Health inspection·October 8, 2023

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop an individualized baseline care plan within 48 hours of admission to reflect the assessment and meet the immediate needs that included interventions to address hearing for one of 12 sampled residents (Resident 189). This deficient practice had the potential to negatively affect the well-being and the delivery of necessary care and services for Resident 189. Findings: A review of Resident 189's Face Sheet indicated Resident 189 was admitted on [DATE] with diagnoses that included malignant neoplasm of lower lobe left lung (cancerous abnormal growth of tissue in the lungs), chronic obstructive pulmonary disease (COPD-a lung disease characterized by long term poor airflow), asthma (swelling and narrowing of the airway making it hard to breathe), and dependence of supplemental oxygen. A review of Resident 189's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 9/29/23, indicated Resident 189 had severely impaired cognition (thought process and ability to reason or make decisions) for daily decision making and required extensive assistance (resident involved in activity, staff provide weight-bearing support) with one-persons physical assistance with bed mobility, transfer, walk in room/corridor, locomotion (movement or the ability to move from one place to another) on/off unit, dressing, eating, toilet use, and personal hygiene. Resident had adequate ability to hear (no difficulty in normal conversation, social interaction, and listening to TV) with hearing aid or hearing appliance if normally used. A review of Resident 189's Nursing admission Assessment, dated 9/25/23, indicated that Resident 189 had poor hearing and used a hearing aid on bilateral ears. During a review of Resident 189's Social Service Assessment, dated 9/27/23, Resident 189's physical status for hearing indicated to adjust tone of voice. It also indicated that Resident 189's family provided hearing aids but report Resident had refused to put it on. During a concurrent observation in Resident 189's room and interview with Resident 189 on 10/6/23, at 7:01 PM, Resident 189 was sitting in bed watching television. When asked a question, Resident 189 placed her right hand next to her right ear and stated she couldn't hear. Resident 189 stated she had hearing aids but did not want to wear them. Resident 189 unable to answer when asked how she was doing and what show she was watching on television. Page 1 of 16 555429 555429 10/08/2023 Villa Gardens Health Care Unit 842 East Villa Street Pasadena, CA 91101

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation in Resident 189's room on 10/6/23, at 7:06 PM, Licensed Vocational Nurse (LVN 1) asked Resident 189 if she needed anything else. Resident 189 looked at LVN 1 and did not answer the question. LVN 1 repeated her question and Resident 189 continued to look at her. Resident 188 overheard LVN 1 talking to Resident 189 and stated, She can't hear anything. During a concurrent observation in Resident 189's room and interview with Certified Nursing Assistant (CNA 1) on 10/7/23, at 5:15 PM, CNA 1 asked Resident 189 what she ate for dinner. Resident 189 put her right hand next to her right ear and did not answer the question. CNA 1 spoke louder and closer to Resident 189 and repeated the question to which Resident 189 answered pasta. CNA 1 stated that the staff need to speak louder when talking to Resident 189. CNA 1 stated Resident 189 has hearing aids but she does not want to use it. CNA 1 confirmed Resident 189 is hard of hearing and communicating with her is difficult specially when wearing a surgical mask. During a concurrent interview and record review on 10/7/23, at 5:38 PM, with Social Services Director (SSD), SSD stated Resident 189 had hearing aids but refuses to wear it. SSD stated Resident 189's family informed him that staff needs to adjust the tone of voice when communicating with Resident 189. SSD confirmed that Resident 189 did not have a baseline care plan for hearing. SSD stated it was the licensed nurses and social service's responsibility to initiate and revise a care plan. SSD stated it was important for Resident 189 to have a care plan for hearing so the staff could be on the same page regarding her care. During a review of the facility's policy and procedure titled, Care Planning, revised on February 2018, indicated, An initial care plan will be developed and implemented on admission with a baseline care plan in place within 48 hours of admission and a summary provided to the resident and resident representative if applicable which will include interventions to provide effective and person-centered care that meets professional standards of quality care. 555429 Page 2 of 16 555429 10/08/2023 Villa Gardens Health Care Unit 842 East Villa Street Pasadena, CA 91101

