Health inspection·October 1, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure four of five sampled resident's (Residents 1, 5, 8, and 9) responsible parties were provided with information regarding formulating advanced directives (legal documents that allow you to spell out your decisions about end-of-life care ahead of time). This failure had the potential to result in violation of Residents 1, 5, 8, and 9's rights to make informed decisions regarding advance directives. Findings: a. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to facility on 6/7/23 and readmitted to the facility on [DATE]. During a review of Resident 1's Initial Assessment/Screening, dated 6/7/23, the Initial Assessment/Screening indicated Resident 1 did not have an advanced directive. The Initial Assessment/Screening did not indicate Resident 1 was offered information that included rights to formulate an advanced directive. During a review of Resident 1's History and Physical (H&P), dated 6/8/23, the H&P indicated, Resident 1 had multiple diagnosis including tracheostomy (a surgically created hole in the windpipe that provides an alternative airway for breathing), cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), and quadriplegia (the condition in which both the arms and legs are paralyzed). During a review of Resident 1's Subacute Psychosocial Assessment and Annual Reassessment, dated 6/29/23, the Subacute Psychosocial Assessment and Annual Reassessment indicated Resident 1 did not have an advanced directive. The form indicated Resident 1 was not provided information regarding the right to formulate an advanced directive. During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/26/23, the MDS indicated Resident 1 was severely impaired in cognitive skills (the ability to make daily decisions). Resident 1 was totally dependent on staff for transfers, dressing, personal hygiene, and toilet use. b. During a review of Resident 5's AR, dated 9/29/23, the AR indicated Resident 5 was admitted to facility on 7/1/23. Page 1 of 9 555634 555634 10/01/2023 Greater El Monte Community Hos 1701 Santa Anita Avenue El Monte, CA 91733

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 5's Initial Assessment/Screening, dated 6/14/22, the Initial Assessment/Screening indicated Resident 5 did not have an advanced directive. The Initial Assessment/Screening did not indicate Resident 5 was offered information that included rights to formulate an advanced directive. During a review of Resident 5's Subacute Psychosocial Assessment and Annual Reassessment, dated 6/24/22, the Subacute Psychosocial Assessment and Annual Reassessment indicated Resident 5 did not have an advanced directive. The form indicated Resident 5 was not provided information regarding the right to formulate an advanced directive. During a review of Resident 5's MDS, dated 6/29/23, the MDS indicated Resident 1 was severely impaired in cognitive skills. Resident 1 was totally dependent on staff for transfers, dressing, personal hygiene, and toilet use. During a review of Resident 5's H&P, dated 7/5/23, the H&P indicated, Resident 5 had multiple diagnosis including tracheostomy, ventilator (a type of breathing apparatus that moves air into and out of the lungs) dependent respiratory failure (when the lungs can't get enough oxygen into the blood), and hypertension (high blood pressure). c. During a review of Resident 8's AR, the AR indicated Resident 8 was admitted to facility on 2/14/23 and readmitted to the facility on [DATE] with the diagnosis of encounter for attention to tracheostomy. During a review of Resident 8's Initial Assessment/Screening, dated 1/17/23, the Initial Assessment/Screening indicated Resident 8 did not have an advanced directive. The form did not indicate Resident 8 was offered information that included rights to formulate an advanced directive. During a review of Resident 8's Subacute Psychosocial Assessment and Annual Reassessment, dated 1/27/23, the Subacute Psychosocial Assessment and Annual Reassessment indicated Resident 8 did not have an advanced directive. The form indicated Resident 8 was not provided information regarding the right to formulate an advanced directive. d. During a review of Resident 9's AR, dated 9/29/23, the AR indicated Resident 9 was admitted to facility on 7/1/23. During a review of Resident 9's Initial Assessment/Screening, dated 4/11/23, the Initial Assessment/Screening indicated Resident 9 did not have an advanced directive. The form did not indicate Resident 9 was offered information that included rights to formulate an advanced directive. During a review of Resident 9's H&P, dated 4/12/23, the H&P indicated, Resident 9 had multiple diagnosis