Health inspection·May 3, 2019

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation and interview, the facility failed to ensure a safe and homelike environment for the resident. For Resident 12, the room had chipped paint, cracked wall, and an opening on the wooden wall baseboard (a plank of wood or plastic that covers the area between the bottom of the wall and the floor). This deficient practice had the potential to harbor pests that could carry diseases or adversely affect the health and safety of vulnerable and medically compromised residents. Findings: During an initial tour of the facility on 4/30/19 at 1:32 p.m., of Resident 12's room, in the presence of the facility's Director of Nursing (DON), there was a part of the wall that was cracked and the paint was chipped. There was also an opening on the wooden wall baseboard. DON confirmed part of the wall was cracked and the paint was chipped and there was an opening on the wooden wall baseboard. DON stated the opening and the cracked wall could be a hiding spot for . The DON did not continue her statement. Page 1 of 17 555237 555237 05/03/2019 San Gabriel Valley Medical Ctr D/P Snf 438 W. Las Tunas Drive San Gabriel, CA 91776

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 observation, interview and record review, the facility failed to ensure a comprehensive person-centered care plan was developed for each resident for 1 of 12 sampled residents ( Resident 1). For Resident 1, the facility failed to implement an individualized, person-centered, comprehensive care plan to address Resident 1's current oral condition. This deficient practice resulted in Resident 1 to not receive the care needed to maintain oral health. Findings: A review of Resident 1's face sheet indicated the resident was admitted to the facility on [DATE]. A review of Resident 1's History and Physical (H&P) dated 11/12/18, indicated the resident had chronic respiratory failure (inadequate gas exchange in the respiratory system) and anoxic encephalopathy (condition where brain tissue is deprived of oxygen and there is loss of brain function). A review of Resident 1's Minimum Data Set (MDS, a care and assessment screening tool) dated 2/17/19, indicated the resident was totally dependent on staff for activities of daily living. The MDS indicated the resident had a tracheostomy (a tube inserted through an opening in the neck to provide an airway) in place and gastrostomy tube (a tube inserted through an opening in the abdomen for tube feeding). A review of Resident 1's April 2019 Physician Nursing Orders Report indicated a physician's order dated 1/9/19 to provide good oral care to Resident 1 per protocol. A review of Resident 1's Long Term Care Oral assessment dated [DATE], indicated the resident required assistance to complete oral care. A review of Resident 1's Sub-Acute Interdisciplinary Plan of Care Conference dated 3/13/19, indicated the family brought up issues on Resident 1's need for oral care. On 4/30/19 at 3:18 p.m., during an observation of Resident 1 at bedside, in the presence of Family Member 1 (FM1), FM 1 pointed at Resident 1's mouth. Resident 1's tongue had white patches and brown deposits at the back of the teeth. Dark deposits at the back of the front teeth were observed. During an interview and record review on 5/2/19 at 10:42 a.m., LVN 1 stated Resident 1's mouth was always dirty with a lot of yellow colored deposits in the gums, tongue and around the inside of the mouth. LVN 1 stated she did not know if Resident 1 had a care plan for oral care. LVN 1 stated she did not know how to locate Resident 1's care plan for oral hygiene. LVN 1 stated the care plan dated 11/7/18, indicated Resident 1 had dry mouth. The goal of the care plan indicated the resident would improve oral hygiene at optimal level as evidenced by tooth repair and increase in oral hygiene frequency. The care plan interventions included staff to provide oral care and dental consultation as needed. The care plan did not indicate Resident 1's current oral condition of having white patches on the tongue and brown deposits at the back of the teeth being addressed. 555237 Page 2 of 17 555237 05/03/2019 San Gabriel Valley Medical Ctr D/P Snf 438 W. Las Tunas Drive San Gabriel, CA 91776

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the facility's subacute policy and procedure titled Care Planning dated 9/2018, indicated the purpose of care planning was to assure a coordinated and comprehensive written plan is developed based on the resident assessment instrument and on the individual needs of the resident. The policy indicated that resident care planning includes participation from all involved health care disciplines at resident care conferences with continual reassessment, and updating at least quarterly, and upon change of condition, until resident's discharge. 555237 Page 3 of 17 555237 05/03/2019 San Gabriel Valley Medical Ctr D/P Snf 438 W. Las Tunas Drive San Gabriel, CA 91776