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for one of four sampled residents (Resident 23) by failing to flush in between each medication administered through the gastrostomy tube (G-tube, tube inserted through the abdomen that delivers nutrition directly to the stomach). Residents Affected - Some This deficient practice had the potential for drug-to-drug interactions (a reaction between two or more drugs) and for the resident to be at risk for adverse reactions (an unwanted, uncomfortable, or dangerous effects the drugs/medications may have). Findings: A review of Resident 23's admission Face Sheet (record of admission) indicated the resident was admitted to the facility on [DATE] with a diagnosis of hydrocephalus (buildup of fluid in the hollow places inside the brain) and urinary tract infection (UTI, an infection in any part of the urinary system, the kidney, bladder, or urethra). A review of Resident 23's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 9/5/23, indicated the resident rarely/never made self-understood or understood others and had severe impairment in cognitive skills (relating to the process of acquiring knowledge and understanding). Resident 23 was dependent on staff (full staff performance every time) for transfer, eating, toileting, and personal hygiene. A review of the History and Physical Examination, dated 7/22/23, indicated Resident 23 does not have the capacity to understand and make decisions. On 10/8/23, at 8:15 a.m., during a medication pass (Med Pass) observation, Licensed Vocational Nurse 2 (LVN 2) prepared and administered the following medications for Resident 23 via G-tube: 1. Docusate sodium 50 mg (milligrams-unit of measure) / five (5) ml (milliliters-unit of measure), 10 ml twice a day (BID) for constipation. 2. Duloxetine Hydrochloride (a medication used to treat depression [ mood disorder that causes a persistent feeling of sadness and loss of interest], anxiety [emotion characterized by feelings of tension, worried thoughts and physical changes], and nerve pain) 30ml (milliliters- unit of measure) twice a day for pain management. 3. Folic Acid 1 mg via G-tube daily as supplement. 4. Keppra (a medication used to treat seizures [is a sudden, uncontrolled burst of electrical activity in the brain]) 500 mg/5ml twice a day for seizure prophylaxis (action taken to prevent disease). 5. D-Mannose 1000 mg one (1) tablet daily for urinary tract prophylaxis. 6. Metoprolol Tartrate 12.5 mg 1/2 tablet for hypertension (high blood pressure). LVN 2 administered the six (6) medications via G-tube without flushing in between each medication 555429 Page 3 of 16 555429 10/08/2023 Villa Gardens Health Care Unit 842 East Villa Street Pasadena, CA 91101

F 0658 administered. Level of Harm - Minimal harm or potential for actual harm During an interview, on 10/8/23 at 9:03 a.m., LVN 2 stated she did not and was supposed to flush between each medication. Residents Affected - Some During an interview on 10/8/23 at 12:17 p.m., the Director of Nursing (DON) stated that best nursing practice and proper technique with Enteral meds would be to flush between each medication administered to avoid interactions between medications through the G-tube per facility policy. A review of the facility's policy and procedure titled, Medication Administration - Enteral Tubes, dated 1/2020, indicated that medications given via G-tube should be flushed with water between each medication to avoid physical interaction of the medications. According to https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3875244/ Administer each drug separately. Each medication should be given separately through the feeding tube. A clean 30-mL or larger oral (non-Luer tip) syringe should be used. Flush the tube again. The tube should be flushed again with at least 15 mL of purified water to ensure that the drug has been delivered and the tube is clear. 555429 Page 4 of 16 555429 10/08/2023 Villa Gardens Health Care Unit 842 East Villa Street Pasadena, CA 91101

