Health inspection·January 24, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their policy to notify the physician for one of three sampled residents (Resident 2), when the facility did not have Resident 2's ordered medications available and did not administer Amiodarone (drug that works to keep heart rhythm regular), Apixaban (drug used to prevent blood clots), Doxazosin (drug used to keep heart rhythm regular) and Metoprolol (drug used to treat high blood pressure) as ordered. This failure had the potential to cause a delay in needed assessments, services, and treatments for Resident 2. Findings: During a review of Resident 2's admission Record (face sheet), the face sheet indicated Resident 2 was admitted to the facility on [DATE] with difficulty walking, muscle weakness and atrial fibrillation (condition when heart beats irregularly). During a review of Resident 2's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 1/1/2024, the MDS indicated Resident 2 was cognitively intact (able to recall and register information). According to the MDS, Resident 2 required was dependent (helper does all the effort) on staff during sit to stand activity and toileting transfer. During a concurrent interview and record review on 1/23/2023 at 11:45 a.m., with Licensed Vocational Nurse (LVN) 1, Resident 2's Medication Administration Record (MAR), dated 12/1/2023 through 12/31/2023 was reviewed. The MAR indicated the following: 1.Amiodarone Tablet 200 milligrams (mg-unit of measure), give 1 tablet (pill) by mouth two times a day for atrial fibrillation, the MAR indicated on 12/30/2023 the 5pm Amiodarone dose was not administered. 2.Apixaban oral tablet 5 mg, Give one tablet by mouth two times a day for atrial fibrillation, the MAR indicated on 12/30/2023, the 5pm Apixaban dose was not administered 3.Doxazosin Mesylate tablet 4mg, give one tablet by mouth two times a day for atrial fibrillation, the MAR indicated on 12/30/2023, the 5pm Doxazosin dose was not administered. 4.Metoprolol Succinate Extended Release (ER-drug designed to slowly release in the body) 24 hours, 25 mg give one tablet by mouth two times a day for hypertension (blood pressure), the MAR indicated Page 1 of 7 056125 056125 01/24/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on 12/30/2023 the 5pm Metoprolol dose was not administered. LVN 1 stated Amiodarone, Apixaban, Doxazosin and Metoprolol were not administered on 12/30/2023 as indicated in the MAR. During a concurrent interview and record review on 1/23/2023 at 12:00 p.m., with LVN 1, Resident 2's eMAR medication progress notes dated 12/30/2023 was reviewed. The progress notes indicated the following: on 12/30/2023 at 7:14 p.m., Amiodarone tablet 200mg was pending pharmacy delivery, on 12/30/2023 at 7:15 p.m., Apixaban tablet 5mg was pending pharmacy delivery, on 12/30/2023 at 7:15p.m., Doxazosin Mesylate tablet 4 mg was pending pharmacy delivery, on 12/30/2023 at 7:16 p.m., Metoprolol Succinate ER Tablet 25 mg was pending pharmacy delivery. LVN 1 stated Resident 2 was not administered four medications ordered by the physician to be given at 5pm on 12/30/2023 because pharmacy did not delivery them yet. During a review of the facility's policy and procedure (P/P) titled Medication Administration Policy, undated, the P/P indicated medications are administered within 60 minutes of scheduled time (one hour before and one hour after). During an interview on 1/24/2024, at 2:30 p.m. with the Assistant Director of Nursing (ADON), the ADON stated Resident 2's physician was not notified Resident 2 did not receive four medications orders. The ADON stated the physician should have been notified per facility policy to ensure Resident 2 does not receive a delay in care or services. The ADON stated failing to notify the physician put Resident 2 at risk for further declines in health and had the potential to delay assessments and therapies. During a review of the facility's policy and procedure (P/P) titled Miscellaneous Special Situations, Unavailable medications, dated August 2019, the P/P indicated nursing staff shall notify the attending physician of the situation and explain the circumstances, expected availability and optional therapies available, obtain a new order and cancel/discontinue the order for the non-available medication. Based on interview and record review, the facility failed to implement their policy to notify the physician for one of three sampled residents (Resident 2), when the facility did not have Resident 2's ordered medications available and did not administer Amiodarone (drug that works to keep heart rhythm regular), Apixaban (drug used to prevent blood clots), Doxazosin (drug used to keep heart rhythm regular) and Metoprolol (drug used to treat high blood pressure) as ordered. This failure had the potential to cause a delay in needed assessments, services, and treatments for Resident 2. Findings: During a review of Resident 2's admission Record (face sheet), the face sheet indicated Resident 2 was admitted to the facility on [DATE] with difficulty walking, muscle weakness and atrial fibrillation (condition when heart beats irregularly). During a review of Resident 2's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 1/1/2024, the MDS indicated Resident 2 was cognitively intact (able to recall and register information). According to the MDS, Resident 2 required was dependent (helper does all the effort) on staff during sit to stand activity and toileting transfer. 