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the resident's plan of care was revised to reflect the resident's needs for one of 12 sampled residents ( Resident 1). For Resident 1, the facility failed to modify the care plan and revise to include new interventions to assist Resident 1 after a decline in ROM to the right finger and left ankle was identified on 3/29/19. This deficient practice had the potential to result in further decline of the resident's condition and for the resident to receive inaccurate care and treatment services. Findings: A review of Resident 1's face sheet indicated the resident was admitted to the facility on [DATE]. A review of Resident 1's History and Physical (H&P) dated 11/12/18, indicated the resident had chronic respiratory failure (inadequate gas exchange in the respiratory system) and anoxic encephalopathy (condition where brain tissue is deprived of oxygen and there is loss of brain function). A review of Resident 1's Minimum Data Set (MDS, a care and assessment screening tool) dated 2/17/19, indicated the resident was totally dependent on staff for activities of daily living. The MDS indicated the resident had a tracheostomy (a tube inserted through an opening in the neck to provide an airway) in place and gastrostomy tube (a tube inserted through an opening in the abdomen for tube feeding). A review of Resident 1's initial Subacute Range of Motion assessment dated [DATE], indicated the following: 1. Full range of motion to the left and right ankles. 2. Full range of motion to the left fingers and minimal loss (75% extension [unable to fully straighten finger]) of range of motion to the right fingers. The recommendations included for RNA to complete bilateral upper extremities and bilateral lower extremities passive range of motion to maintain joint integrity. A review of Resident 1's Physician orders dated 11/7/18, indicated passive ROM to all joints twice a day during waking hours. A review of Resident 1's Subacute Range of Motion assessment dated [DATE], indicated the following assessments: 1. Moderate loss of range of motion to the left ankle (50% dorsiflexion [unable to fully bend backwards]). 2. Minimal loss of range of motion to the right finger (75% extension [unable to fully straighten finger]). 555237 Page 4 of 17 555237 05/03/2019 San Gabriel Valley Medical Ctr D/P Snf 438 W. Las Tunas Drive San Gabriel, CA 91776

F 0657 The recommendations included to continue RNA passive range of motion twice daily as needed/tolerated. Level of Harm - Minimal harm or potential for actual harm A review of Resident 1's Physical Therapy/Patient Progress Notes dated 5/3/19 indicated the right hand had moderate limitation to the fifth finger with minimal limitation of the other fingers. Residents Affected - Few A review of Resident 1's care plan titled Long Term Care, Plan of Care, dated 11/7/18, indicated the resident had Alteration in Mobility related to muscle weakness and quadriplegia. The goal of the care plan indicated Resident 1 would maintain or increase ROM/contracture status. The care plan interventions included passive ROM to all extremities as ordered and tolerated, P.T evaluation quarterly and/or as needed. The care plan was last updated on 2/19/19. Resident 1's plan of care did not indicate that it was revised to include new interventions to assist Resident 1 after a decline in ROM to the right finger and left ankle was assessed on 3/29/19. During an interview, on 5/3/19 at 9:15 a.m., PT 1 stated that currently, Resident 1's right hand/fingers showed moderate limitation or loss of ROM (-45 degrees) during finger extension. PT 1 stated Resident 1's ROM declined from minimal to moderate loss in ROM from the last assessment. PT 1 stated contractures could develop if joint mobility was not maintained and may lead to pain and skin breakdown. A review of the facility's policy and procedure titled Care Planning, revised 8/10 indicated resident care planning includes participation from all involved healthcare disciplines at resident care conferences with continual reassessment and updating at least quarterly and upon change of condition until resident's discharge. When evaluating and reassessing the plan of care for the resident, the following shall be considered : a. Are the resident's problems still current? are there new problems? b. Are the actions/approaches appropriate and effective? 555237 Page 5 of 17 555237 05/03/2019 San Gabriel Valley Medical Ctr D/P Snf 438 W. Las Tunas Drive San Gabriel, CA 91776

