Health inspection·May 28, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not implement and develop a resident-centered fall care plan for one of the five sampled residents (Resident 3). This deficient practice could adversely impact the resident's physical wellbeing and increase the risk of further falls and injuries. Findings: During a review of Resident 3's admission record (Face Sheet), the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including encephalopathy (any damage or disease that affects the brain), sciatica (type of pain compressed nerve), and dementia (group of thinking and social symptoms that interferes with daily functioning). During a review of Resident 3's History and Physical (H&P), dated 4/20/2025, the H&P indicated Resident 3 has the capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set ([MDS] a resident assessment tool), dated 4/18/2025, the MDS indicated Resident 3's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were mildly impaired. The MDS indicated Resident 3 required moderate assistance (provide less than half the effort) for sit to stand, toilet transfer, chair/bed-to-chair transfer, toileting hygiene, bathing, dressing, eating, and required supervision for oral and personal hygiene. The MDS indicated Resident 3 utilized a wheelchair and walker with no impairments on both the upper and lower extremities. During a record review of Resident 3's Care Plan (CP) untitled, the CP indicated the resident is at risk for falls and injuries related to (r/t) balance problems, seizure, alcohol abuse, and history of multiple falls dated 4/23/2025 revised 4/25/2025. The CP intervention indicated continue room near nursing station for better visibility initiated 4/25/2025. During a review of Resident 3's Change of Condition (COC) dated 4/25/2025 at 3:50 a.m., it was noted that Resident 3 experienced an unwitnessed fall as a result of not using the call light to request assistance with a restroom transfer. During an interview on 5/27/2025 at 1:07 p.m. with Resident 3, it indicated that Resident 3 has not experienced any falls at the facility and utilizes both a walker and wheelchair. Resident 3 reported not feeling dizzy or lightheaded upon standing and does not require assistance when getting up. Page 1 of 5 056234 056234 05/28/2025 Marlora Post Acute Rehab Hosp 3801 E Anaheim St Long Beach, CA 90804

F 0656 Additionally, Resident 3 stated that they can walk and go to the bathroom independently. Level of Harm - Minimal harm or potential for actual harm During an interview on 5/27/2025 at 1:28 p.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 3 is a one-person assist and sometimes forgets to use the call light before going to the restroom independently. CNA 1 mentioned that Resident 3 asks for assistance when he needs clothes from his closet and tries to be as independent as possible. CNA 1 added that Resident 3 does not use the call light for bathroom visits but uses it when he requires pain medication. Residents Affected - Few During an interview on 5/ 27/ 25, at 1:38 p.m., Licensed Vocational Nurse 1 (LVN 1) stated that Resident 3 is able to walk independently, use the bathroom without assistance, and perform most of his activities of daily living (ADLs), such as bathing, transferring, eating, and personal hygiene, by himself. LVN 1 stated when a resident has a history (hx) for falls, they do more frequent checked, encourage the residents to use the call light,. LVN 1 stated that they inform the Registered Nurse Supervisor (RNS) when a resident has experienced a fall, as it is important for the RNS to be aware of the situation. Not reporting the fall could result in further decline, excessive pain, and potential injury complications for the resident. LVN 1 mentioned that care plans are developed by all staff members, and they would create the care plan if they initiated the Change of Condition (COC). According to LVN 1, a care plan includes specific goals and interventions designed to address the COC and outline how these goals will be achieved. LVN 1 stated all of the interventions listed on the care plans have to be implemented as they will help lead them to help fix the issues presented. During an interview and record review on 5/27/2025 at 2:03 p.m., the Minimum Data Set Coordinator (MDSC) stated Resident 3 fell on 4/25/2025 and has a history of multiple falls. Knowing the resident's history of falls, alcohol abuse, and balance issues, MDSC confirmed he is automatically considered a fall risk. MDSC stated that based on the assessment and hospital records, they can determine if a resident is at risk for falls and implement necessary interventions like placing them near the nursing station or using floor mats. They will not use side rails for