056125 Page 2 of 7 056125 01/24/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review on 1/23/2023 at 11:45 a.m., with Licensed Vocational Nurse (LVN) 1, Resident 2's Medication Administration Record (MAR) , dated 12/1/2023 through 12/31/2023 was reviewed. The MAR indicated the following: 1.Amiodarone Tablet 200 milligrams (mg-unit of measure), give 1 tablet (pill) by mouth two times a day for atrial fibrillation, the MAR indicated on 12/30/2023 the 5pm Amiodarone dose was not administered. 2.Apixaban oral tablet 5 mg, Give one tablet by mouth two times a day for atrial fibrillation, the MAR indicated on 12/30/2023, the 5pm Apixaban dose was not administered 3.Doxazosin Mesylate tablet 4mg, give one tablet by mouth two times a day for atrial fibrillation, the MAR indicated on 12/30/2023, the 5pm Doxazosin dose was not administered. 4.Metoprolol Succinate Extended Release (ER-drug designed to slowly release in the body) 24 hours, 25 mg give one tablet by mouth two times a day for hypertension (blood pressure), the MAR indicated on 12/30/2023 the 5pm Metoprolol dose was not administered. LVN 1 stated Amiodarone, Apixaban, Doxazosin and Metoprolol were not administered on 12/30/2023 as indicated in the MAR. During a concurrent interview and record review on 1/23/2023 at 12:00 p.m., with LVN 1, Resident 2's eMAR medication progress notes dated 12/30/2023 was reviewed. The progress notes indicated the following: on 12/30/2023 at 7:14 p.m., Amiodarone tablet 200mg was pending pharmacy delivery, on 12/30/2023 at 7:15 p.m., Apixaban tablet 5mg was pending pharmacy delivery, on 12/30/2023 at 7:15p.m., Doxazosin Mesylate tablet 4 mg was pending pharmacy delivery, on 12/30/2023 at 7:16 p.m., Metoprolol Succinate ER Tablet 25 mg was pending pharmacy delivery. LVN 1 stated Resident 2 was not administered four medications ordered by the physician to be given at 5pm on 12/30/2023 because pharmacy did not delivery them yet. During a review of the facility's policy and procedure (P/P) titled Medication Administration Policy , undated, the P/P indicated medications are administered within 60 minutes of scheduled time (one hour before and one hour after). During an interview on 1/24/2024, at 2:30 p.m. with the Assistant Director of Nursing (ADON), the ADON stated Resident 2's physician was not notified Resident 2 did not receive four medications orders. The ADON stated the physician should have been notified per facility policy to ensure Resident 2 does not receive a delay in care or services. The ADON stated failing to notify the physician put Resident 2 at risk for further declines in health and had the potential to delay assessments and therapies. During a review of the facility's policy and procedure (P/P) titled Miscellaneous Special Situations, Unavailable medications , dated August 2019, the P/P indicated nursing staff shall notify the attending physician of the situation and explain the circumstances, expected availability and optional therapies available, obtain a new order and cancel/discontinue the order for the non-available medication. 056125 Page 3 of 7 056125 01/24/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise the comprehensive resident centered care plan interventions for one of three sampled residents (Resident 1), who had a history of frequent falls between the hours of 4 am and 8 am due to the need to urinate. This failure resulted in Resident 1 sustaining multiple falls on 12/12/2023, 12/18/2023, 1/10/2024, and 1/16/2024 which had the potential to injury. Findings: During a review of Resident 1's admission Record (face sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE] with difficulty walking, muscle weakness and aphasia (loss of ability to understand or express speech, caused by brain damage). During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 12/3/2023, the MDS indicated Resident 1 had severe cognitive impairment in attention, orientation, and ability to recall information. According to the MDS, Resident 1 required maximum assistance (helper does more than half the effort) during sit to stand activity and toileting transfer. During an interview on 1/22/2024, at 3:00 p.m. with Resident 1's Responsible Party (RP), RP stated Resident 1 has had many falls because he gets up to go to the restroom and forgets to ask for help. The staff needs to anticipate Resident 1 will try to go to the restroom even if he denies help. RP stated, Resident 1 usually falls in the early morning when he needs to use the restroom for the first time during the day. RP stated she was not involved in discussing care plan interventions for Resident 1 to prevent further falls and it made her feel frustrated. During a concurrent interview and record review on 1/23/2024 at 2:00 p.m., with the Licensed Vocational Nurse (LVN) 1, Resident 1's Change of condition (COC) notes dated December 