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to clean the dryer lint trap for three (3) of 3 dryers as indicated in the policy. Residents Affected - Some This deficient practice had the potential to cause fire in the facility. Findings: During a concurrent observation in the facility laundry room and interview with Environmental Service Director (ESD) on 10/8/23 at 11:03 AM, three large blue laundry carts with unfolded linen inside were noted in front of three washers. ESD placed his hand inside one of the blue laundry carts and stated the linen felt a little damp. ESD stated he did not know if the linen inside the blue laundry carts were clean or dirty. ESD stated all three washers and dryers were working. During a concurrent observation in the laundry room and interview with Laundry Staff 1 (LS 1) and ESD on 10/08/23 at 11:13 AM, three dryers were observed in the dryer room between the linen storage and the washer room. Lint found in the lint traps on all three dryers. Dryer 1 lint trap also had a used band aid and paper towel. LS 1 stated, Lint is removed from the lint traps at the end of the day. LS 1 confirmed not removing the lint from the lint trap in the morning of 10/8/23. ESD verified that lint was found in the lint traps of all three dryers. ESD stated leaving the lint in the lint traps can cause fires and was unsanitary. During a concurrent interview with ESD and record review on 10/8/23 at 3:23 PM, the Daily Dryer Lint Removal logs, dated 10/1/23, for dryers 1, 2, and 3 indicated a scheduled time of 8AM, 12PM, 4PM, and 7:30 PM on Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, and Saturday. ESD stated the log was for the week of 10/1/23 to 10/7/23. ESD confirmed the following: 1. Daily Dryer Lint Removal log for Dryer 1 did have an initial on 10/1/23 and 10/7/23 at 8AM, 12PM, 4PM, and 7:30 PM 2. Daily Dryer Lint Removal log for Dryer 2 did have an initial on 10/1/23 and 10/7/23 at 8AM, 12PM, 4PM, and 7:30 PM 3. Daily Dryer Lint Removal log for Dryer 1 did have an initial on 10/1/23 and 10/7/23 at 8AM, 12PM, 4PM, and 7:30 PM ESD stated the initial on the Daily Dryer Lint Removal indicated lint was removed from the lint trap of the dryer. ESD stated laundry staff who worked on 10/7/23 was newly hired and did not know the lint had to be removed. A review of the facility's undated policy and procedure (P&P) titled, Drying of Laundry, indicated, It is the responsibility of the Supervisor of Housekeeping and Laundry to see that Laundry Personnel operate dryers according to established procedures. The P&P also indicated to, Clean lint traps throughout the day and at end of each shift of operation. 555429 Page 5 of 16 555429 10/08/2023 Villa Gardens Health Care Unit 842 East Villa Street Pasadena, CA 91101

F 0759 Ensure medication error rates are not 5 percent or greater. 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 they were free of medication error rate of five (5) percent or greater, as evidenced by the identification of two medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturer's specifications [not recommendations] regarding the preparation and administration of the medication or biological; or accepted professional standards and principles) out of 25 opportunities (observations during medication administration) for error and yielded a cumulative error rate of eight (8) percent for two of four sampled residents (Resident 4). Resident 4 did not receive Eliquis (a medication used to prevent blood clots) and Carvedilol (a medication used to help control blood pressure [BP]) with food in accordance with the physician's order. Residents Affected - Some This failure had the potential to cause Resident 4 to experience pain and discomfort of the stomach. Findings: During a review of Resident 4's Record of admission indicated the resident admitted to the facility initially on 12/15/22 and was re-admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) and heart failure (a chronic condition in which the heart does not pump and fill blood adequately). During a review of Resident 4's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 9/1/23 indicated the resident usually understood or made self-understood to others and had severe impairment in cognitive skills. Resident 4 required extensive assistance (resident involved in activity, staff provided weight-bearing support) from staff for bed mobility, dressing, and toilet use. During a review of Resident 4's monthly physician's orders with the Report Date Range 10/1/23 to 10/31/23, indicated the resident was ordered for the following medications: 1. Eliquis 2.5 mg, one tablet (tab), PO (by mouth) twice a day (BID), take with food. 2. Carvedilol 6.25 mg one tab, PO BID, give with food. For hypertensive (High blood pressure). During a Med Pass observation on 10/7/23 at 4:20 PM, Licensed Vocational Nurse 1 (LVN 1) prepared the following medications for Resident 4: 1. Eliquis 2.5 mg (milligrams - unit of measure) one tab. 2. Carvedilol 6.25 mg one tab. During an observation in Resident 4's room on 10/7/23 at 4:30 PM, Resident 4 took Carvedilol and Eliquis at the bedside. LVN 1 did not offer Resident 4 food before administering the two (2) medications. During an interview on 10/7/23 at 4:38 PM, LVN 1 stated Resident 4 had an order on 4/4/23 for Eliquis 2.5 mg by mouth (PO) twice a day (BID), take with food and Carvedilol 6.26 mg PO BID take with 555429 Page 6 of 16 555429 10/08/2023 Villa Gardens Health Care Unit 842 East Villa Street Pasadena, CA 91101

