Health inspection·November 15, 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 observation, interview, and record review, the facility failed to ensure the nursing staff and physician were notified in a timely manner when one out of six residents (Resident 47) presented with decreased range of motion (ROM- full movement potential of a joint) of the bilateral (both) ankles. As a result of this deficient practice, Resident 47 had a delay in services including being seen and evaluated by physical therapy (PT - profession aimed in the restoration, maintenance, and promotion of optimal physical function) to see what services he required. Findings: During a review of Resident 47's admission Record, the admission Record indicated Resident 47 was admitted to the facility on [DATE] with diagnoses of depression (mental illness that causes persistent feelings of sadness and loss of interest), Parkinson's Disease (a chronic brain disorder that causes movement problems, and can also affect mental health, sleep, and pain), and malignant neoplasm of the prostate (prostate cancer). During a review of Resident 47's untitled care plan, the care plan initiated 4/11/2024 indicated Resident 47 required assistance for positioning and ambulation due to limited mobility. The care plan goal was to maintain Resident 47's current level of function in mobility. On 11/14/2024 the care plan was updated to include bilateral ankle limitations in ROM. Interventions updated on 11/14/2024 requesting a physical therapy (PT) and occupational therapy (OT- profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) evaluation and Resident 47 being seen by the rehab physician (MD 3) on 11/14/2024 for evaluation. During a review of Resident 47's Joint Mobility Assessment (JMA - a diagnostic procedure that evaluates a joint's mobility and muscle strength) dated 8/13/2024, the JMA indicated Resident 47 did not have any ROM limitations (100% intact ROM) in any of his joints and to continue with the current RNA program. During a review of Resident 47's Order Summary Sheet, the Order Summary Sheet indicated Resident 47 had orders dated 9/11/2024 for Restorative Nursing Assistant (RNA - nursing aide program that helps residents maintain their function and joint mobility) orders for bilateral lower extremity (BLE-legs, ankles, and feet) and bilateral upper extremity (shoulders, arms, wrists, and hands), exercise bike as tolerated followed by ambulation (walking) in parallel bars (the bars provide support for patients who have difficulty standing or walking on their own) as tolerated three (3) times a week. Page 1 of 30 056125 056125 11/15/2024 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 review of Resident 47's minimum data set (MDS, a resident assessment tool) dated 9/19/2024, the MDS indicated Resident 47 was cognitively intact (a person was able to think, learn, remember, use judgment, and make decisions without significant impairment). The MDS indicated Resident 47 had no impairments in his lower extremities. During a review of Resident 47's Progress Note: type Restorative Nursing dated 10/18/2024, the note indicated Resident 47 was able to tolerate RNA treatment with maximum (full assistance by RNAs) assistance and there were no new changes to report. During a review of Resident 47's JMA dated 11/14/2024, the JMA indicated Resident 47 had minimum (75-100% of range intact) ROM limitations on his bilateral ankles. During an observation and concurrent interview on 11/13/2024 at 8:51 a.m., Resident 47 was laying in bed, his right ankle was observed inverted (opposite position, order, or arrangement from usual) in towards his left leg. Resident 47 attempted to move his feet and ankles but only slight movement was observed, Resident 47 was unable to make his right ankle straight. Resident 47 stated both his ankles are stiff, but his right ankle is slightly stiffer. Resident 47 stated it was torture when he had to stand up and walk during therapy because his ankles are stiff. Resident 47 stated he walks on his toes and facility staff tell him not to walk that way, but he physically can not put his feet flat on the floor. During an interview on 11/14/2024 at 2:08 p.m., restorative nursing assistant (RNA 1) stated around mid-October 2024 (unknown date) she noticed Resident 47's right ankle was tighter when he was trying to walk. RNA 1 stated she informed Physical Therapist (PT 1) about Resident 47's right ankle feeling tighter, but he no longer works at the facility, so she was not sure what he did with the information. RNA 1 stated she did not inform anyone from nursing about the increased stiffness because PT 1 was in the facility gym at the same time as herself and Resident 47 when she noticed the increased stiffness of the right ankle. During an interview on 11/14/2024 at 2:56 p.m., the director of rehab (DOR) stated she performed a JMA on Resident 47 on 11/14/2024 (same day as interview) and she noticed a change in Resident 47's ROM of his bilateral ankles. The DOR stated she was going to contact the physician to request an authorization for Physical Therapy (PT) and Occupational Therapy (OT). The DOR stated Resident 47 did have a decline in his bilateral ankle ROM since the last JMA (8/13/2024). The DOR stated, if an RNA noticed a decline in a resident's ROM, they were to inform rehab staff as well as nursing staff so the resident could be reassessed for new needs and services. The DOR stated the physician should be notified the same day a decline in ROM is identified. The DOR stated nursing and rehab has a meeting every month with the RNAs and RNA 1 did not mention the decline in Resident 47's ROM during the October meeting. The DOR stated if she knew about Resident 47's increased stiffness earlier, the physician could have been contacted sooner and she could have assessed for any new interventions therapy could work on for Resident 47. The DOR stated there was no record in Resident 47's chart that PT 1 had been informed about the decline in ROM. During an interview on 11/15/2024 at 11:57 a.m., the director of staff development (DSD) stated it was the responsibility of the RNAs to report any change of condition (COC) or decline in a resident's ROM to the rehab staff and nursing staff right away. The DSD stated the importance of reporting the decline right away was to ensure all the resident's needs were being met and ensure the physician was notified right away by either the rehab staff or nursing staff so they can place new order's if needed. 056125 Page 2 of 30 056125 11/15/2024 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 review of the facility's Restorative Nursing Assistant (RNA) Job Description dated 12/17/2021, the job description indicated it was the responsibility of the RNA to inform the nurse supervisor or charge nurse of any changes in the resident's condition so that appropriate information can be entered on the resident's care plan. During a review of the facility's policy and procedure (P/P) titled Significant Change of Condition, Response dated 12/2023, the P/P indicated if, at any time it is recognized by any one of the team members that the condition or care needs of the resident have changed, the licensed nurse or nurse supervisor should be made aware. The P/P indicated an example of a change of condition was a change in the ability or decline in physical function. The P/P indicated the nurse was to notify appropriate departments for prompt evaluation and the physician was to be contacted in a timeframe that was based on the urgency of the situation. 056125 Page 3 of 30 056125 11/15/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow up on a level 2 Preadmission Screening and Resident Review (PASRR, Level 2 Evaluation helps determine the most appropriate placement of an individual, considering the least restrictive setting, and whether specialized services are needed) evaluation for one of six sampled residents (Resident 47) who had a diagnosis of depression (a mood disorder that can affect a person's thoughts, feelings, behavior, and sense of well-being). This deficient practice had the potential to cause a delay in services for Resident 47. Findings: During a review of Resident 47's admission Record, the admission Record indicated Resident 47 was admitted to the facility on [DATE] with diagnoses of depression, Parkinson's Disease (a chronic brain disorder that causes movement problems, and can also affect mental health, sleep, and pain), and malignant neoplasm of the prostate (prostate cancer). During a review of Resident 47's minimum data set (MDS-a resident assessment tool) dated 9/19/2024, the MDS indicated Resident 47 was cognitively intact (a person is able to think, learn, remember, use judgment, and make decisions without significant impairment) and was taking an antidepressant (a class of prescription medications that treat depression and other mental health conditions). During a review of Resident 47's PASRR Level I (involves completion of an evaluation to determine if an individual has, or is suspected of having, a PASRR condition, i.e., serious mental illness (SMI), intellectual disability (ID), developmental disability (DD), or related condition (RC)) Screening dated 10/5/2024, the PASRR Level 1 indicated Resident 47 was