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 provide oral care to one of one sampled resident (Resident 1), who was dependent with oral care. Residents Affected - Few This deficient practice could lead to oral infections. Findings: A review of Resident 1's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE]. A review of Resident 1's History and Physical (H&P), dated 11/12/18, indicated the resident had chronic (long standing) respiratory failure (condition in which not enough oxygen passes from the lungs into the blood) and anoxic encephalopathy (condition where brain tissue is not getting enough oxygen). A review of Resident 1's Minimum Data Set (MDS - a care and assessment screening tool), dated 2/17/19, indicated the resident was totally dependent on bed mobility and activities of daily living. The MDS indicated the resident had a tracheostomy (a tube inserted through an opening in the neck to provide an airway) in place, gastrostomy tube (a tube inserted through an opening in the abdomen for tube feeding). On 4/30/19, at 3:18 p.m., in the presence of Family Member 1 (FM1), Resident 1 was observed in the bed. FM 1 pointed at Resident 1's mouth. During an observation, Resident 1's tongue had white patches and brown colored deposits at the back of the front teeth. FM 1 stated that Resident 1 used to be meticulous with his oral hygiene prior to his debilitating condition. FM 1 stated the oral care issue had been addressed to the Social Service Director (SSD) on two occassions. During an interview and record review on 5/2/19 at 10:42 a.m., Licensed Vocational Nurse 1 (LVN 1) stated Resident 1's mouth had always been dirty with a lot of yellow colored deposits in the gums, tongue and around the inside of the mouth since he was admitted to the facility. During an interview with the Director of Nursing (DON) on 5/2/19 at 3:45 p.m., the DON stated she was aware that Resident 1's family had issues with Resident 1's impacted (not easily removed) secretions inside the mouth. During an interview with the SSD on 5/2/19 at 4:36 p.m., the SSD stated the problem with Resident 1's mouth was brought up by the family since February 2019. A review of Resident 1's care plan titled, Oral Health, updated 2/19/19, due to dry mouth indicated interventions for staff to provide oral care. 555237 Page 6 of 17 555237 05/03/2019 San Gabriel Valley Medical Ctr D/P Snf 438 W. Las Tunas Drive San Gabriel, CA 91776

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 that a resident who was receiving mechanical ventilation (a life support system designed to replace or support normal ventilator lung function) was provided respiratory care and services by qualified personnel consistent with professional standards of practice such as responding to ventilator alarms and setting for one of 12 sampled residents (Residents 17). Residents Affected - Few This deficient practice had the potential to result in delay of treatment to ventilator assisted residents and adverse consequences for the resident. Findings: a. A review of Resident 17's admission Record, indicated Resident 17 was admitted to the facility on [DATE] with a diagnosis of acute respiratory failure (inadequate gas exchange in the respiratory system). A review of Resident 17's Minimum Data Set (MDS, a care assessment and screening tool), dated 3/19/19, indicated Resident 17 was dependent on staff for eating, oral hygiene, toileting, shower, and upper dressing. Resident 17's MDS indicated the resident was comatose (state of unconsciousness) and was dependent on the ventilator. A review of Resident 17's Physician's Nursing Order Report, dated 2/5/19, indicated a ventilator setting of the fraction of inspired oxygen at 35% (FiO2- fraction of the amount of oxygen a patient is inhaling produced by an oxygen device), positive end-expiratory pressure (peep- airway pressure is maintained above atmospheric pressure at the end of exhalation) of 5, VT (tidal volume- lung volume representing the normal volume of air displaced between normal inhalation and exhalation when extra effort is not applied) of 250 and respiratory rate of 16. A review of Resident 17's Care Plan revised on 4/6/19, indicated the mechanical ventilator settings (Fio2, peep, VT and Rate) are programmed by the respiratory care practitioner (RCP) with a physician's order. On 5/1/19 at 1:45p.m., during an interview, Respiratory Care Practitioner 1 (RCP 1) stated that ventilator checks are done every four hours. RCP 1 stated that the RCPs were the only qualified staff allowed to adjust the Fi02 settings of the ventilator assisted residents. RCP 1 stated that anytime a ventilator alarms, the facility's RCP need to visually check the mechanical ventilator. On 5/1/19 at 4:00 p.m., the facility's records titled Ventilator Competency Checklist for LVNs and CNAs were reviewed together with the Director of Staff Development (DSD), in the presence of the director of nurses (DON). The DSD stated that during the facility's annual skills competency validation, all licensed nurses (licensed vocational nurses and registered nurses) and certified nurse assistants (CNA) were educated on the use and features of the mechanical ventilator. The DSD stated that CNAs were taught to identify the sounds from the mechanical ventilator between high pressure and low pressure alarms. The DSD stated that the CNAs were taught to count up to five seconds to distinguish the alarm sounds on the mechanical ventilator prior to reporting to the licensed nurses or RCP. During the interview, the DSD stated that if a ventilator assisted resident was not getting enough tidal volume from the mechanical ventilator, the respiratory rate would go down to abnormal levels. The 555237 Page 7 of 17 555237 05/03/2019 San Gabriel Valley Medical Ctr D/P Snf 438 W. Las Tunas Drive San Gabriel, CA 91776