including tracheostomy, ventilator dependent, and quadriplegia. During a review of Resident 9's Subacute Psychosocial Assessment and Annual Reassessment, dated 4/28/23, the Subacute Psychosocial Assessment and Annual Reassessment did not indicate if Resident 9 had advanced directives. The form indicated Resident 9 was not provided information regarding the right to formulate an advanced directive. During a review of Resident 9's MDS, dated 7/31/23, the MDS indicated Resident 9 was severely impaired in cognitive skills. Resident 9 was totally dependent on staff for transfers, dressing, personal 555634 Page 2 of 9 555634 10/01/2023 Greater El Monte Community Hos 1701 Santa Anita Avenue El Monte, CA 91733

F 0578 hygiene, and toilet use. Level of Harm - Minimal harm or potential for actual harm During an interview on 9/29/23 at 7:48 p.m. with Registered Nurse (RN) 1, RN 1 stated nurses did not offer advance directives [to residents or responsible parties]. RN 1 stated it was the responsibility of the Interdisciplinary Team (IDT, a team of health care professions who work together to establish plans of care for residents) to check if residents (in general) had advanced directives. Residents Affected - Some During an interview on 9/29/23 at 7:53 p.m. with the Director of Nursing (DON), the DON stated the admitting nurse was responsible for collecting information regarding resident advanced directives. The DON stated the nurse asked about advanced directives upon resident admission. The DON stated advanced directives should be offered to newly admitted residents to know what residents wanted regarding their medical care. During an interview on 9/30/23 at 11:02 a.m. with the DON, the DON stated residents admitted to the facility were not informed of their right to formulate advanced directives. The DON indicated, per the facility's Policy and Procedure (P&P) on advanced directives, the facility shall provide written information describing the right to formulate an advanced directive. During an interview on 10/1/23 at 10:47 a.m. with the Chief Nursing Officer (CNO), the CNO stated the facility needed to inform residents [or responsible parties] of their right to formulate advanced directives to ensure rights of the residents and family members were protected. The CNO stated it was important to offer advanced directives so residents could make informed decisions. During a review of the facility's P&P titled, Advanced Directives, reviewed 6/22/22, the P&P indicated, the facility shall provide to each adult individual and or emancipated minor at the time of his or her admission as an inpatient, written information describing: an individual's right . to formulate advanced directives; and the facilities policies regarding these rights to make healthcare decisions and to formulate advanced directives, and regarding the way such decisions and directives will be implemented in the facility. 555634 Page 3 of 9 555634 10/01/2023 Greater El Monte Community Hos 1701 Santa Anita Avenue El Monte, CA 91733

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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 an adequate communication device was provided for one of one sampled resident (Resident 8), who was ventilated (a machine to provide breathing for a patient who is physically unable to breathe) and understood primarily Vietnamese. Residents Affected - Few This failure had the potential to result in a physical and psychosocial decline for Resident 8 due to the inability to express specific needs. Findings: During a review of the admission Record (AR), the AR indicated Resident 8 was originally admitted to the facility on [DATE]. During a review of Resident 8's Initial Assessment/Screening, dated, 1/17/23, indicated Resident 8's primary and preferred language was Vietnamese. During a review of a History and Physical (H&P), dated 7/5/23, indicated Resident 8 diagnosis included acute (sudden) on chronic (long standing) respiratory failure (too little oxygen passes from your lungs to your blood) with hypoxia (not enough oxygen in the body), ventilator dependent, post tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing) and anxiety (a feeling of worry, nervousness, or unease). During a review of a Minimum Data Set (MDS, a resident assessment and care-screening tool, dated 8/29/23, indicated Resident 8 had moderate impaired cognition (ability to understand and process information). Resident 8 was totally dependent (staff provided weight-bearing support) and required two-persons to assist with bed mobility (resident moves from lying to sitting; moves side to side), transfers (moved between bed to chair), dressing, toilet use, and personal hygiene (combing hair, brushing teeth, shaving). During an observation and concurrent interview on 9/29/23 at 4:34 p.m., with Certified Nursing Assistant 1 (CNA 1) and CNA 2, in Resident 8's room, Resident 8 was observed lying in bed, connected to a ventilator through a tracheostomy tube, Resident 8 was moving the right hand and right foot. CNA 2 asked if, in English, Resident 8 was all right and Resident 8 moved Resident 8's head side to side to indicate, no. CNA 1 and CNA 2 repositioned Resident 8 in bed and asked Resident 8 if Resident 8 was all right a second time. Resident 8 shock Resident 8's head from side to side. CNA 1 and CNA 2 stated they were not sure if Resident 8 understood English. At 4:41 pm, Registered Nurse (RN) 2 entered Resident 8's room. RN 2 asked Resident 8, in English, if Resident 8 wanted to be repositioned. Resident 8 gestured by moving his right hand and attempted to move his legs. During room observation, there was no communication board in Resident 8's room or located anywhere next to the resident's bed. At 4:48 p.m., RN 2, CNA 1, and CNA 2 attempted to communicate with Resident 8, in English, asked if Resident 8 needed to be repositioned and pointed to Resident 8's legs, body, and head. Resident 8 continued to move his head side to side. At 4:50 p.m., RN 2, CNA 1, and CNA 2 pulled Resident 8 up in bed, turned the resident to the other side, and adjusted Resident 8's legs by using two pillows. The staff did not use a communication tool or board to communicate with Resident 8. During an interview with CNA 1, on 9/29/23 at 4:51 p.m., CNA 1 stated CNA 1 communicated with 555634 Page 4 of 9 555634 10/01/2023 Greater El Monte Community Hos 1701 Santa Anita Avenue El Monte, CA 91733

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 8 by reading his lips and by using hand gestures. CNA 1 stated there were no communication tools used to communicate with Resident 8. CNA 1 stated if there were a communication tool, Resident 8 could point and let staff know exactly what he needed or wanted. During an interview on 9/29/23 at 4:52 p.m., CNA 2 stated there was no tool used to communicate with Resident 8. CNA 2 stated if Resident 8 had a communication tool, he would let CNA 2 know what Resident 8 needed, e.g., if he had pain or needed to be suctioned. During an interview on 9/29/23 at 4:55 p.m., with RN 2 stated Resident 8 spoke Vietnamese. RN 2 stated Resident 8 communicated by making facial expressions, hand gestures, or mouthed words in Vietnamese. RN 2 stated it was important for Resident 8 to communicate with the staff to express his concerns, his likes/dislikes, and Resident 8's needs. During an interview with the Director of Nursing (DON) on 9/29/23 at 7:53 p.m., the DON stated for Resident 8 to communicate with the staff, communication tools that included Resident 8's primary language should be readily available and at Resident 8's bedside. During a review of Resident 8's care plan for resident needs and Individualized visits, dated 1/22/23, indicted communication tools such as pictures and google translator was part of the facility's approach plan. During a review of the facility's Policy and Procedure (P & P), titled, Communication Barriers, Reduction of, reviewed on 11/2016, indicated the purpose of the policy was to assist residents in communicating their needs. The resident would be provided methods of communication to assure adequate communication between the resident and staff. The facility would make arrangements for interpreters of alternate means or alternate means of communication, such as pictures, sign language, Braille, etc., to enhance communication between the resident and staff. 555634 Page 5 of 9 555634 10/01/2023 Greater El Monte Community Hos 1701 Santa Anita Avenue El Monte, CA 91733

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 interview and record review the facility failed to ensure one of five sampled residents (Resident 8) was adequately monitored for behaviors to evaluate the effectiveness psychotropic (medication that change the function of the nervous system and result in alterations of perception, mood, cognition, and behavior) medications. These failures had the potential to result in unnecessary administration of medications to Resident 8 and possible side effects of the medication. Findings: During a review of the admission Record (AR), the AR indicated Resident 8 was originally admitted to the facility on [DATE]. During a review of a History and Physical (H&P), dated 7/5/23, indicated Resident 8 diagnosis included acute (sudden) on chronic (long standing) respiratory failure (too little oxygen passes from your lungs to your blood) with hypoxia (not enough oxygen in the