Resident 3, as he is continent and uses a walker. Although Resident 3 has poor balance, his sense of independence leads him to walk on his own without waiting for a CNA. Therefore, a nurse should always be on standby. MDSC stated Resident 3 requires supervision due to a history of falls. If he does not use the call light, they continue to reeducate him on its importance. MDSC reported that Resident 3 experiences forgetfulness, has an unsteady gait, shows confusion, and is non-compliant. Resident 3 sometimes the resident walks to the bathroom on their own when they require supervision. MDSC suggested that Resident 3 should have a care plan for non-compliance related to the use of call lights. MDSC stated Resident 3's fall could have been prevented knowing he has a hx for fall and is weak and indicated residents who have a hx of falls should automatically be placed in the falling star program (facility implemented program to prevent further falls from occurring). During a concurrent interview and record review on 5/28/2025 at 12:38p.m. with Director of Rehab (DOR), DOR stated when Resident 3 was admitted to the facility, he required moderate assistance for bed to wheelchair, wheelchair to toilet transfer and required maximum assistance with the use of the front wheel walker (FWW) on 4/14/2025. DOR stated Resident 3 cannot get up on his own to use the restroom and advised him to use the call light to get assistance as he is unsteady. DOR stated if Resident 3 continued to go to the bathroom without assistance, he could have another fall. During an interview on 5/28/2025 at 2:07p.m. with the Director of Nursing (DON) stated that if a resident expresses a desire to be independent and declines assistance, insisting they can go to the bathroom on their own without assistance or using the call light, this would be included in their care plan.The Director of Nursing (DON) stated that if a resident expresses a desire to be independent 056234 Page 2 of 5 056234 05/28/2025 Marlora Post Acute Rehab Hosp 3801 E Anaheim St Long Beach, CA 90804

F 0656 Level of Harm - Minimal harm or potential for actual harm and declines assistance, insisting they can go to the bathroom on their own without assistance or using the call light, this would be included in their care plan. DON stated the care plan would show that interventions were placed and provided for resident's noncompliance for the use of call lights. DON stated it is important to have a care plan as it is the blue print and shows what types of interventions were done and whether it was effective, so a care plan has to be followed. Residents Affected - Few During a subsequent interview and record review on 5/28/2025 at 2:39p.m. with DON, DON stated on the facility map, Resident 3's current room is close to the nursing station, but the staff would have to get up and walk to see the resident. DON stated Resident 3 is not particularly visible from the nursing station to his current room location and indicated the resident is located close enough to the nursing station where the staff can respond to him quicker if he does not want to use his call light. During a review of the facility's policies and Procedures (P&P), titled Care Planning -Interdisciplinary Team, revised date July 2024, the P&P indicated comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT). During a review of the facility's P&P, titled Care Plans, Comprehensive Person-Centered, revised date March 2022, the P&P indicated the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Care plan interventions are chosen only after data gathering, proper sequencing or events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. 056234 Page 3 of 5 056234 05/28/2025 Marlora Post Acute Rehab Hosp 3801 E Anaheim St Long Beach, CA 90804

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility did not ensure that a resident received medication as prescribed by the physician for two out of four sampled residents (Residents 1 and 3). This deficient practice had the potential to place Resident 1 and 3 at risk of receiving unnecessary medication. 