Health inspection·November 16, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that the call light (device used by residents to call staff) was within reach for one of 19 sampled residents (Resident 75). The call light was observed on the floor, out of reach (more than the arm's length) of Resident 75. Residents Affected - Few This failure had the potential to put Resident 75 at risk for fall that could lead to a serious injury and/ or death. Findings: A record review of Resident 75's face sheet (admission records) indicated Resident 75 was admitted in the facility on 3/11/2023 with admitting diagnoses of generalized muscle weakness (weakness of the muscle that affects the entire body), unsteadiness of the feet, and history of falls. A review of Resident 75's Minimum Data Set (MDS - a standardized assessment tool that measures the health status in nursing home residents), dated 9/1/2023, indicated, Resident 75 requires assistance with activities of daily living, including bed mobility (how resident moves while in bed such as turning from side to side), transferring, walking, dressing (how resident puts on clothing, including footwear), eating, toileting, and personal hygiene. A review of Resident 75's care plan (document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) titled, Falls, dated 9/26/2023, indicated Resident 75 is at risk for falls. The care plan also indicated the resident's call light should be kept within reach. During a concurrent observation and interview on 11/13/2023 at 8:56 AM inside Resident 75's room, Resident 75 was sitting on the right side of the bed, and near the foot of the bed. Resident 75 stated she needed assistance from the facility staff but cannot find her call light to alert the staff. The resident's call light was observed on the floor, on the left side of the bed, and near the head of the bed. During an interview on 11/13/2023 at 9:00 AM inside Resident 75's room with Certified Nursing Assistant (CNA) 4, CNA 4 was called to the room by the surveyor to assist Resident 75. CNA 4 stated the call light is on the floor and is not accessible and within the reach of Resident 75. CNA 4 stated the call light should be close and within the resident's reach. During an interview on 11/13/2023 at 9:52 AM with Licensed Vocational Nurse (LVN) 5, LVN 5 stated Resident 75 needs to have their call light within reach to call for assistance. LVN 5 stated Resident 75 is a fall risk and can suffer an accident if staff fail to assist the resident when resident needed assistance and was unable to call Page 1 of 18 555272 555272 11/16/2023 Atherton Baptist Home 214 South Atlantic Blvd. Alhambra, CA 91801

F 0558 the facility staff. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy titled, Answering the Call Light, revised 9/2022, indicated the facility is to ensure that the call light is accessible to the resident when in bed to ensure timely responses to the resident's needs. Residents Affected - Few 555272 Page 2 of 18 555272 11/16/2023 Atherton Baptist Home 214 South Atlantic Blvd. Alhambra, CA 91801

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were provided a homelike environment for three of 19 sampled residents (Resident 53, Resident 76, and Resident 57) by failing to provide a working wall clock with the correct time. This deficient practice had the potential to negatively impact the resident's quality of life and further confuse the residents. Findings: A review of Resident 53's admission record indicated Resident 53 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm (another term for a cancerous tumor) of unspecified site of right female breast, muscle weakness and difficulty in walking. A review of Resident 53's History and Physical dated 12/14/2022 indicated Resident 53 does not have the capacity to understand and make decisions. A review of Resident 53's Minimum Data Set (MDS - a comprehensive assessment and screening tool) dated 8/23/2023, indicated Resident 53 needs extensive assistance with a one-person assistance for bed mobility (ability to move around in bed), transfers, dressing, toilet use and personal hygiene. During an observation on 11/13/2023, at 9:52 AM, the wall clock in Resident 53's room indicated the time of 2:43 and the seconds hand was stuck on the 44 second indicator. During an interview on 11/13/2023 11:35 AM, Licensed Vocational Nurse (LVN) 5 stated, the wall clock in Resident 53's room was 2:43 and was not the correct time. A review of Resident 76's admission record indicated Resident 76 was admitted to the facility on [DATE] with diagnoses that included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), muscle weakness and generalized weakness. A review of Resident 76's History and Physical, dated 8/15/2023, indicated Resident 76 does not have the capacity to understand and make decisions. A review of Resident 76's MDS dated [DATE], indicated Resident 76 needs extensive assistance with a one-person assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. A review of Resident 57's admission record indicated Resident 57 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder (persistent and excessive worry that interferes with daily activities), age related physical debility, muscle weakness, difficulty in walking. A review of Resident 57's History and Physical, dated 5/24/2023, indicated Resident 57 can make needs known but can not make medical decisions. A review of Resident 57's MDS, dated [DATE], indicated Resident 57 needs extensive assistance with 555272 Page 3 of 18 555272 11/16/2023 Atherton Baptist Home 214 South Atlantic Blvd. Alhambra, CA 91801