body), ventilator dependent, post tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing) and anxiety (a feeling of worry, nervousness, or unease). During a review of a Minimum Data Set (MDS, a resident assessment and care-screening tool, dated 8/29/23, indicated Resident 8 had moderate impaired cognition (ability to understand and process information). Resident 8 was totally dependent (staff provided weight-bearing support) and required two-persons to assist with bed mobility (resident moves from lying to sitting; moves side to side), transfers (moved between bed to chair), dressing, toilet use, and personal hygiene (combing hair, brushing teeth, shaving). During a review of a physician's order, dated 7/1/23, indicated Xanax (medication used to treat anxiety and panic disorders) 0.5 milligrams (mg, unit of measurement) one tablet every eight hours for hyperventilation was ordered for Resident 8. During a review of Resident 8's Medication Administration Record (MAR), dated 7/19/23, indicated alprazolam (Xanax) 0.5 milligrams (mg) every eight hours, was ordered on 7/1/23 for hyperventilation manifested by shortness of breath. A review of Resident 8's Subacute Medication Regimen Review (SMRR), dated 8/19/23, indicated pharmacy recommendations for Xanax that included nursing to document behavior post (after) a dose assessment in Resident 8's MAR. During a review of Resident 8's Medication Administration Record, dated 9/15/23 - 9/30/23, indicated Resident 8 was administered Xanax, every 8 hours, from 9/17/23 to 9/30/23 (total of 40 times). The MAR indicated Resident 8's behavior was monitored and documented four times, on 9/17/23 at 1: 42 p.m., on 9/21/23 at 3:00 p.m., on 9/25/23 at 2:30 p.m., and on 9/26/23 at 2:30 p.m. During a review of a care plan titled Has episodes of being sad or anxious as manifested by 555634 Page 6 of 9 555634 10/01/2023 Greater El Monte Community Hos 1701 Santa Anita Avenue El Monte, CA 91733

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hyperventilation - patient currently taking Xanax, dated 4/12/23, indicated to monitor frequency, duration, and causative factors that triggered target behavior and documenting in the medical record. During a review of a physician's order, dated 7/1/23, indicated Seroquil (medication to treat depression [serious illness that negatively affects how one feels, thinks and acts]) 25 mg one tablet twice a day for psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) related to fear of death manifested by constant yelling was ordered for Resident 8. During a review of Resident 8's Medication Administration Record (MAR), dated 7/19/23, indicated quetianpine (seroquel) 25 milligrams mg twice a day ordered on 7/1/23 for psychosis related to fear of death manifested by constant yelling. A review of Resident 8's Subacute Medication Regimen Review (SMRR), dated 8/17/23, indicated pharmacy recommendations for Seroquel included monitoring for adverse side effects (ASE) and documenting for behaviors every shift. During a review of Resident 8's Medication Administration Record, dated 9/17/23 to 9/30/23, indicated Resident 8 was administered seroquel, twice a day, from 9/17/23 to 9/30/23 (a total of 27 times). The MAR indicated Resident 8's behavior was monitored and documented three out of 27 times (on 9/17/23 at 9:00 a.m., on 9/26/23 at 9:00 a.m., and on 9/30/23 at 11:45 a.m. During a review of a care plan titled Resident receiving antipsychotic medications Seroquel - Psychosis due to fear of death as manifested by shortness of breath, dated 4/19/22, indicated daily assessment for behaviors manifested, monitoring for drug effectiveness, and documenting in the medical record. The CP indicated, monitoring for side effects and reporting to the physician promptly. During an interview and concurrent record review of Resident 8's MARs, on 9/30/23 at 11:13 a.m., with RN 1, RN 1 stated behavioral monitoring for xanax and seroqual was not done daily as recommended by the SMRR. RN 1 stated behavioral monitoring was important because we [the facility] needed to know if the medications were effective or not. RN 1 stated monitoring determined if the medication needed to be adjusted or discontinued. During an interview and concurrent record review of Resident 8's electronic MAR, with RN 3, on 9/30/23 at 4:12 p.m., RN 3 stated it is important to document monitoring to ensure the medications were effective to determine trends and to adjust/increase/decrease medication dosage. During an interview and concurrent record review of Resident 8's SMRR, on 10/1/23 at 8:38 a.m., with the Director of Pharmacy (RX) 2, RX 2 stated pharmacy recommendations should be followed, and monitoring should be done, especially