2023 through January 2024 were reviewed. The COC notes indicated Resident 1 had falls on the following dates 12/12/2023, 12/18/2023, 1/10/2024 and 1/16/2024. LVN 1 stated the COC notes indicated Resident 1 falls occurred during the hours of 4am to 8am when Resident 1 was attempting to get up to use the bathroom without assistance. During a concurrent interview and record review on 1/23/2024 at 2:10 p.m., with the Licensed Vocational Nurse (LVN) 1, Resident 1's Change of condition (COC) notes dated 1/13/2024 was reviewed. The COC indicated on 1/10/2024 at 4 a.m., a loud thump was heard, and Resident 1 was found on the floor trying to get to the restroom. Resident 1 sustained a right elbow laceration and red mark above the right eyebrow. LVN 1 stated Resident 1 frequently forgets to ask for help to get up when trying to use the restroom. During a concurrent interview and record review on 1/23/2024 at 2:15 p.m., with LVN 1, Resident 1's care plan initiated on 11/28/2023 was reviewed. The care plan indicated Resident 1 was at risk for falls. The care plan goals indicated Resident 1 will be free from falls through the review date of 2/26/2024. The care plan intervention indicated to monitor for unsafe behavior communicate with the interdisciplinary team to discuss new and updated interventions as needed. The care plan 056125 Page 4 of 7 056125 01/24/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few interventions did not indicate the pattern of needing to use the restroom early in the morning or his forgetfulness to ask for help. LVN 1 stated there were no interventions revised to reflect Resident 1's pattern of needing to use the restroom early in the morning or his forgetfulness to ask for help. During a concurrent interview and record review on 1/23/2024 at 3:05 p.m., with the Assistant Director of Nursing (ADON), Resident 1's Fall incident report dated 1/16/2024 was reviewed. The incident report indicated LVN 2 found Resident 1 lying on the bathroom floor with limited range of motion on his right arm, right elbow noted with abrasion (skin cut) and slight bleeding. The incident report indicated Resident 1 had the following predisposing factors, confusion, gait imbalance, impaired memory, resident with poor safety awareness, ambulates without assistance. The ADON stated on 1/16/2024, Resident 1 had an unwitnessed fall at approximately 08:15 a.m. The ADON stated, Resident 1 was found in the bathroom attempting to use the restroom and did not ask for assistance. The ADON stated staff must anticipate Resident 1's pattern of getting up to use the restroom without assistance. The ADON stated, Resident 1's care plan should have been updated to reflect resident specific interventions to direct staff to anticipate Resident 1's needs to use the bathroom in the early morning hours especially if Resident 1 did not void during the night. During an interview on 1/24/2024, at 11:00 a.m. with Certified Nurse Aide (CNA) 1, CNA 1 stated Resident 1 usually tries to get up in the morning to walk to the restroom. CNA 1 stated, if staff does not know Resident 1's bathroom routine patterns, staff will not know to anticipate he will try to get up on his own even after he denies the need to urinate. During a concurrent interview and record review on 1/24/2024 at 2:15 p.m., with the ADON, the facility's Policy and Procedure (P&P) titled, Fall Management system dated June 2018 was reviewed. The P&P indicated It was the policy of this facility to provide an environment that remains as free of accident hazards as possible. It was also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and minimize complications if a fall occurs. The P/P indicated a review of the fall incident will include investigation to determine probable causal factors, the investigation will be reviewed by the interdisciplinary team and resident's care plan will be updated. The ADON stated, based on the P&P, Resident 1's probable cause of fall was the resident's need to use the restroom in the morning. The ADON stated, the care plan should have reflected specific resident interventions to address Resident 1's voiding (urination) patterns needs. The ADON stated failing to update the care plan put Resident 1 at risk for further falls that could lead to injury and or death. Based on interview and record review, the facility failed to revise the comprehensive resident centered care plan interventions for one of three sampled residents (Resident 1), who had a history of frequent falls between the hours of 4 am and 8 am due to the need to urinate. This failure resulted in Resident 1 sustaining multiple falls on 12/12/2023, 12/18/2023, 1/10/2024, and 1/16/2024 which had the potential to injury. Findings: During a review of Resident 1's admission Record (face sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE] with difficulty walking, muscle weakness and aphasia (loss of ability to understand or express speech, caused by brain damage). 