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few DSD stated that the licensed nurses (LVN and RN) should be able to identify the high pressure or low pressure respiratory rate (RR) through the alarms and vital signs indicated on the mechanical ventilator. The DSD stated that only licensed nurses (both LVNs and RNs), aside from the RCPs are allowed to assess the resident on a mechanical ventilator. The DSD stated that if the licensed nurse (LVN or RN) determined that more oxygen is necessary, the licensed nurse could increase the FiO2 settings of the mechanical ventilator up to 100% and then, reassess the resident. Once the FiO2 settings had been adjusted, the DSD stated the RCP should be notified of the changes. The DSD stated that aside from the Fi02 settings, only the RCP was allowed to titrate (increase or decrease) the mechanical ventilator settings. On 5/2/19 at 9 a.m., during a medication pass observation, Resident 17's mechanical ventilator alarm was heard. Licensed Vocational Nurse 1 (LVN 1) was observed pressing the silence/reset button of Resident 17's mechanical ventilator. When asked why LVN 1 pressed the silence/reset button of Resident 17's mechanical ventilator, LVN 1 stated that Resident 17 was probably coughing. LVN 1 did not notify the RCP. On 5/2/19 at 2:03p.m., during an interview, CNA 2 stated that when the mechanical ventilator alarms, she would read the alerts that indicated high pressure or low pressure on the mechanical ventilator. CNA 2 stated that if the alarm would not stop, CNA 2 would inspect the mechanical ventilator connections and tighten any loose connections. CNA 2 stated that sometimes during bedside care, CNA 2 would press the mechanical ventilator silence/reset button when the beeping would not stop. CNA 2 stated that if the mechanical ventilator alarm starts again after pressing the silence button, CNA 2 would call the licensed nurse or the RCP. On 5/3/19 at 9:37a.m., during an interview, Licensed Vocational Nurse 3 (LVN 3), stated that there was a silence button on the mechanical ventilator to turn off its alarm. LVN 3 stated that if it was a real disconnection, the alarm will sound again. LVN 3 stated that if the alarm sounds again, that means there was something wrong. LVN 3 stated that when the mechanical ventilator indicated low pressure, LVN 3 would check the connections. LVN 3 stated that changing the FiO2 setting could only be done by LVNs, registered nurses and RCPs. LVN 3 stated that when titrating the FiO2 setting, LVN 3 would adjust the FiO2 and notify the RCP. LVN 3 stated that the RCPs had taught the LVNs and RNs how to unlock the mechanical ventilator to adjust the FiO2 ventilator setting. On 5/3/19 at 11:00 a.m., during an interview, the director of respiratory therapy (DRT) stated that alarms would stop after the issue in the mechanical ventilator had been corrected. DRT stated that only RCPs can reset the mechanical ventilator. DRT stated that if an alarm on the mechanical ventilator was audible, it should be addressed immediately. DRT stated that the facility does not allow the nurses to touch the mechanical ventilator. DRT stated that all alarms from a mechanical ventilator is concerning, therefore, every alarm should be reported to the licensed nurse or RCP. DRT stated that mechanical ventilators were locked and the RCPs are the only qualified staff allowed to unlock it. DRT stated that only RCPs should troubleshoot the mechanical ventilator that included the circuit connections. On 5/3/19 at 1:27 p.m., during an interview, RCP 2 stated that it is the responsibility of the RCP's to input the settings on the mechanical ventilator. RCP 2 stated that only RCPs are allowed to manipulate the mechanical ventilator. RCP 2 stated that the FiO2 setting was included in the standard ventilator setting. A review of the facility's respiratory policy and procedure (P&P) revised on September 2018, titled 555237 Page 8 of 17 555237 05/03/2019 San Gabriel Valley Medical Ctr D/P Snf 438 W. Las Tunas Drive San Gabriel, CA 91776