F 0584 a one-person assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. Level of Harm - Minimal harm or potential for actual harm During an observation on 11/13/2023 at 9:55 AM the wall clock in Resident 76 and 57's room indicated the time of 9:43 and the seconds hand was stuck on the 25 second indicator. Residents Affected - Few During a concurrent observation in Resident 53's room and interview on 11/13/2023 at 11:27 AM, Resident 53's wall clock still read 2:43 and the seconds hand was stopped at the 44-second mark. LVN 5 stated, the wall clock had low battery that is why it was not giving the correct time. LVN 5 also stated, all wall clocks should be in good working order for residents to tell the time correctly. LVN 5 stated, the facility is the resident's home, and the residents needed the correct time in their clock because the wrong time could further confuse the residents. During a concurrent interview with LVN 5 on 11/14/2023 9:52 AM, LVN 5 stated most of the residents in the facility need frequent reorientation and that LVN 5 uses wall clocks to re-orient residents to time. LVN 5 stated, reorienting residents is important to do for the residents' well-being. During an interview with Certified Nurse Assistant (CNA) 3 on 11/15/2023 3:07 PM, CNA 3 stated a resident can get confused, especially at night. CNA 3 stated Resident 53 is forgetful at times. CNA 3 also stated the wall clock is an equipment used to show the residents the current time. CNA 3 stated, it is important to have the correct time in the clock because residents use it to know the time. Having the wrong time can add to the confusion of the residents. Can 3 further stated, Residents 76 and 57 are alert and uses the wall clock to know the time of the day. A review of the facility Policy & Procedure titled, Homelike Environment, revised 2/2021 indicated, Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. 555272 Page 4 of 18 555272 11/16/2023 Atherton Baptist Home 214 South Atlantic Blvd. Alhambra, CA 91801

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a resident-specific care plan addressing the Preadmission Screening and Resident Review II (PASRR - a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are appropriately placed in nursing homes for long term care) recommendations for one of 19 sampled residents (Resident 27). This deficient practice had the potential for Resident 27 to not get the appropriate care and interventions for her mental needs. Findings: A review of Resident 27's Profile Face Sheet (admission record) indicated Resident 27 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included dementia (a brain disorder that results in memory loss, poor judgment and confusion), psychosis (mental disorder characterized by a disconnection from reality), and anemia (condition where the blood does not carry enough oxygen to the rest of the body). A record review of Resident 27's Preadmission Screening and Resident Review (PASRR - a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) Level 1 Screening result dated 5/12/2023 indicated Resident 27 was positive for suspected MI (mental illness) and required a Level II Mental Health Evaluation Referral. A record review of Resident 27's PASRR Individualized Determination Report, dated 5/17/2023, indicated Resident 27 had a significant medical condition with mental stressors and required nursing care. The recommendation for mental health rehabilitation activity included therapeutic community, dance, music, art, exercise, leisure, recreation, orientation, education, and/or skill building activities. The report also indicated the recommendation for supportive services included interactions with facility staff that encourage problem solving, socialization, reality orientation or focus on therapeutic goals. A review of Resident 27's Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 9/15/2023, indicated Resident 27 had severely impaired cognition (thought process and ability to reason or make decisions) for daily decision making. The MDS indicated Resident 27 needed extensive assistance (resident involved in activity, staff provides weight bearing support) with one-person physical assist for bed mobility, transfer, locomotion (movement or the ability to move from one place to another) off unit, dressing, eating, toilet use, and personal hygiene and needed limited assistance (resident highly involved in activity, staff provide guided maneuvering of limbs or other non-weight-bearing assistance) with one-person assist physical assist for locomotion on unit. Resident 27 needed supervision with one-person assist with walk in room and corridor. During an interview with the Director of Nursing (DON), on 11/16/2023, at 8:53 AM, the DON stated PASSR II recommendations are given to the Care Plan Coordinator (CPC) once it is received so CPC can add in the resident's care plan. During a concurrent interview and record review on 11/16/2023, at 9:01 AM, with the CPC, Resident 555272 Page 5 of 18 555272 11/16/2023 Atherton Baptist Home 214 South Atlantic Blvd. Alhambra, CA 91801