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 metabolic encephalopathy (brain disorder that disrupts the body's process of converting food into energy), unspecified mood [affective] disorder (mental health condition characterized as persistent changed in mood and behaviors, and abnormal posture. During a review of Resident 1's Minimum Data Set [MDS] a resident assessment tool), dated 3/14/2025, the MDS indicated Resident 1's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were mildly impaired. The MDS indicated Resident 1 required supervision for toileting hygiene, required set up for eating, oral hygiene, bathing, personal hygiene, and was independent in toilet transfer and chair/bed-to chair transfer. The MDS indicated Resident 1 utilized a walker and did not have any impairments on both sides of the upper (arms/shoulders) and lower (hips/legs) extremities. During a review of Resident 1's Order Summary Report (physician orders) dated 5/22/2025, the order summary indicated Oxycodone-Acetaminophen (combination medication used to relieve moderate to severe pain) tablet 7.5-325 milligram (mg: unit of mass): give one (1) tablet by mouth every four (4) hours (hrs) as needed for breakthrough pain (PR 4-10/10). During a review of the Medication Administration Record (MAR) dated 5/1/ 2025 - 5/ 31/2025, it was noted that Oxycodone-Acetaminophen tablets (7.5-325 mg) were administered to Resident 1 according to the following directive: administer 1 tablet orally every 4 hours as needed for breakthrough pain with a pain rating of 4-10 on a scale of 10. · 5/17/2025 with a pain level of zero (0) at 8:50a.m. · 5/16/2025 with a pain level of 0 at 6:22p.m. · 5/5/2025 with a pain level of three (3) at 8:40a.m. · 5/5/2025 with a pain level of 3 at 2:22p.m. During a concurrent interview and record review on 5/27/2025 at 1:52p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated on the MAR dated 5/1/2025 - 5/31/2025, the check marks indicate that the medication was given. LVN 1 stated Resident 1's pain level on 5/17/2025 was 0 and indicated the order does not indicate to give the medication if the pain level was a 0. LVN 1 stated the order indicated to give medication at a pain level of 4-10, and the pain level of 3 dated 5/5/2025 on the MAR 056234 Page 4 of 5 056234 05/28/2025 Marlora Post Acute Rehab Hosp 3801 E Anaheim St Long Beach, CA 90804

F 0755 does not meet the criteria to administer the medication. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 5/27/2025 at 2:33p.m. with Minimum Data Set Coordinator (MDSC), MDSC stated on the MAR dated 5/1/2025 - 5/31/2025, the pain level documented as 0 is a typo for 5/17/2025 and indicated it should be a number and not zero. The MDS indicated that pain medication was administered when the pain level was 3. The MDSD clarified that if the order specifies administering pain medication for levels between 4 and 10, it is acceptable to administer it at a pain level of 4. However, administering the medication at a pain level of 3 is incorrect. MDSC stated narcotics (a substance used to treat moderate and severe pain) for a pain level of 3 is not needed and giving more medications than the resident need may damage their liver. Residents Affected - Some b. During a review of Resident 3's Face Sheet, the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including encephalopathy (any damage or disease that affects the brain), sciatica (type of pain compressed nerve), and dementia (group of thinking and social symptoms that interferes with daily functioning). During a review of Resident 3's H&P, dated 4/20/2025, the H&P indicated Resident 3 has the capacity to understand and make decisions. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognitive skills were mildly impaired. The MDS indicated Resident 3 required moderate assistance (provide less than half the effort) for sit to stand, toilet transfer, chair/bed-to-chair transfer, toileting hygiene, bathing, dressing, eating, and required supervision for oral and personal hygiene. The MDS indicated Resident 3 utilized a wheelchair and walker with no impairments on both the upper and lower extremities. During a review of Resident 3's Order Summary Report dated 5/27/2025, the order summary indicated Hydrocodone-Acetaminophen (combination medication used to relieve moderate to severe pain) tablet 5-325mg: give 1 tablet by mouth every 4 hours as needed for moderate to severe pain (4-6 to 7-10). During a review of the Medication Administration Record (MAR: detailed record of medication administered to residents) dated 5/1/2025 - 5/31/2025, the MAR indicated Oxycodone-Acetaminophen tablet 7.5-325 mg: give 1 tablet by mouth every 4 hrs as needed for breakthrough pain (PR 4-10/10) was administered to Resident 1 as follows: · 5/22/2025 with a pain level of 0 at 9:29a.m. · 5/25/2025 with a pain level of 0 at 8:13p.m. During a concurrent interview and record review on 5/27/2025 at 2:47p.m. with MDS, MDS indicated the MAR dated 5/1/2025 - 5/31/2025 indicated Resident 3's pain level was 0 on 5/22/2025 and 5/25/2025. MDS stated the MAR should not have been documented as 0 and the medication should have not been given and indicated accuracy is important. During a review of the facility's policies and Procedures (P&P), titled Administering Medications, revised date April 2019, the P&P indicated medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. 056234 Page 5 of 5