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ventilator Alarm Troubleshooting Guidelines, indicated that it is the responsibility of all health care providers in this facility to respond immediately to all ventilator alarms. Personnel will perform corrective action within their scope of practice to resolve the problem. A review of the facility's respiratory P&P revised on September 2018, titled Ventilator Malfunction, indicated, Do not silence alarms without identifying the problem. 555237 Page 9 of 17 555237 05/03/2019 San Gabriel Valley Medical Ctr D/P Snf 438 W. Las Tunas Drive San Gabriel, CA 91776

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on observation, interview, and record review, the facility failed to ensure that the competency skills validation required for the care of residents who were dependent on mechanical ventilators (a life support system designed to replace or support normal ventilator lung function) for two licensed vocational nurses (LVN) and 11 certified nurse assistants out of four LVNs and 11 CNA records reviewed, reflected the appropriate competencies for mechanical ventilator management consistent to their scope of practice. This deficient practice had the potential for the facility's LVNs and CNAs to provide care and services not within their scope of practice. Cross reference with F695. Findings: A review of 12 facility staff records titled Competency Assessment, Education and Validation; Nursing Airway Management indicated eight licensed nurses (four LVNs and four RNs) and four certified nursing assistants (CNAs), were required and validated the same competency and educational assessments on the facility's annual competency skills check list such as demonstrating proper insertion of oral airway in unconscious patient, turning the oxygen on to 10 to 15 liters, and suctions orally/nasally to clear airway. A review of the facility's record titled Ventilator (mechanical ventilator) Competency Checklist dated December 2018, indicated that when LVN 1 and LVN 2's skills were evaluated, both licensed nurses demonstrated competency and ability to independently demonstrate the steps in the administration of the fraction of inspired oxygen (FiO2- fraction of the amount of oxygen a patient is inhaling produced by an oxygen device) at 100%. A review of the facility's record titled Competency Assessment, Education and Validation dated December 2018, indicated LVN 1 and LVN 2 were able to independently demonstrate the proper insertion of an oral airway (a medical device called an airway adjunct used to maintain or open a patient's airway) to an unconscious resident. A review of the facility's record titled Competency Assessment, Education and Validation dated December 2018, indicated CNA1, CNA2, CNA3, and CNA4 were able to Independently demonstrate the proper insertion of an oral airway to an unconscious resident. The Competency Assessment, Education and Validation indicated not applicable (N/A) entry for CNA5, CNA6, CNA7, CNA8, CNA9, CNA10, and CNA11. A review of the facility's record titled Subacute Competency Validation for Nursing Assistants dated 12/13/18, indicated that CNA 2, CNA3, CNA4, CNA5, CNA8, CNA9, CNA10, and CNA11 were Independent in performing the reattachment of a mechanical ventilator to a resident in a timely manner. A review of the facility's record titled Ventilator Competency Checklist dated December 2018, indicated that CNA1, CNA2, CNA3, CNA4, CNA5, CNA6, CNA8, CNA9, CNA10, and CNA11 were competent and able to independently demonstrate the following skills: 1. Administer 100% oxygen. 555237 Page 10 of 17 555237 05/03/2019 San Gabriel Valley Medical Ctr D/P Snf 438 W. Las Tunas Drive San Gabriel, CA 91776