diagnosed with a serious Mental Illness (i.e., depression). The PASRR Level 1 was positive and indicated Resident 47 required a Level 2 PASRR. During a review of Resident 47's Notice of Attempted Evaluation letter (Level 2 PASSR) dated 10/5/2024, the evaluation letter indicated a level 2 PASRR was unable to be completed for evaluation of serious mental illness because facility staff were unresponsive to two or more attempts of communication within 48 hours of the level 1 PASRR. The evaluation letter indicated the case was closed and to reopen the case the facility needed to complete a new level 1 Screening. During an interview and concurrent record review on 11/15/2024 at 10:03 a.m., with the Director of Nursing (DON), Resident 47's Notice of Attempted Evaluation letter (Level 2 PASSR) dated 10/5/2024 was reviewed. The DON stated she supervised completing the level 1 PASRRs and receiving the determination letters for level 2 PASRRs. The DON reviewed Resident 47's level 2 PASRR Notice of Attempted Notification letter dated 10/5/2024 and stated the letter indicated the evaluation was unable to be completed. The DON stated she was unaware that there was an attempt to contact the facility for evaluation until this review. The DON stated the Medical Records department must have received the letter and uploaded it into the electronic medical record (EMR) but she was not informed so she did not follow up to complete a new level 1 screening to reopen the case. The DON stated the importance of a level 2 PASRR was to ensure the facility was meeting all of the resident's needs while in the facility. The DON stated the potential outcome of Resident 47 not receiving his level 2 PASRR evaluation right away was a delay in services if there were new recommendations upon completion of the evaluation. 056125 Page 4 of 30 056125 11/15/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0644 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P/P) titled Resident Assessment, PASRR) dated 12/2021, the P/P indicated It was the policy of this facility to ensure that each resident was properly screened using the PASRR specified by the State. Based upon the assessment, the facility was to ensure proper referral to appropriate state agencies for the provision of specialized services to residents with Serious Mental Illness. Residents Affected - Few 056125 Page 5 of 30 056125 11/15/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 six sampled residents (Resident 8) received her Insulin (a medication that regulates blood sugar levels and is essential for life) as ordered by the physician. Residents Affected - Few This deficient practice had the potential for Resident 8 to become hypoglycemic (occurs when blood sugar level drops too low). Findings: During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes (a common condition that occurs when your body doesn't use insulin properly, resulting in high blood sugar levels) and chronic kidney disease (CKD, a long-term condition that occurs when the kidneys are damaged and can't filter blood properly. This can lead to a buildup of waste and excess fluid in the body). During a review of Resident 8's untitled care plan initiated 8/22/2024, the care plan indicated Resident 8 had diabetes with goals for Resident 8 to be free from any signs or symptoms of hypoglycemia. The interventions for Resident 8 included receiving diabetes medications as ordered by the doctor. During a review of Resident 8's minimum data set (MDS - a resident assessment tool) dated 8/26/2024, the MDS indicated Resident 8 had moderately impaired cognition (the mental process of acquiring knowledge and understanding through thought, experience, and the senses) and was receiving hypoglycemic (medications to lower sugar) agents including insulin. During a review of Resident 8's Order Summary Report, the Order Summary Report indicated the following orders were placed 9/28/2024: 1.) Insulin Glargine (is an injection that treats diabetes by increasing insulin levels in your body. This decreases your blood sugar) Solution 100 units/ milliliter (ml, a unit of measurement)- inject 14 units subcutaneously (situated or applied under the skin) one time a day at bedtime for diabetes. Hold if blood sugar is less than 150 milligrams (mg, a unit of measurement) per deciliter (dL, a unit of measurement) or if patient refused dinner. 2.) Insulin Glargine Solution 100 units/ml- inject 20 units subcutaneously one time a day (9 a.m.) for diabetes, hold if blood sugar is less than 150 mg/dL or if patient refused Breakfast. During a review of Resident 8's MAR for the month of 10/2024 and 11/2024 the following was indicated: 1.) Insulin Glargine 14 units at bedtime, hold if blood sugar was less than 150 mg/dL was given on the following dates with the following blood sugars: 10/7/2024, blood sugar 125, given in the abdomen (stomach) 10/17/2024, blood sugar 124, given in the abdomen. 056125 Page 6 of 30 056125 11/15/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0658 2.) Insulin Glargine 20 units one time a day (9 a.m.), hold if blood sugar was less than 150 mg/ dL was given on the following dates with the following blood sugars: Level of Harm - Minimal harm or potential for actual harm 10/3/2024, blood sugar 94mg/ dL, in the abdomen Residents Affected - Few 10/4/2024, blood sugar 139mg/ dL, in the abdomen 10/13/2024, blood sugar 149 mg/dL, in the abdomen 10/18/2024, blood sugar 122 mg/dL, in the abdomen 10/19/2024, blood sugar 132 mg/dL, in the abdomen 10/26/2024, blood sugar 139 mg/dL, in the left arm 11/2/2024, blood sugar 141 mg/dL, in the abdomen During an interview and concurrent record review on 11/15/2024 at 10:41 a.m., with the director of nursing (DON), Resident 8's MAR was reviewed. The DON stated Resident 8 had physician's order for insulin Glargine (hold if blood sugar less than 150 mg/dL). The DON stated it was important to follow physician's parameters because it indicated if the medication was needed or not needed. The DON stated the parameters were a physician's order and it was important to follow physician's orders because they were there to prevent any adverse effects (an undesirable or harmful outcome) to the medication. The DON stated insulin was a high-risk medication (drugs that can cause significant harm or death to a patient if used incorrectly or misused) and could cause hypoglycemia. During a review of Resident 8's MAR for 10/2024 and 11/2024, the DON acknowledged that Insulin Glargine was given on the dates noted above when the blood sugar was less than 150 mg/dL. The DON stated giving Insulin Glargine below the parameters (insulin dosage based on blood sugar reading) given by the physician posed a risk for hypoglycemia, a change in mental status, jitters (shakiness), sweating, and the resident could lose consciousness. The DON stated the importance of following physician's orders was patient safety and her nurses were not following physician's orders by giving insulin Glargine to Resident 8 below the specified parameters. During a review of the facility's policy and procedure (P/P) titled Preparation and General Guidelines dated 10/2019, the P/P indicated the nurse was to administer medication in accordance with written orders of the attending physician. 056125 Page 7 of 30 056125 11/15/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately assess, monitor the effectiveness of current pain management, and reassess the pain for one of six sampled residents (Resident 47) who was receiving pain medications. Residents Affected - Few This deficient practice had the potential for resident 47 to experience unnecessary pain. Findings: During a review of Resident 47's admission Record, the admission Record indicated Resident 47 was admitted to the facility on [DATE] with diagnoses of depression (a mental illness that causes persistent sadness and loss of interest), Parkinson's Disease (a chronic brain disorder that causes movement problems, and can also affect mental health, sleep, and pain), and malignant neoplasm of the prostate (prostate cancer). During a review of Resident 47's Order Summary Sheet, Resident 47 had an order placed on 11/2/2023 for Percocet (a pain medication that can treat moderate to moderately severe pain) 5-325 milligrams (mg, a unit of measurement) oral tablet give 2 tablets by mouth twice a day for pain management. An order was placed on 9/17/2024 for Tylenol (a pain medication, that treats minor aches and pains) oral tablet 325 mg (give 2 tablets= 650 mg) by mouth one time a day for pain management. The Order Summary Sheet indicated an order for pain management consult was ordered on 11/14/2024 with the Rehabilitation (a medical specialty that helps patients regain their independence after an injury or illness) physician (MD 3) with new orders post evaluation on 11/14/2024 for Cyclobenzaprine HCl (muscle relaxer, used with rest, physical therapy, and other measures to relax muscles and relieve pain and discomfort caused by strains, sprains, and other muscle injuries.) tablet 5mg give 0.5 tablet (2.5 mg) by mouth twice a day for muscle pain for 21 days, and gabapentin (treats nerve pain) oral capsule 100 mg, give 2 capsules (200mg) by mouth three times a day for pain management. During a review of Resident 47's untitled