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some food. LVN 1 stated, she gave Resident 4 the two (2) medications without making sure Resident 4 took it with food, and it should have been given with food to prevent stomach irritation. During an interview on 10/8/23 at 12:17 PM, the Director of Nursing (DON) stated if the medication indicated to administer with food and the nurse did not follow the physician's order to give with food, it could cause the resident to have stomach upset with Eliquis. The DON stated Carvedilol if taken without food, the resident could feel dizzy, weakness, pass out, and/or fall. A review of the facility's policy and procedure titled, Medication Administration General Guidelines, dated 9/18, indicated that medications are administered as prescribed in accordance with manufacturer's specifications, good nursing principles and practices and only by persons legally authorized to do so. The policy also indicated that prior to administration, review, and confirm medication orders for each individual resident on Medication Administration Record. 555429 Page 7 of 16 555429 10/08/2023 Villa Gardens Health Care Unit 842 East Villa Street Pasadena, CA 91101

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services by failing to dispose expired medications found in the medication room as indicated on the facility policy. This deficient practice had the potential for adverse reaction in the event that these expired medications were administered to the residents. Findings, On 10/7/23 at 4:27 PM, during an inspection of the medication room with Licensed Vocational Nurse 1 (LVN 1), the following were observed: a. 16 individual packets of Simply Thick Easy Mix Instant Food Thickener 96 g (Gram - a unit of measure) with an expiration date of 8/3/23. b. Two bottles of Pepto-Bismol (medication used to treat diarrhea, heartburn nausea, and upset stomach) 525 mg (milligrams - unit of measure)/30 ml (milliliter - unit of measure) with an expiration date of 5/20/23. On 10/7/23 at 4:40 PM., LVN 1 stated, There should not be any expired medications left in the medication room because if the residents took the medication, they could get sick. On 10/7/23 at 4:42 PM, the Director of Nursing (DON) stated that staff were not to use expired medications/supplies because it was harmful to residents. The DON stated that all licensed staff were responsible for ensuring medications were not expired and if it was expired, it should be stored separately, or properly discarded. A review of the facility's policy and procedure titled, Medication Storage/ Storage of Medication, dated 9/2018, indicated outdated, contaminated, discontinued, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medications for medication disposal, and reordered from the pharmacy, if a current order exists. 555429 Page 8 of 16 555429 10/08/2023 Villa Gardens Health Care Unit 842 East Villa Street Pasadena, CA 91101

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record reviews, the facility failed to store food under sanitary conditions in one (1) of 1 kitchen, by: Residents Affected - Some a. Failed to ensure pasteurized eggs (gently heated in their shells, just enough to kill the bacteria but not enough to cook the egg) was not stored in the same shelve and/ or beside the regular eggs. b. Failed to ensure opened food items stored in dry goods area were labeled and dated. c. Failed to discard expired food and was not stored in the kitchen. The deficient practice of not separating pasteurized eggs with regular eggs has high risk of accidental usage of regular eggs that to be served to residents and had high potential for transmission of salmonella (a germ that may cause diarrhea, fever, and stomach cramps, leading to hospitalization and death). The deficient practice of failing to ensure unlabeled and expired dry goods are dispose accordingly had the potential to result in growth of bacteria and transmission of 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: During a concurrent observation and interview on 10/6/23 at 6 PM, during an initial Kitchen tour in the presence of Certified Dietary Manager (CDM), a container with white uncooked shelled eggs was observed in refrigerator 4. CDM stated, the eggs were not stamped with P which means pasteurized. There were two (2) boxes of Pasteurized eggs stored with five (5) boxes of regular eggs at the bottom shelves of refrigerator 5. CDM stated, the 5 boxes were labeled as regular eggs and there were 2 boxes of pasteurized eggs next to 5 boxes of regular eggs. CDM stated, pasteurized eggs and regular eggs should not be stored in the same place to avoid confusion because kitchen staff might use the wrong eggs for the residents. During a concurrent observation and interview on 10/6/23 at 9 PM with Director of Dining Services (DDS) and Administrator, DDS and ADM stated, the pasteurized egg and regular egg were kept in the same shelve and beside each other. During concurrent observation in kitchen 1, interview with the DDS on 10/8/23 at 8 AM, several expired and opened items without label of open date were observed. a. Three (3) boxes of biscuits with expiration date of 12/30/21 b. One (1) opened bag of grits with no label of open date and expiration date of 9/15/23. c. One (1) opened unlabeled bottle (no name of item indicated) that contained dark fluid with expiration date of 5/2/22. d. One (1) opened bottle of vinegar with expiration date of 10/15/21. 555429 Page 9 of 16 555429 10/08/2023 Villa Gardens Health Care Unit 842 East Villa Street Pasadena, CA 91101

