Health inspection·February 1, 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 notify the physician when one of three sampled residents (Resident 2) continued to refuse to have restorative nurse aide ([RNA] a nurse who provides rehabilitative care to individuals recovering from illnesses or injuries) therapy exercises provided to him because of pain to his left knee. This deficient practice resulted in and had the potential to cause a delay in Resident 2' s assessment and treatment which could lead to a decline in Resident 1's range of motion ([ROM]. 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 a diagnosis of osteoporosis (brittle bones) During a review of Resident 2's Minimum Data Set ([MDS], a standardized assessment and care-screening tool), dated 12/15/2023, the MDS indicated Resident 2 ' s cognitive skills for daily decision-making were moderately impaired. The MDS indicated, Resident 2 had a functional limitation in ROM to both his lower extremities (the part of the body that include the leg, ankle, and foot) and required partial/moderate assistance (helper lifts, or holds trunk, limbs but provides less than half the effort) when rolling right to left in the bed. During an interview on 1/31/2024, on 4:25 p.m., RNA 1 stated Resident 2 had been refusing therapy due to increased pain in his left knee. RNA 1 stated she had a team meeting with the Director of Staff Development (DSD) and the physical therapist on 1/29/2024 to discuss Resident 2's change of condition (COC). RNA 1 stated the DSD was made aware of Resident 2's refusal of therapy and pain but no new interventions were discussed during the meeting. During a review of Resident 2's Progress Notes, dated 1/2/2024 through 1/29/2024, there was no documentation that Resident 2 ' s physician was notified of Resident 2 ' s refusal of RNA therapy exercises due to pain in his left knee. During a concurrent interview and record review on 2/1/2024 at 3:30 p.m., with the DSD, Resident 2's RNA Intervention and Task report, dated 1/1/2024 through 1/31/2024 was reviewed. The RNA report indicated Resident 2 was to receive passive range of motion ([PROM] when a therapist or aide physically moves or stretches a person's residents ' joint) exercises to his bilateral lower extremities up to five times a week as tolerated. The RNA report indicated between 1/25/2024 and 1/31/2024, Resident 2 did not receive three therapy sessions. The DSD stated Resident 2 refused therapy during those Page 1 of 11 056150 056150 02/01/2024 Catered Manor Care Center 4010 N Virginia Rd. Long Beach, CA 90807

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sessions and the nursing staff should have assessed Resident 2 to determine the reason he refused RNA exercises and then notified Resident 2's physician. During an interview on 2/1/2024, at 4 p.m., the DSD stated during a team meeting RNA 1 reported that Resident 1 was experiencing knee pain and it was causing him to refuse RNA exercises. The DSD stated Resident 2's knee pain was being treated by medication and the nurses should have notified Resident 2's physician. The DSD stated the failure to notify the physician caused a delay in needed services or treatments. During an interview on 2/1/2024, at 4:20 p.m., the DON stated she was not aware that Resident 2 refused to participate in RNA exercises due to pain. The DON stated Resident 2's pain and refusal to participate in RNA exercises was considered a COC and the nursing staff failed to notify Resident 2's physician. The DON stated Resident 2 was at risk for not receiving necessary care. During a review of the facility's policy and procedure (P&P), titled, Change of Condition, dated 2016, the P&P indicated the licensed nurse will appropriately assess, document, and communicate changes of condition including diagnostic results to the primary care provider to provide treatment and services to address changes in accordance with the resident's needs and existing advanced directives. The P&P indicated if the change of condition does not require an immediate 911 transfer the following steps may be followed, document assessment findings and communications as soon as practical, notify physician and responsible party of assessment findings, notify patient and or responsible party of current status and subsequent actions/orders. 056150 Page 2 of 11 056150 02/01/2024 Catered Manor Care Center 4010 N Virginia Rd. Long Beach, CA 90807