care plan initiated on 3/30/2024 and updated on 11/14/2024, the care plan indicated Resident 47 had acute (a short-term pain that has a known cause, such as an injury, surgery, or infection) and chronic (persistent pain that lasts longer than 3 to 6 months, or beyond the typical recovery time for an injury or health condition) pain of the back, spine, and left hip. The care plan indicated pain was not relieved by current pain medications. The goals for Resident 47 included Resident 47 voicing adequate relief of pain or the ability to cope with incompletely relieved pain. Interventions for Resident 47 included evaluating the effectiveness of pain medications, follow the pain scale (a tool that helps people describe how much pain they are feeling), to medicate as ordered, and monitor and record pain characteristics (quality, severity, location, onset, duration, aggravating factors, and relieving factors). During a review of Resident 47's minimum data set (MDS, a resident assessment tool) dated 9/19/2024, the MDS indicated Resident 47 was cognitively intact (a person was able to think, learn, remember, use judgment, and make decisions without significant impairment). During a review of Resident 47's Medication Administration Record (MAR) for the month of 11/2024, the MAR indicated the following pain follow up codes, U= unknown, I= ineffective, and E= Effective. The following was documented in the MAR: 056125 Page 8 of 30 056125 11/15/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0697 Level of Harm - Minimal harm or potential for actual harm 1.) Resident 47 received Tylenol 650 mg one time a day on 8 occasions and the effectiveness was Unknown between 11/1/2024 and 11/14/2024. 2.) Resident 47's pain level on a scale of 1-10 (0= no pain, 1-3 mild pain, 4-6 moderate pain, 7-10= severe pain) was documented daily, every shift (3 times a day) as 0, no pain from 11/1/2024 through 11/14/2024. Residents Affected - Few 3.) Resident 47 was given Percocet 5-325 mg (2 tablets) twice daily every day from 11/1/2024 through 11/14/2024, with a documented pain level of 0 and there was no record in the MAR that Resident 47 was reevaluated for pain after the pain medication was given. 4.) Resident 47's MAR did not indicate his pain characteristics were being monitored. During a review of Resident 47's progress notes- nursing note dated 11/14/2024, the progress note indicated Resident 47 was assessed for pain and reported the Percocet he had been receiving only brings his pain down to a pain level of 3 (pain scale 0-10, 0 being no pain and 10 being most severe pain you can experience). Resident's physician (MD 2) was informed of the pain level and ordered for Resident 47 to be seen and evaluated by MD 3. During a review of Resident 47's pain management review dated 11/14/2024, the review indicated Resident 47 had a change of condition related to pain, his pain during a review was a 10 out of 10 and Resident 47 endorsed almost constant pain during the 5 days prior to the pain management review. Resident 47 complained of back pain, bone pain, neck pain, and joint pain during all hours of the day. During an interview on 11/13/2024 at 8:54 a.m., Resident 47 stated he experienced extreme pain (8-10) while he walked with the Restorative Nursing Assistant (RNA - nursing aide program that helps residents maintain their function and joint mobility)s and suffered from chronic back pain. During an interview on 11/14/2024 at 1:45 p.m., Resident 47 stated the nurses gave him his pain medication because it was scheduled but never asked him his pain level or where his pain was and never came back after his pain medication was given to see if he was still in pain. During an interview on 11/14/2024 at 3:47 p.m., Resident 47 stated a pain specialist (MD 3) came to see him that day and he thought that was weird because he had been complaining of pain since he arrived at the facility, and it was the first time he was offered to see a pain specialist. During an interview and concurrent record review of Resident 47's MAR on 11/15/2024 at 11:57 p.m., the director of staff development (DSD) stated nurses were only documenting the pain score (0-10) in the MAR and not the characteristics of pain. The DSD stated Resident 47 was receiving Percocet pain medication twice daily which is usually used for severe pain with a documented pain scale of 0. The DSD stated the physician (MD 2) should have been notified if Resident 47's pain level was constantly 0 for reevaluation of pain medications. The DSD stated there was no reevaluation for pain in Resident 47's chart after pain medication was given and Resident 47 should have had an evaluation 30 minutes to 1 hour from when he received the pain medication. The DSD stated if it was not documented in the chart, it was not done. The DSD stated the nurses were not documenting a full pain assessment that included pain characteristics per Resident 47's care plan. The DSD stated an accurate pain assessment was important to see if the resident needed the pain medication and to evaluate if the resident's current pain regimen was effective. The DSD stated pain reassessment was important to ensure the pain medication given was effective. 056125 Page 9 of 30 056125 11/15/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 11/15/2024 at 12:23 p.m., Resident 47 stated he felt so much better today and the muscle relaxer (Cyclobenzaprine) they gave him was helping his joints feel less stiff and overall, his body felt better. Resident 47 expressed that he finally felt better that the facility was paying attention to him because he was seen by MD 3 for pain. Resident 47 stated the nurse that gave his pain medication that morning (licensed vocational nurse- LVN 3) asked a lot of questions about his pain prior to receiving the medication and came back after the medication was given to see if it was effective and that was the first time the nurse had done that. During an interview on 11/15/2024 at 12:28 p.m., LVN 3 stated prior to 11/14/2024, Resident 47 would request more Percocet but did not report pain and it was more of a routine for him. LVN 3 stated Resident 47 did not have a physician's order to reassess pain, but they should have been reassessing pain within the hour that the medication was given. LVN 3 stated they did not document the characteristics of pain because it was a chronic pain, and they would only document the characteristics of pain if there were any abnormalities or changes in pain. During a review of the facility's policy and procedure (P/P) titled Pain Recognition and Management dated 12/2023, the P/P indicated the pain medication received, refused and the response to the medication was to be documented in the resident's MAR. The P/P indicated if the pain management program was not effective, the licensed nurse was to contact the resident's physician. 056125 Page 10 of 30 056125 11/15/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

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** Cross Reference: F658 Residents Affected - Few Based on interview and record review, the facility failed to ensure one out of six sampled residents (Resident 8) was free from a significant medication error by failing to follow the physician's ordered parameters (specific instructions) when administering insulin (a hormone medication that regulates blood sugar levels and is essential for life). This deficient practice had the potential for Resident 8 to become hypoglycemic (occurs when your blood sugar level drops too low). Findings: During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes (a common condition that occurs when your body doesn't use insulin properly, resulting in high blood sugar levels) and chronic kidney disease (CKD, a long-term condition that occurs when the kidneys are damaged and can't filter blood properly. This can lead to a buildup of waste and excess fluid in the body). During a review of Resident 8's care plan initiated on 8/22/2024, the care plan indicated Resident 8 had diabetes with goals for Resident 8 to be free from any signs or symptoms of hypoglycemia. Interventions for Resident 8 included receiving diabetes medications as ordered by the doctor. During a review of Resident 8's minimum data set (MDS, a resident assessment tool) dated 8/26/2024, the MDS indicated Resident 8 had moderately impaired cognition (the mental process of acquiring knowledge and understanding through thought, experience, and the senses) and was receiving hypoglycemic (medications to lower sugar) agents including insulin. During a review of Resident 8's Order Summary Report, the Order Summary Report indicated the following orders were placed on 9/28/2024: 1.) Insulin Glargine (is an injection that treats diabetes by increasing insulin levels in your body. This decreases your blood sugar) Solution 100 units/ milliliter (ml, a unit of measurement)- inject 14 units subcutaneously (situated or applied under the skin) one time a day at bedtime for diabetes. Hold if blood sugar is less than 150 milligrams (mg, a unit of measurement) per deciliter (dL, a unit of measurement) or if patient refused dinner. 