F 0812 e. One (1) opened bottle of spicy sauce with no label of open date. Level of Harm - Minimal harm or potential for actual harm f. One (1) opened bottle of peppermint extract with no label of open date. g. Two (2) opened bottle of food coloring with no label of open date. Residents Affected - Some h. Two (2) opened bottles of syrup with no label of open date. i. One (1) opened bottle of food coloring with no label of open date of 9/1/22. j. One (1) container of flour with open date of 4/23/21. DDS stated he did not know why some of the items were not labeled with open date, and on why the expired items are still there and not discarded. DDS stated ,several items such as 3 boxes of expired biscuits, 1 bag of expired grits, 1 opened unlabeled bottle that contained dark fluid with expiration date of 5/2/22, 1 bottle of expired vinegar, 1 opened bottle of food coloring with open date of 9/1/22, and 1 container of flour with open date of 4/23/21 should not be kept or stored in the facility kitchen anymore because it exceeded the expiration date per manufacturers label. DDS stated, the items such as opened bottle of spicy sauce, opened bottle of peppermint extract, opened bottles of food coloring, opened bottles of syrup were opened without labeling it with the open date. During an interview on 10/8/23 at 4 PM with CDM, CDM stated, all items that are being opened in the kitchen should have a label of the date when it was opened or first use. CDM stated it is important not to use expired food items because this can lead to sickness. CDM stated, the items without a label of open date are not safe to use because of uncertainty if it is still good to use or not. A review of facility's policy and procedure (P&P) titled Use of Pasteurized eggs, dated 8/1/2007, indicated having pasteurized eggs and regular eggs on your shelf can present a problem and is recommend selecting either pasteurized or regular eggs because there is no room for error. If you want to take a chance and purchase both then they need to be stored separately and employees must be frequently in-serviced. Those with care centers need to be extra alert to the problems from having both types of eggs in inventory. A review of facility's P&P titled Simplified P&P food storage times and temperatures, with revised date of 5/31/2016, policy indicated definition of expiration date that food must be discarded on this date. It also indicated that staff member is expected to correctly label, and date all opened food items. A review of the Center for Clinical Standards and Quality/ Survey & Certification (S&C) Group's, Centers for Medicare & Medicaid Services (CMS) S&C letter 14-34-Nursing Homes (NH), dated 5/20/2014, the CMS S&C letter 14-34-NH indicated, skilled nursing and nursing facilities should use pasteurized shell eggs or liquid pasteurized eggs to eliminate the risk of residents contracting salmonella enteritis. In accordance with the Centers for Disease Control and Prevention (CDC) and the U.S. Food and Drug Administration (FDA) standards, skilled nursing and nursing facilities should not prepare nor serve soft-cooked, undercooked or sunny-side up eggs from unpasteurized eggs. For the elderly, a small amount of Salmonella bacteria can cause severe illness and even death. 555429 Page 10 of 16 555429 10/08/2023 Villa Gardens Health Care Unit 842 East Villa Street Pasadena, CA 91101