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 ensure care plan interventions for two of three sampled residents (Resident 1's fall on 3/15/2023 and the use of two people during perineal care (cleaning private areas of resident), and repositioning for Resident 2. These deficient Resident 1 and 2) were revised and/or implemented to include the use of floor mats and specifics for visual checks following practices resulted in recommended interventions and interventions that were already in place not being implemented and Resident 2 falling from a bed sustaining abrasions to his face and thumb and had the for additional falls and/or injuries to occur. Findings: a. 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 diagnoses including hemiplegia (inability to move one side of body), hemiparesis (weakness on one side of body), 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 9/5/2021, the MDS indicated Resident 1 ' s cognitive skills for daily decision-making were severely impaired. The MDS indicated Resident 1 required extensive assistance (resident involved in activity, staff providing weight-bearing support) with one to two persons during transfers, toilet use and completion of personal hygiene. During an observation on 1/30/2024, at 1:30 p.m., Resident 1 was observed in her room sitting in her wheelchair. A floor mat was observed on the floor on the right side of Resident 1's bed. There was no floor mat observed on the floor on the left side of Resident 1's bed. During a concurrent interview and record review on 1/30/2024 at 3:10 p.m., with Registered Nurse 1 (RN 1), Resident 1's Interdisciplinary Team ([IDT] a team of health care professionals that plan, coordinate, and deliver care to resident) Progress Notes dated 3/15/2023 was reviewed. The IDT Note indicated on 3/15/2023 at approximately 8:45 a.m., Resident 1 was observed lying on the floor on her back. The IDT Note indicated a recommendation for bilateral (on both sides) floor mats on the sides of Resident 1's bed. RN 1 stated, Resident 1's care plan should have included bilateral floor mats based on the IDT meeting held after Resident 1's fall (3/15/2023). RN 1 stated bilateral floor mats are placed on both sides of a resident's bed and are used to help prevent injury if a resident falls out of the bed. During a concurrent interview and record review on 1/31/2024 at 3:20 p.m., with RN 1, Resident 1's Care Plan revised on 8/7/2023 was reviewed. The Care Plan indicated Resident 1 was at risk for falls and injury, related to (r/t) adverse effect of medications, unsafe balance or gait, presence of acute (sudden) illness, bowel and/or bladder incontinence (unable to control the urge to urinate or have a bowel movement), impaired physical mobility, and fluctuating mental status. The Care Plan's goals indicated to minimize fall incidents and to have no injury from falls. The Care Plan interventions indicated there was no documentation for the use of bilateral floor mats. RN 1 stated Resident 1's Care Plan's interventions did not include the use of bilateral floor mats and the intervention for visual checks where unclear as to how often to check Resident 1. RN 1 stated failure to revise 056150 Page 3 of 11 056150 02/01/2024 Catered Manor Care Center 4010 N Virginia Rd. Long Beach, CA 90807

F 0656 Resident 1's Care Plan placed Resident 1 at risk for further falls that could lead to injury or death. Level of Harm - Minimal harm or potential for actual harm During an interview on 2/1/2024 at 3:30 p.m., the Director of Nursing (DON) stated Resident 1's care plan should have been revised after Resident 1 fell on 3/15/2023 to include the use of floor mats as discussed during the IDT meeting (3/15/2023). The DON stated Resident 1 s care plan should have specified how often Resident 1 should be checked to ensure Resident 1's safety. The DON stated failure to revise Resident 1's care plan could lead to another fall and injury. Residents Affected - Some b. 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 a diagnosis of osteoporosis (brittle bones). During a review of Resident 2's Minimum Data Set ([MDS], a standardized assessment and care-screening tool), dated 12/15/2023, the MDS indicated Resident 2 ' s cognitive skills for daily decision-making were moderately impaired. The MDS indicated, Resident 2 had a functional limitation in range of motion ([ROM] the direction a joint can move to its full potential) to both his lower extremities (the part of the body that include the leg, ankle, and foot) and required partial/moderate assistance (helper lifts, or holds trunk, limbs but provides less than half the effort) when rolling right to left in the bed. During a review of Resident 2's Care Plan dated 9/23/2022, the Care Plan indicated Resident 2 had a self-care deficit as evidenced by the need for assistance with activities of daily living ([ADLs] task such as eating, bathing, dressing, grooming and toileting) related to (r/t) impaired mobility secondary to atrial fibrillation, seizure disorder (uncontrolled electrical activity in the brain, which may produce a physical convulsion, thought disturbances, or a combination of symptoms), obesity (overweight), heart failure (heart cannot pump enough blood to meet the body's needs), and osteoporosis. The Care Plan's goals indicated Resident 2 would be clean, dry, and well-groomed. The Care Plan ' s interventions indicated a two person physical assist was required for bed mobility, transfers and toilet use. During a review of Resident 2's Progress Note, dated 1/13/2024, and timed at 4:15 p.m., the Progress Note indicated Certified Nurse Assistant 1 (CNA 1) was providing care to Resident 2, when Resident 2 slipped from a low air loss mattress ([LAL] a mattress designed to distribute a patient ' s body weight over a broad surface area and help prevent skin breakdown), fell to the floor and sustained an abrasion (scrape) to the left side of his forehead with slight bleeding and an abrasion on his right thumb. During an interview on 2/1/2024, on 4:17 p.m., CNA 1 stated, she cleaned Resident 1 without assistance from another staff when he slid off the bed to the floor. CNA 1 stated she did not know Resident 2 required two people when providing care or for repositioning in bed and stated she did not know what a care plan was. During an interview 2/1/2024 at 3:30 p.m., the Director of Nursing (DON) after reviewing Resident 2's care plan dated 9/23/2022, stated, per Resident 2's Care Plan, Resident 2 required two persons at the bedside when perineal care was provided, when Resident 2's incontinent brief was changed and/or when Resident 2 was repositioned in bed. The DON stated, by failing to follow Resident 2's the care plan, staff placed Resident 2 at risk for injuries or death. During a review of the facility's policy and procedure (P&P), titled, Comprehensive Care Plan, 056150 Page 4 of 11 056150 02/01/2024 Catered Manor Care Center 4010 N Virginia Rd. Long Beach, CA 90807