F 0656 Level of Harm - Minimal harm or potential for actual harm 27's care plan dated 10/3/2023 under the category Activities was reviewed. CPC stated Resident 27 did not have a specific care plan for PASRR II recommendations. CPC stated Resident 27's Activities care plan intervention were generic and not specific to the resident's condition/ wants and like and the interventions were generic. CPC stated every resident has different wants and likes which should be reflected in the care plan interventions. Residents Affected - Few During an interview with the DON on 11/16/2023, at 2:29 PM, the DON stated, all PASSR II recommendations need to be incorporated in the resident's care plan. The DON stated it is important for Resident 27 to have an individualized care plan because of her medical history. The DON stated it is important to have care plan with PASSR II recommendations because this would provide the staff with information on how to address the individual needs of Resident 27. A review of the facility's policy and procedure (P&P) titled, Goals and Objectives, Care Plans, revised on 4/2009, the P&P indicated, Care Plans shall incorporate goals and objectives that lead to the Resident's highest obtainable level of independence. The P&P also indicated, Care plan goals and objectives are derived from information contained in the resident's comprehensive assessment and are resident oriented; are behaviorally stated; are measurable; and contain timetables to meet the resident's needs in accordance with the comprehensive assessment. 555272 Page 6 of 18 555272 11/16/2023 Atherton Baptist Home 214 South Atlantic Blvd. Alhambra, CA 91801

F 0657 Level of Harm - Minimal harm or potential for actual harm 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** Cross Reference with F692 and F726 Residents Affected - Few Based on interview and record review, the facility failed to review and revise a care plan to address a significant weight loss (weight loss of five percent in one month) for one of 19 sampled residents (Resident 35). This deficient practice placed Resident 35 at risk for further decline in nutritional status and continued weight loss, which could result in serious harm. Findings: A review of Resident 35's admission Record indicated Resident 35 was admitted to the facility on [DATE], with diagnoses of chronic obstructive pulmonary disease (COPD- disease that causes obstructed airflow from the lungs), thyrotoxicosis (an abnormal high blood levels of triiodothyronine (T3) and thyroxine (T4) which are your body's thyroid hormones), and hypertension (high blood pressure). A review of the Resident 35's History and Physical (H&P, the initial clinical evaluation and examination of the patient), dated 7/20/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 35's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 10/9/2023, indicated Resident 35 was not cognitively (mental action or process of acquiring knowledge and understanding) intact for daily decision making. The MDS indicated Resident 35 required supervision or touching assistance for eating and oral hygiene. The MDS also indicated Resident 35 required partial/moderate assistance (helper does less than half the effort) for toilet hygiene, shower/bathe, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene (practices conducive to maintaining health and preventing disease, especially through cleanliness). The MDS also indicated Resident 35 required set up or clean-up assistance for toilet transfer and shower transfer. A review of Resident 35's Weight Tracking System indicated as follows: - On 10/12/2023, the resident's weight was 127 pounds (lbs., unit of measurement). - On 11/03/2023, the resident's weight was 123 lbs. - On 11/11/2023, the resident's weight was 120 lbs., (5.51% weight loss in 30 days). A review of Resident 35's Care Plan titled, Nutrition, dated 10/23/2023, indicated Resident 35 had a potential for alteration in nutrition. The care plan did not reflect Resident 35's actual weight loss of 5.5% on 11/11/2023. During a record review of Resident 35's weight, Care Plan, Nurses and Dietary notes and concurrent interview and on 11/15/2023 at 11:30 AM with LVN 2, LVN 2 stated Resident 35 had a weight loss of 5.51 %. LVN 2 stated nurses needed to notify the doctor right away for a weight loss of more than 5 555272 Page 7 of 18 555272 11/16/2023 Atherton Baptist Home 214 South Atlantic Blvd. Alhambra, CA 91801

F 0657 Level of Harm - Minimal harm or potential for actual harm lbs. in one month. LVN 2 stated there were no documentation indicating the resident's doctor was notified from 11/11/2023 to 11/15/2023 regarding Resident 35's weight loss of 5.5 %. LVN 2 stated Resident 35 experienced a change in condition when he lost 7 lbs. LVN 2 stated when Resident 35 lost 7 lbs. in one month, the doctor was not and should have been notified. LVN 2 stated Resident 35's care plan was not and should have been updated due to weight loss. Residents Affected - Few During an interview on 11/15/2023 at 2:45 PM with the Director of Nursing (DON), the DON stated a weight loss of 5% is considered a change of condition. The DON stated the licensed nurses or the dietician needed to notify the doctor right away and find out the underlying cause for the weight loss. The DON stated the resident's weight loss may be due to a mental issue, poor appetite, and may require medication, dietary, and nursing interventions. The DON stated the Care Plan Coordinator (CPC) and Registered Dietician (RD) were in charge of updating the nutrition care plan. The DON stated Resident 35's care plan for nutrition needed to be updated with the addition of new interventions due to the weight loss. A review of the facility's policy and procedure titled, Goals and Objectives, Care Plans, revised 4/2009, indicated goals and objectives are reviewed and/or revised when there has been a significant change in the resident's condition. 555272 Page 8 of 18 555272 11/16/2023 Atherton Baptist Home 214 South Atlantic Blvd. Alhambra, CA 91801

