharmacy five (5) days in advance of need to assure an adequate supply is on hand. 056125 Page 4 of 8 056125 01/17/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident who had a history of back surgery, and was admitted to the facility for pain management with an order for Hydrocodone-Acetaminophen ([Norco] a combination medication used to relieve moderate to severe pain)10-325 milligrams ([mg] a unit of measurement) for severe pain, had the order for Norco refilled in time enough to ensure its availability for 1 of 3 sampled residents (Resident 1). The facility failed to: 1. Ensure licensed nurses ordered a refill of Norco 10/325 mg for Resident 1's moderate to severe pain management before its quantity was depleted, leaving Resident 1 in severe pain. 2. Ensure Registered Nurse Supervisor (RNS 1) contacted Resident 1's physician or the facility ' s Medical Director for authorization to take Norco 10/325 mg from the facility's emergency kit ([E-Kit] a kit that contains a small quantity of medications that can be dispensed when pharmacy service is not available) where six Norco 10/325 mg tablets were available, to administer to Resident 1 for severe back pain. 3. Ensure Resident 1 was medicated to control her severe pain as ordered by the physician and care planned. 4. Ensure licensed nurses followed the facility's Policy and Procedure (P&P) titled, Medication Orders, Controlled Substance Prescriptions, to refill Norco and send the request form to the pharmacy five (5) days in advance to assure an adequate supply of Norco was on hand for administration to Resident 1. These deficient practices resulted in Resident 1 experiencing uncontrolled severe back pain for approximately 22 hours. Resident 1 was eventually transferred to a General Acute Care Hospital (GACH) on 12/25/2023 at 10 a.m., for evaluation of uncontrolled back pain where she was administered intravenous ([IV] in the vein) Morphine (a medication used for severe pain) to relieve her uncontrolled severe pain. Findings: A review of Resident 1's admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included orthopedic (a medical specialty that deals with the treatment of bones that did not grow correctly or sustained damaged) aftercare (care provided following a surgical procedure), arthrodesis status (orthopedic surgery in which two or more bones in a joint are fused (joined together) to become one larger bone), and difficulty in walking. A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care planning tool), dated 12/19/2023, indicated Resident 1 was able to make independent decisions that were reasonable and consistent and was able to understand and be understood by others. The MDS indicated Resident 1 experienced severe pain frequently over the last five days making it hard to sleep. A review of Resident 1's Care Plan, dated 12/14/2023, indicated Resident 1 had acute/chronic pain related to lumbar stenosis (a narrowing of the spinal canal in the lower part of the back) with five prior lumbar surgeries with misplaced plates, rods, and screws, removal of hardware decompression (a 056125 Page 5 of 8 056125 01/17/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0755 Level of Harm - Actual harm Residents Affected - Few release of physical pressure from plates, rods, and screws used to keep spine stable), laminectomy (a surgical procedure to relieve pressure on the nerves by removing the arched back piece of the vertebrae [backbone]) and fusion (surgery to connect two or more bones together) of the thoracic 11 (the middle section of the spine) vertebrae through the sacrum bone 1 (a triangle shaped bony structure at the base of the lumbar vertebrae). The care plan goal for Resident 1 was to verbalize adequate pain relief or the ability to cope with incompletely relieved pain. The Care Plan interventions included to anticipate Resident 1's need for pain relief and respond immediately to any complaint of pain and administer analgesics (pain medications) as ordered by the physician. A review of Resident 1's Physician's Orders indicated the following: 1. On 12/14/2023 - an order for Tylenol 325 mg, give two tablets by mouth every four hours as needed for mild pain (from 1 to 3) rated on a zero to 10 pain rating scale (a subjective [personal view] measure in which individuals rate their pain on an 11 point scale; 0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain, and 10=worst imaginable pain). 2. On 12/24/2023 - Norco 10/325 mg one tablet every four hours as needed for moderate pain (4-6) to severe pain (7-10). A review of Resident 1's Progress Note, dated 12/14/2023 and timed at 12:52 p.m., indicated Resident 1 was admitted to the facility from a GACH after an elective surgery to remove misplaced back hardware with severe stenosis, had hardware decompression with a history of multiple back surgeries. The Progress Note indicated Resident 1 was transferred to the facility (12/14/2023) for observation and management of physical condition/symptoms, and medication management for pain. A review of Resident 1's Controlled Medication Count Sheet, dated 12/23/2023 and timed at 9:20 a.m., indicated Resident 1 had one tablet of Norco 10/325 mg left. A review of Resident 1's Pharmacy Medication Order form, dated 12/23/2023 indicated, Resident 1's refill order for Norco 10/325 mg was faxed to the pharmacy on 12/23/2023 at 11:56 p.m., when Resident 1 had only one tablet (for one time dose) of Norco remaining available. A review of Resident 1's Medication Administration Record (MAR), dated 12/2023 indicated Resident 1's last (available at the facility) dose of Norco10/325 mg was administered at 1:01 p.m., on 12/24/2023. The MAR indicated Resident 1's pain level was a 10 on a pain scale of 1 to 10 and was administered Tylenol 650 mg (usually given for mild pain rating 1-3) on 12/25/2023, at 8:36 a.m. A review of Resident 1's Change in Condition Evaluation (COC), dated 12/25/2023 and timed at 10:05 a.m., indicated at 9:30 a.m., Resident 1 had an uncontrolled severe pain rated at 10. The COC indicated Resident 1 was tearful and had decreased mobility. The COC indicated there was no pain medication available, and the facility was waiting for Resident 1's pain medication (Norco 