2.) Insulin Glargine Solution 100 units/ml- inject 20 units subcutaneously one time a day (9 a.m.) for diabetes, hold if blood sugar is less than 150 mg/dL or if patient refused Breakfast. During a review of Resident 8's MAR for the month of 10/2024 and 11/2024 the following was indicated: 1.) Insulin Glargine 14 units at bedtime, hold if blood sugar was less than 150 mg/dL was given on the following dates with the following blood sugars: 10/7/2024, blood sugar 125, given in the abdomen (stomach) 056125 Page 11 of 30 056125 11/15/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0760 10/17/2024, blood sugar 124, given in the abdomen Level of Harm - Minimal harm or potential for actual harm 2.) Insulin Glargine 20 units one time a day (9 a.m.), hold if blood sugar was less than 150 mg/ dL was given on the following dates with the following blood sugars: Residents Affected - Few 10/3/2024, blood sugar 94mg/ dL, in the abdomen 10/4/2024, blood sugar 139mg/ dL, in the abdomen 10/13/2024, blood sugar 149 mg/dL, in the abdomen 10/18/2024, blood sugar 122 mg/dL, in the abdomen 10/19/2024, blood sugar 132 mg/dL, in the abdomen 10/26/2024, blood sugar 139 mg/dL, in the left arm 11/2/2024, blood sugar 141 mg/dL, in the abdomen During an interview and concurrent record review on 11/15/2024 at 10:41 a.m., with the director of nursing (DON), of Resident 8's MAR was reviewed. The DON stated Resident 8 had physician's parameters (insulin administration dosage based on blood sugar levels) for insulin Glargine (hold if blood sugar less than 150 mg/dL). The DON stated it was important to follow physician's parameters because it indicated if the medication was needed or not needed. The DON stated the parameters were a physician's order and it was important to follow physician's orders because they were there to prevent any adverse effects (an undesirable or harmful outcome) to the medication. The DON stated insulin was a high-risk medication (drugs that can cause significant harm or death to a patient if used incorrectly or misused) and could cause hypoglycemia. During a review of Resident 8's MAR for 10/2024 and 11/2024, the DON acknowledged that Insulin Glargine was given on the dates noted above when the blood sugar was less than 150 mg/dL. The DON stated giving Insulin Glargine below the parameters given by the physician posed a risk for hypoglycemia, change in mental status, jitters (shakiness), sweating, and loss of consciousness. The DON stated the importance of following physician's orders was patient safety and her nurses were not following physician's orders by giving insulin Glargine below the specified parameters. During a review of the facility's policy and procedure (P/P) titled Preparation and General Guidelines dated 10/2019, the P/P indicated the nurse was to administer medication in accordance with written orders of the attending physician. 056125 Page 12 of 30 056125 11/15/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review the facility failed to follow the menu and did not meet the nutritional needs of 46 of 81 residents on regular texture diets (diets with no restriction) when the residents did not receive three (3) ounce ([oz] unit of measurement) portions. This failure had the potential to result in decreased intake of nutrients resulting in unintended (not done on purpose) weight loss. Findings: During a review of the facility's daily spreadsheet titled Menus Cycle 4, dated 11/12/2024, the spreadsheet indicated residents on regular diet textures would get 3 oz of Meatloaf. During an observation on 11/12/2024 at 11:03 a.m., at the tray-line area (an area where meals were assembled on the trays), the meatloaf on the steam table varied in portion sizes. During a concurrent observation and interview on 11/12/2024 at 11:13 a.m., with [NAME] 1, [NAME] 1 weighed random pieces of meatloaf using the facility food scale. [NAME] 1 stated the first piece of meatloaf was 2.6 oz, the second piece was 3.6 oz, and the last piece was 2.5 oz. [NAME] 1 stated the portion size of the meatloaf should be 2 oz and she weighed the meatloaf once and increased the portion sizes because there were too many complaints from the residents that the portions were small. During an interview on 11/12/2024 at 11:20 a.m., with [NAME] 1, [NAME] 1 stated the portion sizes for meatloaf was 3 oz and not 2 oz after checking the menu spreadsheets. During an interview on 11/12/2024 at 11:25 a.m., with the Dietary Supervisor (DS), the DS stated the staff referred to menu spreadsheet to check the correct portion sizes of the food served in tray-line. The DS stated it was not okay for the meatloaf to be inaccurate in portion size and staff needed to follow the spreadsheet to ensure residents were getting an adequate amount of nutrition. During an interview on 11/12/2024 at 11:54 a.m., with the Registered Dietitian (RD), the RD stated it was important to check and follow the menu spreadsheet for portion sizes of the food to ensure they were providing adequate nutrition to the residents. The RD stated residents who got lesser portions would not get adequate nutrition which could lead to weight loss and residents who got bigger than recommended portions could gain weight as a potential outcome. During a review of the facility's standardized recipe titled Meatloaf (S-B/T), undated, the standardized recipe indicated Suggested portion size: 3 oz. Procedure: Slice into 3 oz portions. Top with gravy. (Should get 20 portions per pan). During a review of the facility's Policies and Procedures (P&P) titled Food Preparation, dated 2023, the P&P indicated, Procedure: (1) The facility will use approved recipes, standardized to meet the resident census. This count is kept current so that an accurate amount of food is prepared. (2) Recipes are specific as to portion yield, method of preparation, quantities of ingredients, and time and temperature guidelines. During a review of the facility's P&P titled Portion Control, dated 2023, the P&P indicated, 056125 Page 13 of 30 056125 11/15/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0803 Level of Harm - Minimal harm or potential for actual harm Policy: To provide specific portion control information. Procedure: To be sure portions served equal sizes listed on the menu, portion control equipment must be used. A variety of portion control equipment should be available and utilized by employes portioning food. (3) A diet scale should be used to weigh meats. A scale that will weigh over two pounds or less accurate for weighing food in ounces. It is not always necessary to weigh every slice of meat, but test weighing should be done periodically to ensure accuracy. Residents Affected - Some 056125 Page 14 of 30 056125 11/15/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and appearance when: Residents Affected - Some a. The buttered carrots had no butter flavor. b. The mashed potatoes were bland in taste and had no flavor. This failure had the potential to result in 80 of 81 facility residents, getting food from the kitchen including Residents 27, 42,78, and 82 at risk of unplanned weight loss, a consequence of poor food intake. Findings: During a review of Resident 42's admission Record, the admission record indicated the facility admitted Resident 42 on 10/17/2024 with diagnoses including, but not limited to, chronic kidney disease ([CKD] a long term condition where the kidneys are damaged and cannot filter blood properly), chronic obstructive pulmonary disease ([COPD] a common lung disease that makes it difficult to breathe and protein-calorie malnutrition (a nutritional status where the body is lacking nutrients leading changes in the body composition and functions). During a review of Resident 42's Minimum Data Set (MDS, a resident assessment tool), dated 10/23/2024, the MDS indicated Resident 42' cognition (process of thinking and reasoning) was moderately intact for daily decision making. The MDS indicated Resident 42 required partial or moderate assistance (helper does less than half the effort) when eating. During a review of Resident 42's Order Summary Report, dated 11/3/2024, the order summary report indicated an order for a fortified (adding food items on the tray to provide additional nutrients) diet, no added salt([NAS] no salt packet served on the tray) with regular texture and thin liquid (fluids with no restriction) consistency. During an interview on 11/12/2024 at 11:44 a.m., with Resident 42, Resident 42 stated the food was bland. During a review of Resident 82's admission Record, the admission record indicated the facility admitted Resident 82 on 10/16/2024 with diagnoses including, but not limited to, dysphagia (difficulty swallowing), and protein calorie malnutrition. During a review of Resident 82's MDS, dated [DATE], the MDS indicated Resident 82 was able to understand and make decisions. The MDS indicated Resident 82 required set up and clean-up assistance when eating. During a review of Resident 82's Order Summary Report, dated 11/5/2024, the order summary report 056125 Page 15 of 30 056125 11/15/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0804 Level of Harm - Minimal harm or potential for actual harm indicated Resident 82 was ordered NAS, mechanical soft chopped texture (foods that are soft and easy to chew), thin liquid consistency diet. During an interview on 11/12/2024 at 11:44 a.m., with Resident 82, Resident 82 stated the food