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Cross Reference with F657 and F726 Residents Affected - Few Based on interview and record review, the facility failed to maintain acceptable parameters of nutritional status for one of one sampled resident (Resident 35) in accordance with the facility policy by failing to: a. Notify the resident's physician of Resident 35's significant weight loss (weight loss of five percent in one month) of 5.5 percent (%) in a month . b. Conduct an Interdisciplinary Team Nutrition Alert meeting (a systematic and interdisciplinary approach to identify, track, intervene, monitor, and follow-up with residents at high risk for significant weight changes, dehydration (harmful reduction in the amount of water in the body), and any other nutrition-related concerns) to address Resident 35's significant weight loss. c. Obtain and implement interventions to prevent further weight loss. This deficient practice placed Resident 35 at risk for further decline in nutritional status, which could result in harm. Findings: A review of Resident 35's admission Record indicated Resident 35 was admitted to the facility on [DATE], with diagnoses of chronic obstructive pulmonary disease (COPD- disease that causes obstructed airflow from the lungs), thyrotoxicosis (an abnormal high blood levels of triiodothyronine (T3) and thyroxine(T4) which are your body's thyroid hormones), and hypertension (high blood pressure). A review of the Resident 35's History and Physical (H&P, the initial clinical evaluation and examination of the patient), dated 7/20/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 35's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 10/9/2023, indicated Resident 35 was not cognitively (mental action or process of acquiring knowledge and understanding) intact for daily decision making. The MDS indicated Resident 35 required supervision or touching assistance for eating and oral hygiene. The MDS also indicated Resident 35 required partial/moderate assistance (helper does less than half the effort) for toilet hygiene, shower/bathe, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene (practices conducive to maintaining health and preventing disease, especially through cleanliness). The MDS also indicated Resident 35 required set up or clean-up assistance for toilet transfer and shower transfer. A review of Resident 35's Weight Tracking System indicated as follows: - On 10/12/2023, the resident's weight was 127 pounds (lbs., unit of measurement). - On 11/03/2023, the resident's weight was 123 lbs. 555272 Page 9 of 18 555272 11/16/2023 Atherton Baptist Home 214 South Atlantic Blvd. Alhambra, CA 91801

F 0692 - On 11/11/2023, the resident's weight was 120 lbs., (-5.51% weight loss in 30 days). Level of Harm - Minimal harm or potential for actual harm A review of Resident 35's Care Plan titled, Nutrition, dated 10/23/2023, indicated to monitor weight and notify the doctor of significant weight changes. The care plan also indicated to notify the doctor of significant loss of appetite or meal refusals. Residents Affected - Few A review of Resident 35's Daily Charting for Eating Total % of Intake indicated as follows: - On 11/1/2023, the resident consumed 26-50% for dinner. - On 11/7/2023, the resident consumed 0% for lunch. - On 11/8/2023, the resident consumed 25% or less for lunch and 0% for dinner. - On 11/9/2023, the resident consumed 25% or less for lunch and 25% or less for dinner. - On 11/11/2023, the resident consumed 26-50% for dinner. - On 11/12/2023, the resident consumed 26-50% for lunch and 26-50% for dinner. - On 11/14/2023, the resident consumed 25% or less for lunch. - On 11/15/2023, the resident consumed 25% or less for lunch and 26-50% for dinner. A review of the Interdisciplinary Notes (nursing notes) for the month of November 2023, did not indicate the doctor was notified of Resident 35'weight loss of 5.5%. A review of the Dietary Notes for the month of November 2023, did not indicate the doctor was notified of Resident 35's 5.5% weight loss. During a concurrent record review of Resident 35's Weight Tracking System and Nursing Notes and an interview on 11/15/2023 at 11:22 AM with the Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 35 had experienced a loss of appetite since he recently lost his wife last month who was also his roommate. LVN 1 stated Resident 35 was not eating enough and needed encouraging during mealtimes. LVN 1 stated Resident 35 lost seven (7) lbs. from 10/12/2023 to 11/11/2023. LVN 1 stated a 7 lb. weight loss was significant. LVN 1 stated when residents have a weight loss of three (3) to five (5) lbs., the licensed nurses needed to contact the doctor right away. LVN 1 stated there was no documented evidence the doctor was contacted to obtain interventions to address and prevent Resident 35 from further weight loss. During an interview on 11/15/2023 at 12:27 PM with the Assistant Director of Dining Services (ADDS), the ADDS stated a 5% weight loss within 30 days is considered a significant weight loss. The ADDS stated when residents have a 5% weight loss, a nutrition alert would be done, and a meeting would be conducted to address the weight loss by providing nutritional interventions. The ADDS stated a nutrition alert meeting was not done this week since the Registered Dietician (RD) was on vacation. The ADDS stated nutrition alerts were done weekly. The ADDS stated the last Nutrition Alert Meeting Minutes was done on 11/7/2023. During an interview on 11/15/2023 at 2:45 PM with the Director of Nursing (DON), the DON stated a 555272 Page 10 of 18 555272 11/16/2023 Atherton Baptist Home 214 South Atlantic Blvd. Alhambra, CA 91801