10/325 mg) to be delivered. The COC indicated Resident 1's physician was notified of Resident 1's pain level and an order was obtained to transfer Resident 1 to the GACH ' s emergency room (ER) for uncontrolled severe back pain. A review of Resident 1's physician order dated 12/25/2023, indicated to transfer Resident 1 to the GACH ER for uncontrolled severe back pain. A review of Resident 1's Transfer Form, dated 12/25/2024 indicated Resident 1 was transferred to 056125 Page 6 of 8 056125 01/17/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0755 the GACH on 12/25/2023 at 10 a.m. for uncontrolled severe back pain. Level of Harm - Actual harm A review of Resident 1's Narcotic Prescription Form Long Term Care Facility Patient, indicated a fax confirmation indicating the order for Norco (Hydrocodone-Acetaminophen) refill was faxed to the pharmacy on 12/25/2023 at 3:59 a.m. Residents Affected - Few A review of Resident 1's GACH ER records, dated 12/25/2023 and timed at 11:13 a.m., indicated Resident 1's chief complaint was uncontrolled severe back pain that started on 12/24/2023, and radiated down Resident 1's right leg. The ER record indicated Resident 1 received IV Morphine to relief her uncontrolled severe pain. During a concurrent interview and record review, on 1/11/2024, at 3:34 p.m., with Registered Nurse Supervisor (RNS 1) Resident 1's MAR dated 12/2023 was reviewed. The MAR indicated on 12/25/2023 Tylenol 650 mg was given at 8:36 a.m., for a pain level of 10 out of 10. RNS 1 stated Tylenol 650 mg was administered to Resident 1 because Norco was not available. RNS 1 stated Norco had been ordered (12/24/2023) and was expected to be delivered to the facility at any time. RNS 1 stated there were six tablets of Norco available in the facility's E-Kit but because Resident 1 was being transferred to the GACH, she (RNS 1) did not think to call the Medical Director to obtain an order to retrieve Norco from the E-Kit and instead gave Resident 1 Tylenol 650 mg. RNS 1 stated she should have called the Medical Director to get authorization to access the Norco from the E-Kit earlier so that Resident 1's pain could have been under control sooner. During an interview on 1/11/2024 at 4:25 p.m., the Assistant Director of Nursing (ADON) stated, when medications are close to running out and get down to approximately 7-10 tablets, a medication order should be placed to refill the medication. The ADON stated in order to obtain a refill for a narcotic, the licensed nurse has to call the physician, the physician then calls the pharmacy to authorize the refill. Then ADON stated if the medication needed to be retrieved from the E-Kit, the licensed nurse has to call the physician, the physician then calls the pharmacy to authorize the medication to be taken from the E-Kit, then the pharmacy calls the facility to authorize the licensed nurse to retrieve the medication from the E-Kit. The ADON stated the nursing staff should have ordered Resident 1's pain medication before it was completely out of stock and called the physician and/or the Medical Director to get access to the Norco in the E-Kit so that Resident 1's pain could be controlled by preventing a delay in Resident 1's pain medication administration and transfer to the GACH. During an interview on 1/12/2024 at 4:24 p.m., a Certified Nurse Assistant (CNA 1) stated Resident 1 was in a lot of pain, (12/24/2023 during the night), she (Resident 1) was moaning, crying, and had shooting pain down both of her hips. CNA 1 stated he (CNA 1) approached the charge nurse (CN 1) three to four times during her shift (11 p.m.-7 a.m.) to ask if Resident 1's pain medication had been approved, and the charge nurse told him no it had not. During an interview on 1/12/2024 at 12:59 p.m., Licensed Vocational Nurse (LVN 2) stated, it was important to order the pain medication before its quantity became too low, so they did not run out of it, leaving Resident 1 in severe pain. LVN 2 stated she did not realize Resident 1's pain medication was running out. During an interview on 1/16/2024 at 3 p.m., the Director of Nursing (DON) stated the nurse should have sent the refill order for Norco at least three days ahead, so there was no delay in Resident 1 receiving pain medication. 056125 Page 7 of 8 056125 01/17/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0755 Level of Harm - Actual harm Residents Affected - Few A review of the facility's P&P, titled Medication Orders, Controlled Substance Prescriptions, dated 8/2019 indicated emergency pharmacy service is available on a 24-hour basis. Emergency needs for medication are met by using the facility's approved emergency medication supply or by special order from Med-Plus Pharmacy LTC. Med-Plus Pharmacy LTC supplies emergency medications including emergency drugs, antibiotics, controlled substances, products for infusion in limited quantities in portable, sealed containers in compliance with applicable State regulation. To access medication from the emergency kit secondary to a new order or when medication for which there is a current prescription is not readily available, the nurse confers with the prescriber to determine whether the order is a true emergency., i.e., order cannot be delayed util the scheduled pharmacy delivery. If the medication is a controlled substance, the prescriber either faxes a complete prescription to the facility and pharmacy or communicates the verbal order to both the nurse and directly to the pharmacist along with details about the situation to verify that it meets the criteria of an emergency situation. A review of the facility's P&P, titled, Medication Orders, Controlled Substance Prescriptions, dated 8/2019, indicated, if a partial fill quantity of schedule II ([CIIs] drugs that require additional care because of the potential for the patient to intentionally or unintentionally abuse the drug) medication remains, refills are written on a medication order form or ordered by peeling the top label from the label and placing it in the appropriate area on the order form provided by the pharmacy for that purpose and requested from the pharmacy five (5) days in advance of need to assure an adequate supply is on hand. 056125 Page 8 of 8