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some dated 2008, the P&P indicated, it is the policy of this facility to develop, in conjunction with the resident/and or resident representative the comprehensive resident care plan. The care plan is directed toward achieving and maintaining optimal status of health, functional ability, and quality of life. It is reviewed and revised by the Interdisciplinary Team quarterly following assessment for significant change. The P&P indicated the individualized care plan is accessible to all care givers to assure resident specific care information is exchanged and the consistent delivery of care services and approaches. 056150 Page 5 of 11 056150 02/01/2024 Catered Manor Care Center 4010 N Virginia Rd. Long Beach, CA 90807

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 a physician's order for Ivermectin (a drug used to treat parasitic (an organism [an individual animal, plan, or single-celled life form] that lives on or in a host organism and gets its food from or at the expense of its host) infections such as scabies [a parasitic infestation caused by tiny mites that burrow into the skin and lay eggs, causing intense itching and a rash]) was transcribed and administered to one of three sampled residents (Resident 1). Residents Affected - Few This deficient practice resulted in Resident 1 not receiving Ivermectin as ordered by the physician and had the potential for further itching and discomfort to occur. 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 diagnoses including hemiplegia (inability to move one side of body), hemiparesis (weakness on one side of body), 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 9/5/2021, the MDS indicated Resident 1's cognitive skills for daily decision-making were severely impaired. During a review of Resident 1's Physician's Order, dated 10/20/2023, the Physician's Order indicated Resident 1 was to receive Ivermectin 3.0 milligrams ([mg] a unit of measurement) tablet, take 12 mg (4 tablets) once weekly for four weeks. During a concurrent interview and record review on 1/31/2024 at 2:30 p.m., with the Director of Staff Development (DSD), Resident 1's Medication Administration Record (MAR) dated 10/1 2023 through 10/31/2023 was reviewed. The MAR indicated there was no documentation that Ivermectin was transcribed to the MAR. The DSD stated the Physician's Order for Ivermectin dated 10/20/2023 was not carried out. The DSD stated the nursing staff failed to input the Physician ' s Order for Ivermectin into the electronic health record system which resulted in Resident 1 not receiving Ivermectin, per the Physician's Order. The DSD stated the nursing staff put Resident 1 at risk for continued itching from scabies infestation. During an interview on 2/1/2024, at 1 p.m., the facility's Pharmacist Consultant (PharmD) stated Ivermectin is a drug that works to kill parasites and must be given per the physician's order. The PharmD stated failure to give Ivermectin as ordered by the physician put Resident 1 at risk for continued Scabies infestation and/or itching. During an interview on 2/1/2024, at 3:30 p.m., the Director of Nursing (DON) an order was received for Ivermectin from Resident 1's dermatologist (a medical practitioner specializing in the diagnosis and treatment of skin disorders) but the medication order for Ivermectin was not entered into the facility's computer system and the medication was not administered to Resident 1 as ordered by the dermatologist. The DON stated Resident 1 was placed at risk for decline in mental and physical health. During a review of the facility's policy and procedure (P&P) titled, Point ClickCare HER User Standards, dated 7/2020, the P&P indicated the purpose of the policy is to provide a method of writing 056150 Page 6 of 11 056150 02/01/2024 Catered Manor Care Center 4010 N Virginia Rd. Long Beach, CA 90807