was horrible. Residents Affected - Some During a review of Resident 78's admission Record, the admission record indicated the facility admitted Resident 78 on 8/30/2024 with diagnoses including, but not limited to, chronic systolic (congestive) heart failure (a serious condition that occurs when heart cannot pump enough blood to meet the body's needs), acute respiratory failure ([ARF], a serious medical condition occurs when the body's is unable to provide enough oxygen to the blood and organs or remove enough carbon dioxide from the body) and ascites (a condition where fluid builds up in the abdomen that covers the abdominal organs.). During a review of Resident 78's MDS, dated [DATE], the MDS indicated Resident 78 was able to understand and make decisions. The MDS indicated Resident 78 required set up and clean-up assistance when eating. During a review of Resident 78's Order Summary Report, dated 8/30/2024, the order summary report indicated an order for NAS, regular texture, thin liquids diet. During an interview on 11/12/2024 at 10:19 a.m., with Resident 78, Resident 78 stated the food sucks and it's like poison. Resident 78 stated the kitchen offered alternative like sandwiches, but it was not good. During a review of Resident 27's admission Record, the admission record indicated the facility admitted Resident 27 on 10/5/2024 with diagnoses including, but not limited to, dysphagia, obstructive and reflux uropathy (a blockage in the urinary tract that prevents urine from draining causing it to back up into the kidneys), and essential hypertension ([HTN] high blood pressure). During a review of Resident 27's MDS, dated [DATE], the MDS indicated Resident 27 was not able to understand and make decisions. The MDS indicated Resident 27 required set up and clean-up assistance when eating. During a review of Resident 27's Order Summary Report, dated 10/5/2024, the order summary report indicated an order for a NAS, regular texture, thin liquid consistency diet. During an interview on 11/12/2024 at 10:25 a.m., with Resident 27, Resident 27 stated the food was not good. During a review of the facility's daily spreadsheet titled Menus Cycle 4, 2024 dated 11/12/2024, the spreadsheet indicated residents on regular diet (diet with no restriction) and NAS would get the following food items: Meatloaf four (4) ounces (oz, unit measurement) Mashed potato half (1/2) cup (cup, household measurement) Gravy 056125 Page 16 of 30 056125 11/15/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0804 Buttered carrots ½ c Level of Harm - Minimal harm or potential for actual harm Roll 1 each Margarine 1 each Residents Affected - Some Winter fruit cup 3 ¼ oz Beverage 8 oz During a concurrent observation and interview on 11/12/2024 at 12:20 p.m., of the test tray (a process of checking the temperature, tasting, and evaluating the quality of food) with the Dietary Supervisor (DS) and Registered Dietitian (RD), the DS stated the buttered carrots did not seem to have a butter flavor and the mashed potatoes were bland in taste. The DS stated the cook maybe did not follow the recipe. The DS stated the residents may not eat the food and would not be happy with the food if was not flavorful. During a review of the facility's Policies and Procedures (P&P) titled Food Preparation, dated 7/19/2024, the P&P indicated, POLICY: Food shall be prepared by methods that conserve nutritive value, flavor, and appearance. PROCEDURE: (1) The facility will use approved recipes, standardized to meet the resident census. (3) Prepared food will be sampled. The Food and Nutrition Services employee who prepares the food will sample it to be sure the food has a satisfactory flavor and consistency. Use a clean spoon or put a small portion of the food in a dish and taste from the dish. (4) Poorly prepared food will not be served-such food is to either be improved, prepared again, or replaced with an appropriate substitution. Note that increased amounts of herbs and spices (not salt) may be added, since potency of products may vary. During a review of the facility's standardized recipe titled Buttered Carrots, undated, the standardized recipe indicated Ingredients: sliced carrots, salt, black pepper, melted margarine. If using butter buds instead of margarine: prepare the butter buds liquid by combining the warm water with the butter buds. Mix well. During a review of the facility's standardized recipe titled Mashed Potatoes, undated, the standardized recipe indicated Ingredients: water, potato pearl, margarine, salt, black pepper. 056125 Page 17 of 30 056125 11/15/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview and record review, the facility failed to prepare foods in a form designed to meet individual needs when residents on puree level four (4) diet (diet consisted of food that are soft with pudding like consistency) received meatloaf that could not hold its shape and puree carrot were weeping water. This failure had the potential to result in coughing, choking (to keep from breathing the normal way) and death for eight (8) of 81 residents on the puree diet. Findings: During a review of the facility's daily spreadsheet titled Menu Cycle 4, dated 11/12/2024, the spreadsheet indicated residents' meals on puree level 4 diet would include the following foods on the tray: Puree meatloaf half (1/2) cup ([c] household measurement) Mashed potato with gravy ½ c Puree buttered carrots 1/3 c Puree bread 1 piece (pc) Margarine 1 pc. Puree winter fruit cup 1/3 c Beverage 8 oz. During a concurrent observation and interview on 11/12/2024 at 10:31 a.m., with [NAME] 1 in the tray-line (an area where foods were assembled on the trays) area, [NAME] 1 stated she already prepared the puree foods. The puree carrots in the steamtable appeared watery with a runny consistency and the puree meat looked like it would not hold its shape. During a concurrent observation and interview on 11/12/2024 at 12:27 p.m., with Dietary Supervisor (DS) and Registered Dietitian (RD), of the test tray (a process of checking the temperature, tasting, and evaluating the quality of food), the DS stated the puree meatloaf was spread out on the plate while the other puree food held its shape. The DS then read the diet manual definition of puree diet and stated, puree diet should be lump free, not firm and sticky, should hold it shape in place and no liquids seeping from the food. The DS stated the puree meatloaf did not hold its shape on the plate and there was liquid coming out from the puree carrots. The RD stated the puree diets are for residents with dysphagia (difficulty swallowing) and for those without teeth. The RD stated residents could aspirate (when something you swallowed enters the airways and lungs) especially for those residents with difficulty swallowing as a potential outcome of eating foods that were no prepared in the proper textures. The RD stated another potential outcome is that residents may not enjoy their food. 056125 Page 18 of 30 056125 11/15/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 11/13/2024 at 1:35 p.m., with [NAME] 1, [NAME] 1 stated puree food was a difficult texture to make and the meat was always watery. During a review of the facility's Diet Manual titled Dysphagia Diets, Puree IDDSI Level 4, dated 1/2022, the diet manual indicated Definition: A diet used in the dietary management of dysphagia with the food texture prepared lump-free, not firm or sticky ad holds its shape on the plate. The diet requires no biting or chewing. Any liquids must not separate from the food and the food can fall off a spoon a spoon intact. The food is more easily swallowed and prevents aspiration. All prepared pureed recipes should be tested prior to service to ensure the texture meets the International Dysphagia Diet Standardization Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) guidelines. During a review of the facility's recipe titled Meatloaf (S-B/T) not dated, the recipe indicated, Puree: Place portion needed from regular prepare recipe into a food processor process to a fine texture. For every five portions needed, prepare a slurry with 1 tablespoon thickener and ½ cup hot liquid. Mix well with a wire whip. Add ½ of the slurry to the meat. Process for 1 minute. If too dry, add more slurry until meat is pudding consistency. During a review of the facility's recipe titled Buttered Carrots not dated, the recipe indicated, Puree: take drained portions needed from regular prepared recipe and place in a food processor. Process until fine. For every 5 portions, add 3 tablespoon thickener and ¼ cup liquid. Process until smooth, scrape down sides of the bowl. Reprocess 30 second. Reheat to 165°F and serve with #12 scoop. During a review of IDSSI website titled IDDSI dated 7/2019, the IDSSI website indicated, Level 4 Pureed is usually eaten with spoon, falls off spoon in a single spoonful when tilted and continues to hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid. 056125 Page 19 of 30 056125 11/15/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: a. Staff improperly labeled food products. 1. Jello was not labeled with product name. 2. Dry potato was improperly labeled. 3. Resident's food from outside was not labeled with the resident's name. b. Three (3) dented cans were stored with non-dented cans. c. There was chipped, cracked, and rusted kitchen utensils and equipment. 