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few weight loss of 5% is considered a change of condition. The DON stated the licensed nurses or the dietician needed to notify the doctor right away and find out the underlying cause for the weight loss. The DON stated the resident's weight loss may be due to a mental issue, poor appetite, and may require medication, dietary, and nursing interventions. The DON stated the Care Plan Coordinator (CPC) and Registered Dietician (RD) were in charge of updating the nutrition care plan. The DON stated Resident 35's care plan for nutrition needed to be updated with the addition of new interventions due to the weight loss. During an interview on 11/16/2023 at 8:15 AM with the Director of Staff Development (DSD), the DSD stated when the Certified Nursing Assistant (CNA - general) or Restorative Nursing Aide (RNA - general) was made aware of a resident weight loss of more than 5 lbs. in one month, the CNA or RNA need to notify the charge nurse and dietician. The DSD stated the licensed nurses would need to document the weight loss and notify the doctor right away. The DSD also stated the CNA/RNA would need to notify the charge nurse so the charge nurse could contact the doctor to try to prevent continued weight loss, find other factors contributing to the weight loss, and order any necessary laboratory work. During an interview on 11/16/2023 at 9:21 AM with the CPC, the CPC stated meetings for significant weight loss were done weekly on Tuesdays. The CPC stated, We did not have the weekly weight loss meeting last Tuesday (11/14/2023) since the RD was on vacation. The CPC stated Resident 35's care plan titled, Nutrition, indicated to monitor weight and notify MD of significant changes. A review of the facility's policy and procedure titled, Nutrition Alert/High Risk, revised 1/2023, indicated unplanned significant weight loss of 5% in one month qualifies a resident for Nutrition Alert/High Risk. Regularly scheduled Nutrition Alert/High Risk meetings are held on a weekly schedule to review all identified residents on the Nutrition Alert/High Risk. A review of the facility's policy and procedure titled, Nutrition (Impaired)/Unplanned Weight Loss, revised 9/2017, indicated the staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. A review of the facility's policy and procedure titled, Change in a Resident's Condition or Status, revised 2/2021, indicated the nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical condition. The nurse will also notify the resident's attending physician when there has been a specific instruction to notify the physician of changes in the resident's condition. Notifications to the physician will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. 555272 Page 11 of 18 555272 11/16/2023 Atherton Baptist Home 214 South Atlantic Blvd. Alhambra, CA 91801

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. Cross Reference with F657 and F726 Based on interview and record review, the facility failed to ensure Restorative Nursing Aide 1 (RNA 1) had the appropriate skill sets and proficiencies to provide nursing services for resident in response to a change in condition of significant weight loss (five percent weight loss in one month) for one of 19 sampled residents (Resident 35). This deficient practice had the potential to place Resident 35 and other residents who may be at risk for decline in nutritional status, suffer from unplanned weight loss. Findings: A review of Resident 35's Weight Tracking System indicated as follows: - On 10/12/2023, the resident's weight was 127 pounds (lbs., unit of measurement). - On 11/03/2023, the resident's weight was 123 lbs. - On 11/11/2023, the resident's weight was 120 lbs., (-5.51% weight loss in 30 days). During a concurrent record review of Resident 35's Nursing Notes and interview with Licensed Vocational Nurse 1 (LVN 1) on 11/15/2023 at 11:22 AM, LVN 1 stated Resident 35 lost seven (7) lbs. from 10/12/2023 to 11/11/2023. LVN 1 stated a 7 lb. weight loss was significant. LVN 1 stated when residents have a weight loss of three (3) to five (5) lbs. they needed to contact the doctor right away. LVN 1 stated there was no documented evidence that the doctor was contacted for Resident 35's weight loss to obtain orders for further interventions to prevent weight loss. During a concurrent record review of Resident 35's weight and interview on 11/15/2023 at 11:30 AM with LVN 2, LVN 2 stated RNA 1 was responsible for taking Resident 35's weight and informing the Registered Dietician (RD) and licensed nurse of weight loss. During a concurrent interview and record review of Resident 35's Weight Record with RNA 1, RNA 1 stated Resident 35 was placed on weekly weights on 11/11/2023. RNA 1 stated Resident 35's weight was 120 lbs. on 11/11/2023. RNA 1 stated Resident 35's weight would be taken weekly after 11/11/2023 and his weight would be compared to the weights taken the following weeks. RNA 1 stated she disregarded all previous weights prior to the weekly weight started on 11/11/2023. RNA 1 stated she needed to report to the licensed nurses when residents have a weight loss of 5 lbs or more. RNA 1 stated she did not report Resident 35's weight loss of 7 lbs. from 10/12/2023 to 11/11/2023. A review of the facility's policy and procedure titled, Restorative CNA Position Description, dated 3/2011, indicated the RNA was to complete weekly and monthly weights for residents and report unusual weight changes to the Charge Nurse. A review of the facility's policy and procedure titled, Nutrition (Impaired)/Unplanned Weight Loss, revised 9/2017, indicated the staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. 555272 Page 12 of 18 555272 11/16/2023 Atherton Baptist Home 214 South Atlantic Blvd. Alhambra, CA 91801