for psychotropic medications. RX 2 stated, this was important for pharmacist can make informed recommendations regarding dose adjustments. During a revie of the facility's Policy and Procedure (P & P), titled, Subacute Clinical Services - Pharmacy, revised on 9/2011, indicated assessment of appropriateness of indication for the use of each medication administered: expected outcome of therapy . appropriateness of dosing parameters. The P & P indicated, identification of goals for each patient that reflect the patient's unique needs and goals should be specific and measurable. The monitoring plan should state what to monitor for and how frequently monitoring is done. 555634 Page 7 of 9 555634 10/01/2023 Greater El Monte Community Hos 1701 Santa Anita Avenue El Monte, CA 91733

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 observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were maintained in one of one kitchen, when, Residents Affected - Some 1.The dietary cook (DC), who had a beard, was observed without a beard cover while in the food preparation area. 2. The door gaskets (a rubber seal around the door to insulate refrigeration to maintain desired temperature) on Refrigerator 3 was observed torn. The door gasket located on the left had a tear of 9 inches long and the door gasket located on the right had a tear of ¾ of an inch long. 3. The ice machine drainpipe was not located above the water drain. Liquid waste was observed discharging on the kitchen floor. These failures had the potential to result in cross contamination (process by which bacteria can be transferred from one area to another) and unsanitary food conditions and could potentially result in foodborne illnesses (illness caused by food contaminated with bacteria). Findings: 1.During an initial walkthrough of the kitchen, on 9/29/23 at 3:23 p.m., and concurrent interview with the DC, the DC had a beard and was [standing] in the food preparation area located in the kitchen. The DC was not wearing a mask or a beard cover. The DC stated the DC should have worn a mask of beard cover to prevent facial hair from falling onto the food [served to the residents], I'm sorry. During an interview with the Dietary Supervisor (DS) on 9/29/23 at 3:28 p.m., the DS stated face masks or beard covers should be worn [when in the food preparation area] to prevent hair from getting into the resident's food. During a review of the facility Policy and Procedure (P&P) titled Infection Control - Food and Nutrition Services, revised on 4/2021, indicated to prevent the spread of pathogens (any organism that can produce a disease) by way of food handling. Cleanliness, all staff working in direct contact with food, food-contact surfaces, and food-packaging materials shall conform to hygienic practices while on duty to the extent necessary to protect against contaminating food. Wearing, where appropriate, in an effective manner, hair nets, headbands, caps, beard covers, or other effective hair restraints. 2.During a follow up walkthrough of the kitchen on 10/1/23 at 9:29 a.m., with the maintenance supervisor (MS), the MS stated the gasket on the left side of Refrigerator 3 had a nine-inch tear and the gasket on the right side of the door had a ¾ of an inch tear. During an interview with MS on 10/1/23. At 9:33 a.m., the MS stated, to ensure the temperature is contained within the refrigerator, gaskets should not have any tears. During an interview with the DS, on 10/1/23 at 9:36 a.m., the DS stated refrigerator gaskets should not have any tears, this was important to ensure the coldness was sealed and the temperature remained cold. 555634 Page 8 of 9 555634 10/01/2023 Greater El Monte Community Hos 1701 Santa Anita Avenue El Monte, CA 91733

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the facility's P & P, titled, Equipment Preventative Maintenance, reviewed on 6/2022, indicated preventative maintenance will be performed on all equipment to prolong equipment life and to ensure efficient operation and reliability of the equipment. To manifest a notable efficiency of equipment and operator by its appearance. 3.During an observation and concurrent interview, with the MS on 10/1/23 at 9:31 a.m., the drain from the ice machine was dripping water and the water was spilling onto the kitchen floor. The MS stated water from the ice machine should be draining directly into the floor drain (the distance between the ice machine drain and floor drain creates an air gap) to avoid mildew or contamination [in the kitchen]. During an interview with the Maintenance Manager (MM) on 10/1/23 at 2:28 pm, stated the facility did not have a policy pertaining to air gaps for ice machines. 555634 Page 9 of 9