F 0684 Level of Harm - Minimal harm or potential for actual harm orders, obtaining physician orders, and completing medications/treatment passes efficiently and accurately. The P&P indicated the procedural guidelines for physician orders: licensed nurses and therapists will obtain and complete new orders, new orders will be entered electronically, the DON or designee will review new orders for accuracy and completeness. The P&P indicated the licensed nurse will review the dashboard at a minimum of twice each shift for new orders. Residents Affected - Few 056150 Page 7 of 11 056150 02/01/2024 Catered Manor Care Center 4010 N Virginia Rd. Long Beach, CA 90807

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility's Interdisciplinary Team (IDT) failed to meet, following one of three sampled residents (Resident 2) fall with injury on 1/13/2024 to determine the cause of Resident 2's fall and recommend interventions to put in place in order to prevent other falls and/or injuries from occurring. This deficient practice resulted in the facility not exploring the root cause of Resident 2 ' s fall and had the potential for other falls to occur. 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 a diagnosis of osteoporosis (brittle bones). During a review of Resident 2's Minimum Data Set ([MDS], a standardized assessment and care-screening tool), dated 12/15/2023, the MDS indicated Resident 2's cognitive skills for daily decision-making were moderately impaired. The MDS indicated, Resident 2 had a functional limitation in range of motion ([ROM] the direction a joint can move to its full potential) to both his lower extremities (the part of the body that include the leg, ankle, and foot) and required partial/moderate assistance (helper lifts, or holds trunk, limbs but provides less than half the effort) when rolling right to left in the bed. During a review of Resident 2's Progress Note, dated 1/13/2024, and timed at 4:15 p.m., the Progress Note indicated Certified Nurse Assistant 1 (CNA 1) was providing care to Resident 2, when Resident 2 slipped from a low air loss mattress ([LAL] a mattress designed to distribute a patient ' s body weight over a broad surface area and help prevent skin breakdown), fell to the floor and sustained an abrasion (scrape) to the left side of his forehead with slight bleeding and an abrasion on his right thumb. During a review of Resident 2's clinical record, the clinical record indicated there was no documented evidence that the Interdisciplinary Team (IDT) met to discuss Resident 2's fall with injury on 1/13/2024 to determine how the resident fell and recommend interventions to prevent other falls from occurring. During an interview on 2/1/2024 at 3:30 p.m., and a subsequent interview on the same day at 4:45 p.m., the Director of Nursing (DON) stated, after reviewing Resident 2 ' s care plan dated 9/23/2022, Resident 2 required two persons at the bedside when perineal care was provided, when Resident 2 ' s incontinent brief was changed and/or when Resident 2 was repositioned in bed. The DON stated, by failing to follow Resident 2 ' s the care plan, staff placed Resident 2 at risk for injuries or death. The DON stated the IDT did not meet nor did they investigate to determine the cause of Resident 2 ' s fall on 1/13/2024. The DON stated failure to investigate as per policy, to determine the root cause of Resident 2 ' s fall placed Resident 2 at risk for another fall. The DON stated the cause of Resident 2 ' s fall was failure to provide care to Resident 2 using two people, per Resident 2 ' s care plan, and this should have been addressed by the IDT to prevent future falls. During a review of the facility ' s policy and procedure (P&P), titled, Fall Prevention and 056150 Page 8 of 11 056150 02/01/2024 Catered Manor Care Center 4010 N Virginia Rd. Long Beach, CA 90807

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Response, dated 8/2023, the P&P indicated each resident will be assessed for fall risk factors and will receive care and services in accordance with individualized level of risk to minimize likelihood of falls. The P&P indicated when any resident experiences a fall, the interdisciplinary team should review underlying circumstances and establish person-centered fall prevention interventions accordingly, these include, meet as soon as practically possible following the event, review fall circumstances and attempt to determine root-cause, customize interventions/approaches based on actual or suspected causal factors, and review and update the care plan/[NAME] as indicated. 056150 Page 9 of 11 056150 02/01/2024 Catered Manor Care Center 4010 N Virginia Rd. Long Beach, CA 90807