1. Chopping boards had scratches and had sauce splatter stored in the clean area. 2. Fruit cutter had rust. 3. Potato container cover had chips. 4. Can opener had chips. 5. 056125 Page 20 of 30 056125 11/15/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0812 48 of 48 resident's tray were cracked. Level of Harm - Minimal harm or potential for actual harm d. Kitchen equipment and food preparation surfaces were not cleaned and sanitized. Residents Affected - Some 1. Clean area for storing pots and pans had crumbs and food particles. 2. Pans had food residue, spill and burnt surfaces. 3. Toaster had breadcrumbs residue. 4. Tray-line (an area where foods were assembled on the trays) top had rust and brown dirt particles. 5. Microwave had food splatter and dry sauces. e. Cook did not check the food temperature prior to tray-line service. f. Mashed potato in the steamtable was 125 degrees Fahrenheit ([°F] a scale of temperature). g. Staff did not perform hand hygiene. 1. Cook touched the garbage cover then put on new gloves. 2. Cook picked up a paper towel off the floor then proceeded plating food in tray-line. 3. Staff picked up two pieces of paper towel off the floor then proceeded working. 056125 Page 21 of 30 056125 11/15/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0812 h. Level of Harm - Minimal harm or potential for actual harm Resident's freezer temperature was not monitored and checked. Residents Affected - Some These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 80 of 81 medically compromised residents who received food and ice from the kitchen. Findings: a. 1. During an observation on 11/12/2024 at 8:42 a.m., of the reach-in freezer, a green food item was not labeled with name. During an interview on 11/12/2024 at 9:11 a.m., with the Dietary Supervisor (DS), the DS stated their process of labeling and dating foods were as follows: (1) Label with product name. (2) Label with the date the product was made. (3) Label with expiration date. The DS stated they label food with the product name so that cooks could identify the food items and they label it with the date so that the staff could know the shelf life (length of time which a food item remains usable) of the product. The DS stated if food was not labeled with product name, the staff would not know the food product and could cause cross-contamination as a potential outcome to residents. 2. During an observation on 11/13/2024 at 9:27 a.m., of the dry potato container, the label indicated a use by date of 11/11/2024 and an expiration date of 11/9/2024. During an interview on 11/13/2024 at 9:55 a.m. with the DS, the DS stated the dry potato label was a typographical error and the expiration year was 2025 instead of 2024. 3. During a concurrent observation and interview on 11/13/2024 at 10:24 a.m. with Licensed Professional Nurse 1 (LVN 1), LVN 1 stated the residents' food inside the Resident Refrigerator was not labeled with the resident's name that the food item belonged to. LVN 1 stated it was important to label outside food with resident's name to make sure they were giving the right food to the right resident to comply with diets and food allergies. LVN 1 stated potential outcome to the residents could be allergic reactions and incorrect diets given to the residents. 056125 Page 22 of 30 056125 11/15/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of facility's Policies and Procedures (P&P) titled Labeling and Dating of Foods, dated 2023, the P&P indicated, POLICY: All food items in the storeroom, refrigerator, and freezer need to be labeled and dated based on established procedures for either food safety or product rotation (FIFO- First In-First Out). Once daily, the PM cook and or PM diet aide will be responsible to inspect the refrigerators and discard perishable foods that are TCS in order to ensure food safety. Working containers holding food or food ingredients that are removed from their original packages for use in the food facility, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar, shall be identified with common name of the food, except that containers holding food that can be readily and unmistakably recognized, such as dry pasta, need not be identified. During a review of facility's Policies and Procedures (P&P) titled Foods Brought by Family or Visitors, dated 7/21/2023, the P&P indicated It is the policy of the facility that food(s) brought to a resident by family/visitors must be accepted by the resident; inspected before facility storage and stored and served in accordance with food safety professional standards. The use of outside foods is a possible intervention for residents with low intake, distinct food preferences, cultural/ethnic preferences, etc. This intervention preserves the resident right to self-determination as much as possible. (5) Resident food shall be stored in the following locations: Resident refrigerator or in the kitchen. Resident food stored in the facility kitchen will be easily distinguishable from facility food. All foods shall be labeled with the resident name, location, and date. During a review of Food Code 2022, the Food Code 2022 indicated, 3-501.17 Commercially processed food, open and hold cold, (B) except specified in (E) - (G) of this section, refrigerated, ready-to-eat time/temperature control for food safety food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacture's use-by- date if the manufacturer determined the use-by date based on food safety. b.During a concurrent observation and interview on 11/12/2024 at 9:50 a.m. in the dry storage room with the DS, there were three (3) dented cans stored with the undented cans. The DS stated they separated dented cans in a designated area as dented cans could get a hole that the naked eye could not see and spoil, and it was bad for resident's consumption and residents could get sick from botulism (a rare but serious illness that occurs when the body's nervous system is attacked by a toxin produced by the bacteria). During a review of facility's P&P titled Food Storage-Dented Cans, dated 2023, the P&P indicated, POLICY: Food in unlabeled, rusty, leaking, broken containers or cans with side seam dents, rim dents, or swells shall not be retained or used by the facility. PROCEDURE: All dented cans (defined as side seam or rim dents) and rusty cans are to be separated from remaining stock and placed in a specified labeled area for return to purveyor for refund. All leaking cans are to be disposed immediately. During a review of Food Code 2022, the Food Code 2022 indicated, 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601.12, honestly presented. 3-201.11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of §3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victim to conditions that endanger their safety, make them 056125 Page 23 of 30 056125 11/15/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0812 Level of Harm - Minimal harm or potential for actual harm adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard. Residents Affected - Some c.During an observation on 11/12/2024 at 10:10 a.m., the chopping boards had scratches with dried up sauce spilled, the large white chopping board was chipped, the fruit slicer had rust and the container cover for the potatoes was chipped. 1.2.3. During a concurrent observation and interview on 11/12/2024 at 12:40 p.m., with the DS, the DS stated the chopping boards had scratches, and the potato container cover had cracks. The DS stated it was not okay to have kitchen equipment with cracks and scratches as the cracked pieces could get in the food and it would be a cross-contamination issue. The DS stated the slicer looked rusted, needed to be thrown away and should not be used in the kitchen due to cross-contamination. The DS stated the large chopping boards had chips and stains. The DS stated the large chopping boards should not be used and needed to be replaced. 4. During an observation on 11/13/2024 at 9:18 a.m., of the can opener, the can opener metal shelving had a chip. 5. During an observation on 11/13/2024 at 9:33 a.m., of the dishwashing process, 48 of 48 resident's meal trays had cracks and chips. During an interview on 11/13/2024 at 9:52 a.m., with the DS, the DS stated the can opener was just replaced last month and it should not have any chips as the particles could go in the can of food resulting in cross-contamination. During a concurrent observation and interview on 11/13/2024 at 10:06 a.m., with the DS, the DS stated the resident's tray had exposed metals and had cracks and chips. The DS stated they needed to get rid of them as residents and staff could get injured and it could be a physical contaminant to the resident's food. The DS stated cross contamination would be the potential outcome to the residents for having cracked and chipped trays. During a review of the facility's P&P titled Sanitation, dated 2023, the P&P indicated, (11) All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas. (12) Plastic ware, china, and glassware that becomes unsightly, unsanitary, or hazardous because of chips and cracks, or loss of glaze shall be discarded. Plastic ware is bleached as necessary to prevent staining. (20) Separate chopping boards are to be used for preparing meats and vegetables. After each use, chopping boards shall be thoroughly cleaned and sanitized. During a review of Food Code 2022, the Food Code 2022 indicated, 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. (3) Free of sharp internal angles, corners, and crevices, (4) Finished to have smooth welds and joints. d.During an observation on 11/12/2024 at 10:24 a.m. in the pots and pans storage area, the clean pots and pans had dirt, crumbs, and food debris on them. The Pans had food spillage and burnt 056125 Page 24 of 30 056125 11/15/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some surfaces. The Bread toaster was covered with plastic and had breadcrumbs and tray-line roof had rust and brown dirt particles. 