F 0726 2. Identify indications and possible hazards such as high/low pressure alarms. Level of Harm - Minimal harm or potential for actual harm 3. High/low respiratory rate and ventilator associated pneumonia (lung infection that develops in ventilator assisted resident). Residents Affected - Some On 5/1/19 at 1:45 p.m., during an interview, Respiratory Care Practitioner 1 (RCP 1) stated that ventilator checks were done every four hours. RCP 1 stated that the RCPs were the only qualified staff allowed to adjust the fraction of inspired oxygen (FiO2- fraction of the amount of oxygen a patient is inhaling produced by an oxygen device) settings of ventilator assisted residents. On 5/1/19 at 4:00 p.m., the facility's record titled, Ventilator Competency Checklist for LVNs and CNAs were reviewed together with the Director of Staff Development (DSD), in the presence of the director of nurses (DON). The DSD stated that during the staff's annual skills competency validation, all licensed nurses (licensed vocational nurses and registered nurses) and certified nurse assistants (CNA) were educated on the use and features of the mechanical ventilator. The DSD stated that the CNAs were taught to identify the sounds from the mechanical ventilator between high pressure and low pressure alarms. The DSD stated that the CNAs were taught to count up to five seconds to distinguish the alarm sounds on the mechanical ventilator prior to reporting to the licensed nurse or RCP. The DSD stated that the licensed nurses (LVN and RN) should be able to identify the high pressure or low pressure respiratory rate (RR) through the alarms and vital signs indicated on the mechanical ventilator. The DSD stated that only licensed nurses (both LVNs and RNs), aside from the RCPs are allowed to assess the resident on a mechanical ventilator. The DSD stated that if the licensed nurse (LVN or RN) determined that more oxygen is necessary, the licensed nurse could increase the FiO2 settings of the mechanical ventilator up to 100% and then, reassess the resident. Once the FiO2 settings had been adjusted, the DSD stated the RCP should be notified of the changes. The DSD stated that aside from the Fi02 settings, only the RCP was allowed to titrate (increase or decrease) the mechanical ventilator settings. On 5/2/19 at 9:00 a.m., Licensed Vocational Nurse 1 (LVN 1) was observed pressing the silence/reset button of Resident 17's mechanical ventilator during a medication pass observation,When asked why LVN 1 pressed the silence/reset button of Resident 17's mechanical ventilator, LVN 1 stated that Resident 17 was probably coughing. LVN 1 did not notify the RCP. On 5/2/19 at 2:03p.m., during an interview, CNA 2 stated that when the mechanical ventilator alarms, she would read the alerts that indicated high or low pressure on the mechanical ventilator. CNA 2 stated that if the alarm would not stop, CNA 2 would look if there were any loose connections attached to the mechanical ventilator. CNA 2 stated that sometimes she would press the mechanical ventilator silence/reset button when the beeping would not stop. CNA 2 stated that if the mechanical ventilator alarm starts again after pressing the silence button, CNA 2 would call the licensed nurse or the RCP. On 5/2/19 at 2:23p.m., during an interview, CNA 1 stated that CNAs cannot touch anything from the mechanical ventilators. On 5/3/19 at 11:00 a.m., during an interview, the director of respiratory therapy (DRT) stated that the facility does not allow LVN and CNA to touch the mechanical ventilators. When asked about the appropriateness of educating and validating the CNAs demonstrating oral airway placement in the facility's competency checklist, the DRT stated that CNAs should not be expected to perform the task of oral airway placement independently. 555237 Page 11 of 17 555237 05/03/2019 San Gabriel Valley Medical Ctr D/P Snf 438 W. Las Tunas Drive San Gabriel, CA 91776

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 5/3/19 at 11:00 a.m., during an interview, the director of respiratory therapy (DRT), stated that alarms would stop after the issues in the mechanical ventilator had been corrected. DRT stated that only RCPs can reset the mechanical ventilator. DRT stated that if an alarm on the mechanical ventilator is audible, it should be addressed immediately. DRT stated that all alarms from a ventilator machine is concerning, therefore, every alarm should be reported to the licensed nurse or RCP. DRT stated that mechanical ventilators are locked and that the RCPs were the only staff allowed to unlock it. DRT stated that only RCPs should troubleshoot the mechanical ventilator that included the circuit and connections. A review of a Fact Sheet provided by the Respiratory Board of California and Board of Vocational Nursing and Psychiatric Technicians, undated, indicated that LVNs and Psychiatric Technicians (PT) role in the care for mechanically ventilated residents, are authorized to provide care when the care is not specifically related to the mechanical ventilator. The Fact Sheet indicated that LVNs and PTs are not authorized to change any setting on the mechanical ventilator, manipulating ventilator breath circuits including disconnecting or reconnecting the circuit for any purpose, troubleshooting artificial airway problems and ventilator-related controls and alarms. The Fact Sheet indicated that RCPs, LVNs and PTs must follow their respective scopes of practice of patient safety. 555237 Page 12 of 17 555237 05/03/2019 San Gabriel Valley Medical Ctr D/P Snf 438 W. Las Tunas Drive San Gabriel, CA 91776