056125 Page 5 of 7 056125 01/24/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 12/3/2023, the MDS indicated Resident 1 had severe cognitive impairment in attention, orientation, and ability to recall information. According to the MDS, Resident 1 required maximum assistance (helper does more than half the effort) during sit to stand activity and toileting transfer. During an interview on 1/22/2024, at 3:00 p.m. with Resident 1's Responsible Party (RP), RP stated Resident 1 has had many falls because he gets up to go to the restroom and forgets to ask for help. The staff needs to anticipate Resident 1 will try to go to the restroom even if he denies help. RP stated, Resident 1 usually falls in the early morning when he needs to use the restroom for the first time during the day. RP stated she was not involved in discussing care plan interventions for Resident 1 to prevent further falls and it made her feel frustrated. During a concurrent interview and record review on 1/23/2024 at 2:00 p.m., with the Licensed Vocational Nurse (LVN) 1, Resident 1's Change of condition (COC) notes dated December 2023 through January 2024 were reviewed. The COC notes indicated Resident 1 had falls on the following dates 12/12/2023, 12/18/2023, 1/10/2024 and 1/16/2024. LVN 1 stated the COC notes indicated Resident 1 falls occurred during the hours of 4am to 8am when Resident 1 was attempting to get up to use the bathroom without assistance. During a concurrent interview and record review on 1/23/2024 at 2:10 p.m., with the Licensed Vocational Nurse (LVN) 1, Resident 1's Change of condition (COC) notes dated 1/13/2024 was reviewed. The COC indicated on 1/10/2024 at 4 a.m., a loud thump was heard, and Resident 1 was found on the floor trying to get to the restroom. Resident 1 sustained a right elbow laceration and red mark above the right eyebrow. LVN 1 stated Resident 1 frequently forgets to ask for help to get up when trying to use the restroom. During a concurrent interview and record review on 1/23/2024 at 2:15 p.m., with LVN 1, Resident 1's care plan initiated on 11/28/2023 was reviewed. The care plan indicated Resident 1 was at risk for falls. The care plan goals indicated Resident 1 will be free from falls through the review date of 2/26/2024. The care plan intervention indicated to monitor for unsafe behavior communicate with the interdisciplinary team to discuss new and updated interventions as needed. The care plan interventions did not indicate the pattern of needing to use the restroom early in the morning or his forgetfulness to ask for help. LVN 1 stated there were no interventions revised to reflect Resident 1's pattern of needing to use the restroom early in the morning or his forgetfulness to ask for help. During a concurrent interview and record review on 1/23/2024 at 3:05 p.m., with the Assistant Director of Nursing (ADON), Resident 1's Fall incident report dated 1/16/2024 was reviewed. The incident report indicated LVN 2 found Resident 1 lying on the bathroom floor with limited range of motion on his right arm, right elbow noted with abrasion (skin cut) and slight bleeding. The incident report indicated Resident 1 had the following predisposing factors, confusion, gait imbalance, impaired memory, resident with poor safety awareness, ambulates without assistance. The ADON stated on 1/16/2024, Resident 1 had an unwitnessed fall at approximately 08:15 a.m. The ADON stated, Resident 1 was found in the bathroom attempting to use the restroom and did not ask for assistance. The ADON stated staff must anticipate Resident 1's pattern of getting up to use the restroom without assistance. The ADON stated, Resident 1's care plan should have been updated to reflect resident specific interventions to direct staff to anticipate Resident 1's needs to use the bathroom in the early morning hours especially if Resident 1 did not void during the night. 056125 Page 6 of 7 056125 01/24/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 1/24/2024, at 11:00 a.m. with Certified Nurse Aide (CNA) 1, CNA 1 stated Resident 1 usually tries to get up in the morning to walk to the restroom. CNA 1 stated, if staff does not know Resident 1's bathroom routine patterns, staff will not know to anticipate he will try to get up on his own even after he denies the need to urinate. During a concurrent interview and record review on 1/24/2024 at 2:15 p.m., with the ADON, the facility's Policy and Procedure (P&P) titled, Fall Management system dated June 2018 was reviewed. The P&P indicated It was the policy of this facility to provide an environment that remains as free of accident hazards as possible. It was also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and minimize complications if a fall occurs. The P/P indicated a review of the fall incident will include investigation to determine probable causal factors, the investigation will be reviewed by the interdisciplinary team and resident's care plan will be updated. The ADON stated, based on the P&P, Resident 1's probable cause of fall was the resident's need to use the restroom in the morning. The ADON stated, the care plan should have reflected specific resident interventions to address Resident 1's voiding (urination) patterns needs. The ADON stated failing to update the care plan put Resident 1 at risk for further falls that could lead to injury and or death. 056125 Page 7 of 7