1. During a concurrent observation and interview on 11/12/2024 at 12:37 p.m., with the DS, the DS stated the preparation areas and other areas in the kitchen were cleaned after each meal. The DS stated the clean storage area for pots and pans had food debris from breakfast and it was not okay due to cross-contamination. DS stated if there was cross-contamination, residents could get sick with stomach issues like vomiting and stomach pain as a potential outcome. 2.3.4. During a concurrent observation and interview on 11/12/2024 at 12:43 p.m., with the DS, the DS stated the bread toaster had crumbs and it should have been cleaned after each use. The DS stated this was a cross-contamination issue. The DS stated the tray-line roof was cleaned after every meal however, it looked dirty and rusted due to the steam coming out from the steamtable. The DS stated it was not acceptable due to cross-contamination of food in the tray-line. The DS stated residents could get sick with stomach pain and diarrhea as a potential outcome of the cross-contamination. 5. During an observation on 11/13/2024 at 9:20 a.m. of the microwave, the microwave had food splatters and dry sauces. During a concurrent observation and interview on 11/13/2024 at 9:52 a.m., with the DS, the DS stated the microwave was cleaned every after use, however, there was dried up spillage and food inside. The DS stated it was not acceptable to have dried up food spillage in the microwave due to cross-contamination. During a review of facility's P&P titled Sanitation, dated 2023, the P&P indicated, POLICY: The Food and Nutrition Service Department shall have equipment of the type and in the amount necessary for the preparation, serving and storing of food. There shall be adequate equipment for cleaning and disposal of waste and general storage. All equipment shall be maintained as necessary and kept in working order. (16) The kitchen staff is responsible for all the cleaning with the exception of ceiling vents, light fixtures, and the hood over the stove, while will be cleaned by maintenance staff. During a review of the facility's job task assignment log titled AM/PM Cooks Job Assignments, undated, the log indicated a schedule to clean all counter tops after use for AM cooks and cover, toaster, cutting boards for PM cooks. During a review of Food Code 2022, the Food Code 2022 indicated, 4-601.11 (E) Except when dry cleaning methods are used as specified under § 4-603.11, surfaces of utensils and equipment contacting food that is not time/temperature control for safety food shall be cleaned: (1) At anytime when contamination may have occurred; (2) At least every 24 hours for iced tea dispensers and consumer self-service utensils such as tongs, scoops, or ladles; (3) Before restocking consumer self-service equipment and utensils such as condiment dispensers and display containers; and (4) In equipment such as ice bins and beverage dispensing nozzles and enclosed components of equipment such as ice makers, cooking oil storage tanks and distribution lines, beverage and syrup dispensing lines or tubes, coffee bean grinders, and water vending equipment: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specification, at a frequency necessary to preclude accumulation of soil or mold. e.During an observation on 11/12/2024 at 11:03 a.m., of the tray-line, [NAME] 056125 Page 25 of 30 056125 11/15/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1 started plating the food from the steamtable to the plates and trays without checking the temperature of the foods. During an interview on 11/12/2024 at 11:25 a.m., with the DS, the DS stated staff took the food temperature before plating the food in the tray-line to ensure food was hot and not undercooked. The DS stated the food temperature record log was blank. During a review of facility's P&P titled Meal Service, dated 2023, the P&P indicated, POLICY: Meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner and served at the appropriate temperatures. (2) Food and Nutrition Services staff member will take the food temperatures prior to service of the meal with a thermometer prior to service of the meal with a thermometer that has been cleaned and sanitized. f.During an observation on 11/12/2024 at 11:03 a.m., [NAME] 1 took the mashed potatoes temperature in the steamtable and it was 125°F. During an interview on 11/12/2024 at 11:25 a.m., with the DS, the DS stated the holding temperature of food was 140°F, and if the mashed potatoes was not at 140°F, the residents could complain that the food was cold. During a review of facility's P&P titled Meal Service dated 2023, the P&P indicated (3) The food will be served on tray-line at the recommended temperatures indicated below and recorded on the daily therapeutic menu in the temperature column of regular food and next to the food item under the therapeutic diet column of each food served. Hot food serving temperature must be at or above minimum holding temperature of 140°F. the temperatures may also be recorded on a temperature log. The temperature of foods should be periodically monitored throughout the meal service to ensure proper hot or cold holding temperature. g.1. During an observation on 11/12/2024 at 11:06 a.m., [NAME] 1 touched the lid of the garbage can and put on new gloves without performing hand hygiene. 2. During an observation on 11/12/2024 at 11:20 a.m., [NAME] 1 touched the lid of the garbage can then went back to plating food for the residents. During an interview on 11/12/2024 at 4:06 p.m., with the DS, the DS stated staff must wash their hands as soon as they enter the kitchen, touched their face, hair and when they were coming back from their break. The DS stated staff must not touch the cover of the garbage can or wash their hands after their hands were in contact with dirt on the garbage can because of cross-contamination. During an observation on 11/13/2024 at 9:17 a.m., Dietary Aide 1 (DA 1) picked up two (2) pieces of paper towel off the floor then went back to work without handwashing. During an interview on 11/13/2024 at 1:28 p.m., with [NAME] 1, [NAME] 1 stated she needed to wash hands every time she started working and thought that it was okay to not wash hands as long as she could change her gloves. [NAME] 1 stated it was not oaky to touch the garbage lid then go back to work as the bacteria could be on the trash can and it could go to her hands and transfer to the food she handled. [NAME] 1 stated residents could get sick with diarrhea as a potential outcome. During a review of the facility's P&P titled Handwashing Procedure, dated 2023, the P&P indicated 056125 Page 26 of 30 056125 11/15/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Hand washing is important to prevent the spread of infection. When to wash hands: (8) Touching trash can or lid. During a review of Food Code 2022, the Food Code 2022 indicated 2-301.14 When to Wash. Food employees shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in food preparation including working with exposed [NAME], clean equipment and utensils, and unwrapped single- service and single-use article and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (C) After caring for or handling service animals or aquatic animals as specified in 2-403.11(B); P (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco products, eating, or drinking; (E) After handling soiled equipment or utensils;(F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; G) When switching between working with raw food and working with ready-to eat food; (H) Before donning gloves to initiate a task that involves working with food; and (I) After engaging in other activities that contaminate the hands. h.During a concurrent observation and interview on 11/13/2024 at 10:20 a.m., with LVN 1, LVN 1 stated the 11-7 nurse shift monitored the temperature of the residents' refrigerator however the freezer temperature was not monitored, and they did not have a log. LVN 1 stated she did not know the reason why the freezer was not monitored because there was ice cream stored in there. LVN 1 stated they monitored the refrigerator and freezer for infection control purposes to ensure food was not spoiled and contaminated. LVN 1 stated residents could get sick with diarrhea and stomach issues if food was not in their proper temperatures. During a review of the facility's P&P titled Sanitation, dated 2023, the P&P indicated 21. Correct temperatures for the storage and handling of foods are used. Thermometers will be used to check temperatures of refrigerators, freezers, and food storeroom. Thermometers will be also used to check the food at mealtimes. During a review of the facility's P&P titled Cold Storage Temperature Monitoring and Record Keeping, dated 2023, the P&P indicated Food and Nutrition Services staff shall review and record temperatures of all refrigerators and freezers to ensure the correct temperatures for food storage and handling. Freezer temperature standards are 0°F or below. During a review of the facility's P&P titled Foods Brought by Family or Visitor, dated 2023, the P&P indicated (8) The temperature of the refrigerator and freezer will be monitored and logged by Nursing/Food Services staff in accordance with the facility professional food safety standards. Any deviations from the correct temperature standards will be reported to the Maintenance Department and/or the DSS for guidance and correction. 