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 interview and record review, the facility failed to ensure the treatment of one sampled resident (Resident 1) with Permethrin (a medication used to kill scabies) was reported to the Infection Preventionist Nurse ([IPN] a person who is responsible for identifying, investigating, monitoring, and reporting healthcare associated infections) in order to ensure methods such as isolation, monitoring of rashes and proper cleaning and disinfection of linens and equipment used by Resident 1 was implemented. Residents Affected - Few This deficient practice resulted in the IPN nurse being unaware of a possible scabies diagnosis, a delay in implementing infection control methods and had the potential for acquiring and spreading scabies throughout the facility and to the community. 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 diagnoses including hemiplegia (inability to move one side of body), hemiparesis (weakness on one side of body), 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 9/5/2021, the MDS indicated Resident 1's cognitive skills for daily decision-making were severely impaired. During a review of Resident 1's Progress Note dated 10/20/2023, the Progress Note indicated Resident 1's Family Member (FM) was concerned about a rash on Resident 1's left flank (the area on the sides and back of the abdomen, between the lower ribs and the hips). The Progress Note indicated Resident 1's FM requested that a dermatologist (a medical doctor that specializes in the diagnosis and treatment of skin disorders) to be contacted. During a review of Resident's Order Summary Report (Physician's Order), dated 10/20/2023 through 1/30/2024, the Physician ' s Order indicated to apply Permethrin external cream 5%, apply topically (on top of) Resident 1's general body one time a day every Thursday for dermatitis unspecified (skin condition in which skin becomes red, bumpy, itchy, and swollen) for four weeks. Apply one tube from the neck to the toes, leave it on for 12 hours and rinse, once a week for four weeks. During a concurrent interview and record review on 1/30/2024 at 3:30 p.m., with the Director of Nursing (DON), Resident 1's Physician's Orders dated 10/20/2023 through 1/30/2024 was reviewed. The Physician ' s Orders indicated to apply Permethrin external cream 5% to Resident 1's body from his neck to toes, leave on for 12 hours then rinse, once a week for 4 weeks. The DON stated Resident 1 was administered Permethrin, which is a drug used to treat scabies, by Licensed Vocational Nurse 1 (LVN 1) and LVN 1 should have informed the IPN when he received an order to treat Resident 1 with Permethrin, per their scabies policy, and so the IPN could investigate/assess Resident 1 to determine if scabies was present and implement infection control precautions. During a review of Resident 1's Treatment Administration Record (TAR) dated 10/1/2023 through 11/30/2023, the TAR indicated Resident 1 received Permethrin as ordered by the physician on 10/26/2023, 11/2/2023, 11/9/2023 and 11/16/2023. 056150 Page 10 of 11 056150 02/01/2024 Catered Manor Care Center 4010 N Virginia Rd. Long Beach, CA 90807

F 0880 Level of Harm - Minimal harm or potential for actual harm During an interview on 1/31/2024, at 4:30 p.m., the IPN stated she was not aware that Resident 1's dermatologist ordered Permethrin. The IPN stated, per the facility's policy, she should have been notified so proper infection protocols such as isolation, monitoring of rashes and proper cleaning and disinfection of linens and equipment used by Resident 1 could be implemented. The IPN stated the staff ' s failure to comply with their policy put Resident 1, other residents, and staff at risk for potential scabies infestation. Residents Affected - Few During an interview on 2/1/2024, at 1 p.m., the facility's Pharmacist Consultant (PharmD) stated Permethrin is prescribed to kill parasites (an organism [an individual animal, plant or single celled life form] that lives on or in a host organism and gets its food from or at the expense of its host) The PharmD stated Permethrin acts on the nervous system of the parasite to cause death and it is not usually prescribed to residents unless a scabies infestation is suspected. During an interview on 2/1/2024, at 3:30 p.m., the DON stated nursing staff must notify the IPN when any rashes are assessed on residents' skin and/or if a resident is prescribed medications such as Permethrin, which is classified as a drug to treat scabies infestation. The DON stated the facility failed to implement their policy to inform the IPN of all suspected or diagnosed cases of scabies, and put residents, staff, and visitors at risk for scabies infestation. During a review of the facility's policy and procedure (P&P) titled, Scabies Care, dated 2012, the P&P indicated the purpose of the policy is to adequately treat cases of scabies and prevent transmission to others, all suspected or diagnosed cases should be reported to the infection preventionist. The P&P indicated before starting treatment, explain to the resident, family members, and health care workers what the problem is and how it is transmitted from person to person. educate the resident, family, and staff on the need for maintaining cleanliness of person, clothing, and bedding, advise all people who have had close contact with the resident to watch for signs of infestation and if necessary to see a physician for treatment. 056150 Page 11 of 11