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a coordination of care between facility and hospice (care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure) staff for one of two sampled resident (Resident 24) in accordance with the facility's hospice agreement by failing to ensure: a. A physician's order for hospice care from December 2022 to October 2023 b. A current physician's certification for hospice benefit from 3/2023 to 10/2023 c. A hospice comprehensive assessment to include a documented evidence of hospice staff progress notes visit and hospice staff visit calendar d. Hospice care plan was developed This deficient practice had the potential for Resident 24 not to receive the hospice care and services necessary to promote comfort and quality of life. Findings: A review of Resident 24's admission Record indicated Resident 24 was originally admitted to the facility on [DATE]. Resident 24's diagnoses included hemiplegia and hemiparesis (weakness or loss of strength on one side of the body), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), and facial weakness. A review of Resident 24's History and Physical, dated 11/20/22, indicated that Resident 24 does not have capacity to understand and make decisions. H&P also indicated that Resident had cerebral vascular accident ([CVA] stroke, an interruption in the flow of blood to cells in the brain). A review of Resident 24's Minimum Data Set (MDS, a comprehensive assessment and care-screening tool), dated 5/13/23, indicated Resident 24 was severely impaired with cognitive skills [ability to think, understand, and reason]) for daily decision making. The MDS indicated Resident 24 required one- person extensive assistance for transfer, locomotion off unit, dressing and toilet use. Resident 24 also required one-person limited assistance for bed mobility and locomotion on unit. The MDS indicated Resident 24 received hospice care while a resident in the facility. A review of Resident 24's Physician's order with report date range of 10/1/23 to 10/31/23, did not indicate that Resident 24 was under hospice. A review of Resident 24's hospice flow sheet binder indicated the following: a. A physician's certification for hospice benefit, with a start date on 11/18/22 b. Hospice comprehensive assessment dated on 11/18/22. Resident 24's hospice comprehensive assessment indicated SN frequency of 2 times a week, and Certified Home Health Agency (CHHA) frequency of 2 times a week. The hospice binder also had a Licensed Vocation Nurse (LVN) visit notes, dated 555429 Page 11 of 16 555429 10/08/2023 Villa Gardens Health Care Unit 842 East Villa Street Pasadena, CA 91101

F 0849 11/19/22, 11/22/22, 11/30/22, 12/3/22, 12/7/22, 12/14/22, 12/17/22. Level of Harm - Minimal harm or potential for actual harm c. Frequency of Hospice staff visit calendar for the months of January and February 2023 Residents Affected - Few During an interview with LVN 3 on 10/7/23 at 6:30 PM, LVN 3 stated that each resident on hospice has their own binder which contains all of the Resident's records. LVN 3 Resident stated Resident 24 has a hospice binder. LVN 3 stated that having a hospice binder was important for the facility staff because it was where they check hospice nurses' visits and documentation. During a concurrent interview with LVN 4 and record review of Resident 24's hospice binder and facility nurse's documentation on 10/8/23 at 5 PM, LVN 4 stated there was no physician's order that Resident 24 was under hospice. LVN 4 stated that Resident 24 has been admitted to hospice since November of last year. LVN 4 acknowledged that she did not add Resident 24's admission to hospice order since November of last year. LVN 4 stated that hospice staff should communicate with the facility staff when they plan to visit or have visited a resident, LVN 4 added facility staff should document hospice staff's resident visit under the hospice and facility progress notes. LVN 4 stated that per Resident 24's hospice flow sheet in the hospice binder indicated the following: a. Hospice CHHA last visit was on 8/17/23 b. Hospice LVN last visit was on 10/5/23 c. Hospice RN last visit was on 9/28/23 LVN 4 stated, there were was no other documentation of the hospice nurses' visit in Resident 24's hospice flow sheet besides the date, name, and hospice staff signature. LVN 4 stated that there waswere no facility nurse's notes indicating documentation of hospice nurse visit. LVN 4 validated there was no progress note regarding hospice communication/ coordination of resident care with the facility staff during Hospice CHHA visit on 8/17/23, Hospice LVN visit on 10/5/23, and Hospice RN visit on 9/28/23. LVN 4 stated there was no hospice care plan developed that would indicate hospice staff visits. The facility's hospice agreement, dated 7/19/2016, indicated Joint Responsibilities/Mutual Promises that when a Facility resident is authorized by Hospice for admission to the Hospice Program, or when the Facility admits a Hospice Patient to the Facility, Hospice and Facility shall jointly develop and agree upon the Patient's Plan of Care. The hospice and the facility will establish a method to ensure that the needs of patients are addressed and met 24 hours a day. This communication will be documented in the patient's medical record by both parties. 555429 Page 12 of 16 555429 10/08/2023 Villa Gardens Health Care Unit 842 East Villa Street Pasadena, CA 91101