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor the effectiveness of psychotropic medications (a type of medication that affects brain activities associated with mental processes and behavior) for one of five sampled residents (Resident 76). This failure had the potential to put the resident at risk for not receiving the appropriate treatment. Findings: A review of Resident 76's face sheet (admission record) indicated the resident was admitted on [DATE] with admitting diagnoses of dementia (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), psychosis (mental disorder that affects how a person thinks, feels, and behaves), and cognitive communication deficit (loss of ability to communicate). A review of Resident 76's Minimum Data Set (MDS - a standardized assessment tool that measures health status in nursing home residents), dated 9/1/2023, indicated the resident has impaired cognition (an individual's ability to process thoughts and the ability to perform the various mental activities most closely associated with learning and problem solving) and requires extensive assistance with bed mobility and activities of daily living. A review of Resident 76's physician's orders, dated 7/17/2023, indicated the resident is to be given 50 milligrams (mg) of Seroquel (a medication that treats several kinds of mental health conditions), at bedtime, for psychosis manifested by voicing of being afraid causing the resident to constantly get up unassisted or unsafely to go somewhere. A review of Resident 76's physician's orders, dated 7/18/2023, indicated the resident is to be given 25 mg of Seroquel, once daily, for psychosis manifested by voicing of being afraid causing the resident to constantly get up unassisted or unsafely to go somewhere. A review of Resident 76's titled medication administration record (MAR), did not indicate documentation from 7/18/2023 to 11/14/2023 that staff have been monitoring Resident 76's behavior of voicing of being afraid. During a concurrent interview and record review of Resident 76's MAR for 7/2023 to 11/2023, on 11/15/2023 at 8:44 AM, Licensed Vocational Nurse (LVN) 2 stated, there was no documented evidence in the resident's MAR that the resident's behavior of voicing of being afraid was monitored and documented. LVN 2 stated, staff have not been monitoring Resident 76's behavior of voicing of being afraid and that monitoring should have been done to ensure the effectiveness of Seroquel and that residents receive the correct treatment for their medical condition. During an interview on 11/15/2023 at 10:40 AM with Certified Nursing Assistant (CNA) 4, CNA 4 stated that Resident 76 did not verbalize to the staff before attempting to get up. CNA 4 stated that she has never recalled the resident ever voicing out ever being afraid. 555272 Page 13 of 18 555272 11/16/2023 Atherton Baptist Home 214 South Atlantic Blvd. Alhambra, CA 91801

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 11/15/2023 at 3:07 PM with CNA 3, CNA 3 stated that Resident 76 has not voiced out ever being afraid. During an interview on 11/15/2023 at 3:14 PM with LVN 5, LVN 5 stated, she has never heard Resident 76 voicing that the resident is afraid since the medication was ordered on 7/18/2023. LVN 5 stated, if licensed nurses were able to monitor and document Resident 76's behavior of voicing of being afraid, then the licensed nurses could have known that there was no behavior noted by licensed nurses and other CNAs and that they would have been able to notify the physician to check if the medication can be reduced or is still necessary. During an interview on 11/15/2023 at 10:45 AM with the Care Plan Coordinator (CPC), CPC stated, residents receiving psychotropic medications have care plans (document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) that address the plan to monitor each behavior associated with each psychotropic medication. CPC stated that behavior monitoring every shift is done to assess if psychotropic medications are still necessary and for the gradual dose reduction (the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) of medications. During an interview on 11/15/2023 at 2:26 PM with the Director of Nursing (DON), the DON stated, monitoring of Resident 76's behavior is necessary to ensure the effectiveness of Resident 76's Seroquel and to assess if the medication is still needed or if the dose can be reduced according to the resident's needs. A review of the facility's policy titled, Psychotropic Medication Use, dated 7/2022, indicated that psychotropic medication management includes adequate monitoring for the effectiveness of the medication. 555272 Page 14 of 18 555272 11/16/2023 Atherton Baptist Home 214 South Atlantic Blvd. Alhambra, CA 91801