F 0790 Provide routine and 24-hour emergency dental care for each resident. 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 have a system in place in ensuring adequate level of oral health through periodic examination, prophylaxis by a dental hygienist and other required dental treatments for two of two sampled residents (Resident 1 and 4) in accordance with the facility policy. Residents Affected - Few This deficient practice had the potential for residents to not receive needed oral/dental services and could lead to complications such as dental cavities and infections. Findings: 1. A review of Resident 1's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE]. A review of Resident 1's History and Physical (H&P), dated 11/12/18, indicated the resident had chronic (long standing) respiratory failure (condition in which not enough oxygen passes from the lungs into the blood) and anoxic encephalopathy (condition where brain tissue is not getting enough oxygen). A review of Resident 1's Minimum Data Set (MDS - a care and assessment screening tool), dated 2/17/19, indicated the resident was totally dependent on bed mobility and activities of daily living. The MDS indicated the resident had a tracheostomy (a tube inserted through an opening in the neck to provide an airway) in place, gastrostomy tube (a tube inserted through an opening in the abdomen for tube feeding). On 4/30/19, at 3:18 p.m., in the presence of Family Member 1 (FM1), Resident 1 was observed in the bed. FM 1 pointed at Resident 1's mouth. During an observation, Resident 1's tongue had white patches and brown colored deposits at the back of the front teeth. FM 1 stated the family requested to the Social Service Director (SSD) for dental consult on 4/24/19. A review of Resident 1's care plan titled, Oral Health, updated 2/19/19, included interventions for staff to provide dental consultation as needed. 2. A review of Resident 4's Face Sheet indicated the resident's most current readmission to the facility was on 7/1/18. A review of Resident 4's H & P, dated 7/1/18, indicated the resident had diagnoses that included chronic respiratory failure and gingival hyperplasia (an overgrowth of gum tissue around the teeth often a symptom of poor oral hygiene or a side effect of using certain medications). A review of Resident 4's MDS, dated [DATE], indicated the resident had moderate cognitive (mental) impairment and the resident was totally dependent on bed mobility, transfers and activities of daily living. On 5/2/19, at 11:13 a.m., Resident 4's Progress Record, dated 7/25/12, was reviewed with the MDS nurse. The Progress Record indicated that Resident 4 had a dental consult on 7/25/12, from a previous admission. The MDS nurse stated she could not find other documentation that indicated Resident 4 had 555237 Page 13 of 17 555237 05/03/2019 San Gabriel Valley Medical Ctr D/P Snf 438 W. Las Tunas Drive San Gabriel, CA 91776

F 0790 routine dental consults after 7/25/12. Level of Harm - Minimal harm or potential for actual harm On 5/2/19, at 4 p.m., the Director of Nursing (DON) stated it was the SSD's responsibility to ensure that residents had routine dental consults and follow up dental services. Residents Affected - Few During an interview with the SSD, MDS Nurse and DON on 5/2/19 at 4:36 p.m., the SSD stated the problem with Resident 1's mouth was brought up by the family in February 2019. The SSD stated that he was not responsible in coordinating and tracking routine dental consults for all the residents in the facility. The MDS Nurse stated that the responsibility for ensuring and monitoring dental consultation for residents would be the DON. The DON stated that the facility did not have a current system in place to monitor the need for dental services or routine dental consults. A review of the facility's policy and procedures titled, Dental Services, revised on 8/2010, indicated that it is the policy that each resident admitted shall be encouraged and assisted by all those responsible for his/her care to obtain and maintain an adequate level of oral health through periodic examination, prophylaxis by a dental hygienist and other required dental treatments by the resident's personal dentist. The facility shall mainatain an agreement with an Advisory Dentist to advise and assist in providing dental care to all residents in the facility. The policy indicated that all dental and/or appointments would be kept in a dental log maintained by Social Services. 555237 Page 14 of 17 555237 05/03/2019 San Gabriel Valley Medical Ctr D/P Snf 438 W. Las Tunas Drive San Gabriel, CA 91776