056125 Page 27 of 30 056125 11/15/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly by not ensuring two (2) of the dumpster's (a large trash metal container designed to be emptied into a truck) were not overflowing with trash, and the dumpster lids remained closed. Residents Affected - Some This failure had the potential to result in attracting birds, flies, insects, pest and possibly spread infection to 80 of 81 facility residents. Findings: During an observation on 11/12/2024 at 3:58 p.m., at the dumpster area, 2 dumpsters were overflowing with trash and the lids could not close. During a concurrent observation and interview on 11/12/2024 at 4:02 p.m., with the Dietary Supervisor (DS), the DS stated staff threw all the food trash into those dumpsters. The DS stated the dumpsters were overflowing with trash and were open and it was not okay as it could attract pest and rodents that could come in the facility. The DS stated rodents could carry diseases and could pass the disease to the resident as a potential outcome. During a concurrent observation and interview on 11/12/2024 at 4:09 p.m., with the Environmental Services Director (EVSD) at the dumpster area, the EVSD stated their trash vendor collected their trash once a day and would usually come around 3PM to 3:30 p.m., however they were late today because it was holiday yesterday. The EVSD stated the dumpster was overflowing and it was not okay that it was not closed as it could attract flies and the environment would smell. The EVSD stated this practice was not safe for the resident as it could get resident sick as a potential outcome. During a review of facility's Policies and Procedures (P&P) titled Miscellaneous Areas, dated 2023, the P&P indicated, Procedure: (1) All food waste must be placed in sealed leak-proof, non-absorbent, tightly closed containers (i.e. plastic bags) and shall be disposed of as necessary to prevent a nuisance or unsightliness. (2) Garbage and trashcan must be inspected daily that no debris is on the ground. or surrounding area, and that the lids are closed. The trash collection area is a potential feeding ground for vermin and rodents and must be kept clean. During a review of Food Code 2022, indicated, 5-501.116 Cleaning Receptacles. Proper storage and disposal of garbage and refused are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage of breeding place for insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be possible source of contamination of food, equipment, and utensils. Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Proper equipment and supplies must be made available to accomplish thorough and proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated. 056125 Page 28 of 30 056125 11/15/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff wore personal protective equipment ([PPE], clothing or equipment that protects the wearer from injury or illness) while providing direct resident care for one of three sampled residents (Resident 70) who was on enhanced barrier precaution/protection ([EBP], infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug resistant organisms). Residents Affected - Some This failure had the potential to result in the transmission of infectious microorganisms and increase the risk of causing an outbreak in the facility. Findings: During a review of Resident 70's admission Record, the admission Record indicated Resident 70 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of metabolic encephalopathy (a brain disorder that occurs when an underlying condition causes a chemical imbalance in the blood that affects the brain), gastrostomy tube ([G-Tube], a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension ([HTN], high blood pressure). During a review of Resident 70's Minimum Data Set ([MDS] a resident assessment tool), dated 8/29/2024, the MDS indicated Resident 70 was moderately impaired in cognitive skills (thought process) for daily decision-making and was dependent (helper does all of the effort to complete the activity or the assistance of two or more helpers is required) on mobility such as rolling left and right, sit to lying position, lying to sitting on the side of the bed and self-care abilities such as eating, toileting, oral and personal hygiene. During a review of Resident 70's Order Summary Report, the Order Summary Report indicated enhanced barrier precautions, PPE required for high resident contact care activities. Indication was G-Tube every shift. During an observation on 11/12/2024 at 9:26 a.m., inside of Resident 70's room, the Certified Nursing Assistant (CNA) 1 did not have on proper PPE when tending to Resident 70's care in the room. The signage on the doorway indicated Resident 70 was on EBP and PPE needed to be worn when resident care was provided. CNA 1 only had gloves on when picking up Resident 70's blanket from the bed and adjusting the blanket on Resident 70. CNA 1 then stepped out of Resident 70's room and did not perform hand hygiene. During an observation on 11/12/2024 at 10:01 a.m., in Resident 70's room, Resident 70 was lying in bed in a supine (on the back) position. Resident 70 did not want to be interviewed and asked to be left alone. Resident 70 had a pillow underneath her right arm, a walker at the end of the bed and tube feeding machine next to the patient. During an interview on 11/15/2024 at 10:52 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 70 was on EBP because Resident 70 had a G-Tube for feedings. LVN 2 stated residents with any openings in the body such as wounds, a foley catheter (a flexible tube that drains urine from the bladder into a collection bag), or G-Tube are on EBP. Staff are to wear PPE to protect other 056125 Page 29 of 30 056125 11/15/2024 Alamitos Belmont Health and Rehabilitation 3901 E Fourth Street Long Beach, CA 90814

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some residents and themselves from infection. Staff who do not wear proper PPE when providing care to the residents are at risk for spreading infection and soiling their clothes when in contact with the openings from the residents. Infections can spread from resident to resident, resident to staff or resident to visitors. During an interview on 11/15/2024 at 2:47 p.m., with the Director of Nursing (DON), the DON stated the purpose of EBP was to protect the resident and staff from possible infections. The DON stated residents with wounds or devices such as a foley catheter, G-tube, or if the resident had a history of infection are on EBP. The proper PPE staff should have on are gloves, gown, mask when encountering anything that may belong to the resident such as their personal belongings or anything at the bedside. The DON stated when staff are not following PPE guidelines, infections can spread and be passed on to other staff members, residents and even visitors which can cause an outbreak. The correct way of donning (putting on) PPE was gown, mask, gloves. Gloves are put on last and should cover the sleeves of the gown. The correct way of doffing (taking off) PPE was gloves, gown, and mask and the perform hand hygiene. The DON stated all staff should perform hand hygiene before going into a resident's room and after leaving a resident's room. During a review of the facility's policy and procedure (P/P) titled IPCP Standard and Transmission-Based Precautions, revised 3/2024, indicated enhanced barrier protection used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothes then indirectly transferred to residents or from resident to resident (e.g. residents with wounds and indwelling medical devices are at especially high risk of both acquisition and colonization with MDROs) examples of high contact resident care activities requiring gown and glove use for EBP include dressing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use like central vascular line, indwelling urinary catheter, feeding tube, tracheostomy/ventilator. During a review of the facility's P/P titled, Hand Hygiene, dated 12/2022, indicated five moments of hand hygiene are before patient contact, before aseptic procedure, after patient contact, after body fluids, secretions contact, and after environment contact health care personnel must perform hand hygiene when it is needed during each five moments of hand hygiene. 056125 Page 30 of 30