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. Based on observation, interview, and record review, the facility failed to: 1. Label food in the kitchen with item name, opened and expiration date, and discard expired food as indicated on the facility's policy and procedure. a. Two opened packages of bread (English muffin and white loaf bread) in the working station were not labeled to indicate date food items were opened. b. Three trays of blueberry dessert, cornbread, and chocolate cake placed on a rack in the dry storage room were not labeled with item name and date when they were made. c. An opened box of cinnamon streusel coffee mix and corn flakes crumbs were not labeled to indicate date when it was opened. d. A container with brown grains in the dry storage did not have a label to indicate the food item. e. Four packages of mandarin orange sauce were not labeled to indicate expiration date. f. A package of chocolate chip cookies was not labeled to indicate expiration date. g. A tray of expired left over Boston cream pie dated 6/23/2023 was not discarded. 2. Ice cream freezer log did not have a documentation for temperatures taken from 11/1/2023 to 11/13/2023 and Freezer 1 has no temperature documented for 11/13/2023. 3. The facility failed to follow infection control measures in the kitchen when: a. A personal tumbler with tea was in Freezer 1. b. An open box of gloves was placed on top of food container and tray of disposable utensils. c. A book and opened package of table napkins were in the main freezer storage. These deficient practices had the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness ([food poisoning] with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever) and can lead to other serious medical complications and hospitalization. Findings: 1. During a concurrent observation in the kitchen and interview with the Dining Services Director (DND) and Kitchen Staff 2 (KS 2) on 11/13/2023 at 8:45 AM, there was no label on the two opened packages of bread (English muffin and white loaf bread) in the working station. DND stated, We label the bread after opening the bag and before putting it back in the refrigerator. KS 2 stated, No, I do not have label on the breads. Are we supposed to label them? 555272 Page 15 of 18 555272 11/16/2023 Atherton Baptist Home 214 South Atlantic Blvd. Alhambra, CA 91801

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation in the kitchen and interview with the DND on 11/13/2023 at 8:53 AM, there were no labels to include the date and name of the item of the three trays of blueberry dessert, cornbread, and chocolate cake placed on a rack in the dry storage room were made. DND stated, The food trays needed to be labeled with the food item and date it was prepared every time. During a concurrent observation in the dry storage room and interview with the DND on 11/13/2023 at 8:59 AM, in the dry storage were the following: a. An opened box of cinnamon streusel coffee mix and corn flakes crumbs without a label to indicate when it was opened. b. A container with brown grains did not have a label to indicate the food item. DND stated, he could not verify what was inside the container because it did not have a label to identify the food item. The DND stated the container should have been labeled with the food item. DND stated the opened box of cinnamon streusel coffee mix and corn flakes crumbs was not and should have an open date label. During a concurrent observation in the kitchen and interview with the DND on 11/15/2023 at 11:30 AM, there was no label to indicate the date when the milk container inside the refrigerator was opened. DND stated, the kitchen staff should label the milk container with the date it was opened. During a concurrent observation in the main freezer storage and interview with the DND on 11/15/2023 at 11:38 AM, in the main freezer storage were the following: a. There were four packages of mandarin orange sauce with no expiration date. b. A package of chocolate chip cookies with no expiration date. c. A tray of expired left over Boston cream pie dated 6/23/2023. DND stated all food items stated the food items were supposed to be labeled with item name and dated with the open and used by date. A review of the facility's policy and procedure titled, Food and Supply Storage, dated 1/2023, indicated all food, non- food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Cover, label and date unused portions and open packages. Discard food past the use - by or expiration date. Dry storage store foods in their original packages. Foods that must be opened must be stored in NSF approved containers that have tight - fitting lids. Label both the bin and the lid. Hang scoop. Scoops may be stored in bins on a scoop holder. The food level must be no closer than one inch below the handle of the scoop. 2. During a concurrent observation in the kitchen and interview with the Kitchen Staff 1(KS 1) on 11/13/2023 at 8:39 AM, Freezer 1 had no temperature recorded on the freezer log on 11/13/2023. KS 1 stated, There was no thermometer inside the freezer that is why there is no temperature recorded for Freezer 1 this morning. During a concurrent observation in the kitchen and interview with the DND on 11/13/2023 at 8:49 AM, 555272 Page 16 of 18 555272 11/16/2023 Atherton Baptist Home 214 South Atlantic Blvd. Alhambra, CA 91801