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 clean and sanitize all resident contact surfaces for three of 23 rooms (room [ROOM NUMBER], 819, 823) in accordance with the facility's policy and ensure the facility is free of pests. Residents Affected - Some This deficient practice had the potential for the development and spread of infections to all residents in the facility. Findings: a. During an observation of room [ROOM NUMBER] Bed A, on 4/30/19 at 10:18 a.m., there were multiple yellowish stains on the bedrails of the bed, multiple yellowish stains on the foot of the IV pole and multiple whitish stains on the foot of the over-bed table. b. During another observation, on 4/30/19 at 10:20 a.m., there were multiple yellowish stains on room [ROOM NUMBER] Bed A's bedrails. The wall and floor tiles of the bath/toilet room were observed to have scattered brownish to black discolorations. During a concurrent observation and interview on 4/30/19 at 1:48 p.m., in the presence of Housekeeper 2 (HK 2) and Certified Nurse Assistant 4 (CNA 4), the same observations were verified. CNA 4 stated the black discoloration on the wall tiles of the bathroom looked like mildew. CNA 4 stated it can be inhaled and get sick. During an interview, on 4/30/19 at 2:22 p.m., the Housekeeping Supervisor (HS) stated that there was one housekeeper scheduled for the facility. The housekeeper (HK 1) cleans all the residents' rooms in the facility on a daily basis. In each room, HK 1 should also clean high touched areas (contact surfaces), including the bathrooms/toilet. The HS stated that the residents' bathrooms/toilet in each room would still be cleaned daily even if it was not being used. c. During an observation on 5/1/19 at 10:41 a.m., room [ROOM NUMBER] was designated a contact isolation room (involves skin [or mucosa] to skin contact and the direct physical transfer of microorganisms [germs] from one person to another). Housekeeper 1 (HK1) was observed putting on personal protective equipment (PPE's) such as a mask, gown, and gloves prior to entering room [ROOM NUMBER]. HK1 was observed cleaning room [ROOM NUMBER]. HK 1 did not clean/disinfect the bedrails, the exterior of the feeding pump, the IV pole and the call light control of Resident 14. A review of the facility's list of residents on contact isolation provided on 5/2/19, indicated room [ROOM NUMBER] had two residents (Residents 13 and 14) and was designated contact isolation room for Carbapenem-resistant Enterobacteriaceae (CRE, a bacterial infection resistant to the carbapenem class of antibiotics) in the urine. During an observation of room [ROOM NUMBER] Bed A and room [ROOM NUMBER] Bed A on 5/3/19 at 10:38 a.m., in the presence of the Director of Nursing (DON), she stated that these areas (bedrails, IV poles, bedside table) should be cleaned daily and disinfected to help prevent the spread of germs. A review of the facility's policy and procedures revised on 4/16/19, titled, Occupied Patient Room Cleaning XRO (cleaning system) Term Cleaning, indicated that all patient contact surfaces should 555237 Page 15 of 17 555237 05/03/2019 San Gabriel Valley Medical Ctr D/P Snf 438 W. Las Tunas Drive San Gabriel, CA 91776

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some be sanitize, including but not limited to bedside table, phone, call button, IV pole handles, low ledges, light switches, and door knobs. Wipe stains and spots from walls and other vertical surfaces. The policy indicated that the resident's bathroom should be included in the cleaning process. d. On 4/30/19 at 9:20 a.m., in the presence of CNA 4, HK 2 and HK 3, a live cockroach was observed inside Resident 39's closet. During a concurrent interview, CNA 4, HK 2 and HK 3 stated they saw the roach and HK 3 killed the roach and threw the roach in the garbage can inside the room (room [ROOM NUMBER]). 555237 Page 16 of 17 555237 05/03/2019 San Gabriel Valley Medical Ctr D/P Snf 438 W. Las Tunas Drive San Gabriel, CA 91776

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the shower head was in good repair in one of 13 resident shared bathrooms. This deficient practice had a potential for hazard due to pooling of water on the floor. Findings: During an observation on 4/30/19 at 10:20 a.m., room [ROOM NUMBER] and room [ROOM NUMBER] shared bath/toilet, there was a pool of water observed on the floor. The shower head in the bathroom was leaking. During a concurrent observation and interview on 4/30/19 at 1:48 p.m., in the presence of Housekeeper 2 (HK 2) and Certified Nurse Assistant 4 (CNA 4), the same observations were verified. HK 2 stated he could not turn off the leaking shower head. 555237 Page 17 of 17