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 implement appropriate infection control practices for one sampled resident (Resident 26) as indicated on the facility's policy and procedure by failing to ensure availability and use of EPA (Environmental Protection Agency) approved disinfectant solution in cleaning a contact isolation ( used when a patient has an infectious disease that may be spread by touching either the patient or other objects the patient has handled) room with Clostridioides difficile (C. diff, a germ that causes diarrhea). Residents Affected - Few This failure placed all the residents, staff, and the visitors at higher risk for cross contamination, and increased spread of C. diff infection in the facility and the community. Findings: During a review of Resident 26's admission Record indicated Resident 26 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 26's diagnoses included dementia (memory loss), chronic kidney disease (a gradual loss of kidney function), and benign prostatic hyperplasia (condition in men in which the prostate gland is enlarged and not cancerous). During a review of Resident 26's Minimum Data Set (MDS, an assessment and care screening tool), dated 9/1/23, indicated Resident 26 required total dependence to one-person physical assist with locomotion on and off unit, and required two (2)- person physical assists during transfer. Resident 26 also required extensive assistance (resident involved in activity, staff provide weight bearing support) with 2-person physical assist with bed mobility and toilet use, and required 1- person physical assist with dressing, eating and personal hygiene. During a review of Resident 26's Physician's Orders, indicated an order dated 10/3/23 to start Resident 26 on Vancomycin (medication to treat infection) 250 milligrams (mg, unit of measurement) 1 tablet, orally four (4) times a day for 10 days, for C. diff. It also indicated an order to place resident 26 on contact isolation. During an observation outside resident 26's room and interview with Licensed Vocational Nurse (LVN) 1 on 10/8/23 at 11:45 AM, , LVN 1 stated that resident 26 is on contact isolation for C. diff. LVN 3 stated that bleach cleaning solution (EPA approved disinfectant solution) are to be used when cleaning surfaces inside a C. diff contact isolation room and with items like blood pressure monitor that was used with resident who has C. diff. LVN 1 stated, as far she know, only bleach cleaning solution can kill the C. diff organism, and all supplies that's needed to be reused from a C. diff isolation room should be disinfected for everyone's safety. LVN 1 unable to provide an EPA approved disinfectant solution that is readily available outside nor inside Resident 26' room for staff to use. LVN 1 stated that the personal protective equipment (PPE) cart that is placed outside Resident 26's room did not have an EPA approved disinfectant solution that is available for the staff. During an observation outside resident 26's room and interview with Infection Preventionist Nurse (IPN) on 10/8/23 at 12 PM, IPN stated that Resident is on contact isolation because of C. diff. IPN stated to use hydrogen peroxide wipes to clean things from inside Resident 26's contact isolation room. IPN stated and pointed the tub with green covering that labeled hydrogen peroxide which is placed on top of the PPE cart outside Resident 26's room, that this is the disinfectant to be used by staff in disinfecting items from C. diff room. IPN later stated, she realized that hydrogen peroxide tub 555429 Page 13 of 16 555429 10/08/2023 Villa Gardens Health Care Unit 842 East Villa Street Pasadena, CA 91101