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the ice cream freezer log did not have a documentation for temperatures taken from 11/1/2023 to 11/13/2023. DND stated, The staff should be checking the freezer temperature and log it in every shift, in the morning and in the afternoon. A review of the facility's policy and procedure titled, Cold Storage Temperatures, dated 1/2023, indicated temperatures of food storage areas and cold food vendors are monitored and action is taken to maintain temperatures within ranges recommended by licensing and surveying agencies. Each refrigerated storage unit shall have an independent thermometer in addition to the built in thermometer. The thermometer shall be placed in the warmest part of the unit, typically near the door, readily accessible and placed so that it is not in the direct line of the air stream from the unit's fan. Supervisor each morning at opening and evening at closing, record temperatures of each storage unit, initial each entry. 3. During a concurrent observation and interview with the DND on 11/15/2023 at 11:27 AM, There was a personal tumbler with tea in Freezer 1. DND stated, Personal item should not be in the freezer. During a concurrent observation and interview with the DND on 11/15/2023 at 11:32 AM, there was a set of keys left in the small delivery cart containing clean plates. DND stated the keys were for the doors in the kitchen and it should not have been left in the delivery cart. DND stated, The person in charge in the morning should have it on them all the time. During a concurrent observation and interview with the DND on 11/15/2023 at 11:35 AM, an opened box of gloves was placed on top of the tray of the disposable utensils. DND stated, It should not be there. During a concurrent observation in the freezer storage and interview with the DND on 11/15/23 11:48 AM, there was a book and opened package of table napkins in the main freezer storage. DND stated, the items should not have been stored there. A review of the facility's policy and procedure titled, Associate Security Policies for Department, revised 1/2023, indicated jackets, sweaters, handbags, cell phones and other personal items are to be stored in appropriate locations as defined by management. These items must not be stored in food production or service areas. Department keys are never loaned or borrowed. All keys should remain on the person to which they are assigned. Any extra keys should be secured in the unit safe. 555272 Page 17 of 18 555272 11/16/2023 Atherton Baptist Home 214 South Atlantic Blvd. Alhambra, CA 91801

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 standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for one of one sampled resident (Resident 2) when the oxygen tubing observed touching the floor. Residents Affected - Few This deficient practice had the potential to spread respiratory infection to Resident 2. Findings: A review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE]. Resident 2's diagnoses included chronic obstructive pulmonary disease (COPD) is a chronic inflammatory lung disease that causes obstructed airflow from the lungs, acute respiratory failure (occurs when you do not have enough oxygen in your blood) with hypercapnic (happens when you have too much carbon dioxide in your blood) and chronic bronchitis (is inflammation and irritation of the bronchial tubes[these tubes are the airways that carry air to and from the air sacs in your lungs]). A review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 10/26/2023, indicated Resident 2 has intact cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. Resident 2 total dependent (helper does all the effort. Resident does none of the effort to complete the activity) in toileting hygiene, shower/bathe self, upper/lower body dressing, and putting on/taking off footwear. During an observation inside Resident 2's room on 11/13/2023 at 10:16 AM, Resident 2 was receiving oxygen at two (2) liters per minute (lpm) via nasal cannula with humidifier. The oxygen tubing was observed touching the floor. During a concurrent observation in Resident 2's room and interview with Licensed Vocational Nurse (LVN) 1 on 11/13/2023 at 10:17 AM, LVN 1 stated, Oxygen tubing should not be touching the floor. We stick it inside the bag located at the back of the oxygen machine because of infection control. Bacteria or germs will go into Resident's nose, eyes, mouth and spread the infection. If the oxygen was touching the floor, we have to replace it right away. During a concurrent observation in Resident 2's room and interview with LVN 1 on 11/13/23 at 10:23 AM, LVN 1 stated, The oxygen tubing was touching the floor. It was contaminated, so to be safe, we have to change it immediately. A review of facility's policy and procedure (P&P) titled, Departmental (Respiratory Therapy)- Prevention of Infection, dated 11/2011, P&P indicated to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. 555272 Page 18 of 18