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few is not an EPA approved disinfectant solution for room on isolation due to C. diff. IPN stated, the facility's policy and procedure regarding C. diff is following the Centers of Disease Control (CDC) and Prevention guidelines for C. diff which is indicated in Los Angeles County department of public health acute communicable disease control program guidelines. During a review of Los Angeles County department of public health acute communicable disease control program, with revision date of 8/27/08, resourced from Centers for disease control and prevention: Overview of C. difficile Infections, indicated to use an EPA-registered hypochlorite-based (bleach) disinfectant for disinfection of environmental surfaces in the rooms and bathrooms of patients infected with C. difficile. 555429 Page 14 of 16 555429 10/08/2023 Villa Gardens Health Care Unit 842 East Villa Street Pasadena, CA 91101

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete the facility's Infection Surveillance Log Form (ISL - a form used by the facility to indicate if the resident met the criteria for the use of antibiotic [medication used to treat infection]) which is part of the facility's Antibiotic Stewardship Program (protocols and a system in the facility to monitor antibiotic use) prior to the administration antibiotic medication for three of three sampled residents (Resident 22, 26, and 90). Residents Affected - Some This deficient practice had the potential for Residents 22, 26, and 90 to develop infection that is resistant (organism that is not able to be killed and continued to grow) to antibiotics or multiple drug resistant organism (MDRO, are define as microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents) that is difficult to treat due to unnecessary or inappropriate antibiotic use. Findings: A review of Resident 22 's admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis that included Gastro-esophageal reflux disease (GERD- stomach acid repeatedly flow back into the tube connecting mouth and stomach). A review of Resident 22 's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 9/19/23, indicated Resident 22 had moderate cognitive impairment (ability to think, understand, and reason). The MDS indicated Resident 22 required extensive assistance (resident involved in activity, staff provided weight-bearing support) from staff for bed mobility, transfer, and toilet use. A review of Resident 22 's physician's order, dated 10/1/23, indicated to administer Cephalexin (medication used to treat infection caused by bacteria) 500 milligrams (mg - unit of measurement of mass) by mouth (PO), four times a day (QID) for seven (7) days, for Urinated Tract Infection (UTI- an infection in any part of the urinary system, the kidney, bladder, or urethra). A review of Resident 26 's admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis that included benign prostatic hyperplasia (BPH- is a condition in men in which the urinary stream may be weak or stop and start). A review of Resident 26 's Minimum Data Set, dated [DATE], indicated Resident 26 had moderate cognitive impairment. The MDS indicated Resident 26 required extensive assistance from staff for bed mobility, toilet use, and personal hygiene. A review of Resident 26's physician's order, dated 10/3/23, timed at 12pm, indicated to administer Vancomycin 250 mg (medication used to treat infection caused by bacteria) one (1) tablet by mouth, four times a day for 10 days, for C-diff (Clostridium difficile-the bacteria can spread person to person) infection. A review of Resident 90 's admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis that included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). 555429 Page 15 of 16 555429 10/08/2023 Villa Gardens Health Care Unit 842 East Villa Street Pasadena, CA 91101

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 90 's Minimum Data Set, dated [DATE], indicated Resident 90 's cognitive and decision-making skills were intact. A review of Resident 90's physician's order, dated 10/2/23, indicated to administer Cephalexin 500 mg by mouth, BID (two times a day) for five (5) days, for left arm cellulitis (the bacteria enter the skin and causes skin infection). A review of the ISL form indicated to list all signs and symptoms by number listed on Signs & Symptoms Selection to support criteria for medication use. The ISL form had no documented evidence that the signs and symptoms of infection were listed for Resident 22, 26, and 90 's to indicate if the prescribed antibiotic were adequate to treat the infection. During a concurrent interview and record review on 10/8/23 at 4:36 pm, the Infection Preventionist Nurse (IPN) stated she filled out the ISL form and reviewed the resident's lab results. If the process indicated that the resident did not have an infection, then she would notify the physician. During an interview on 10/8/23 at 4:43 PM, IPN stated there was no evidence ISL form was completed to indicate the signs and symptoms of infection for Resident 22, 26, and 90 and if the residents met the criteria for the use of antibiotics. The IPN also stated, it is important to list signs and symptoms on the ISL form so physician could use this information to prescribe the appropriate antibiotic to target specific infection. 555429 Page 16 of 16