Health inspection·May 19, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview and record review the facility failed promote dignity and respect by ensuring the privacy curtains were long enough to cover the entire bed area for three of 3 sampled residents (Resident 5,6 and 8), when the staffs were performing hygiene care or when the residents request to have privacy. This deficient practice violated the resident's rights for privacy which resulted in in Resident 8 ' s feeling embarrassed and potentially cause other residents to experience psychosocial (mental, emotional, social, and spiritual effects) decline or feelings of intimidation. Findings: During an observation on 5/16/23 at 10:20 AM, Residents 8 ' s bedroom. The privacy curtain around Resident 8 ' s bed did not cover the entire bed, leaving the foot part of the bed exposed. In a concurrent interview, Resident 8 stated he has no privacy even with the privacy curtain drawn around the bed because it did not cover the entire are of the bed and It is embarrassing. Resident 8 explained he asked the staffs to change the curtain for some months now, but it was not changed. During and observation and interview on 5/16/23 at 10:11 A.M with CNA 5 stated, Resident ' s 8 ' s privacy curtain is not long enough to provide full privacy to Resident 8. CNA 5 stated she has informed charge nurse of issue but did not receive a response. During and observation on 5/16/23 at 10:40 AM of Resident 5 and 6 ' s rooms was observed with the curtain that did not cover the entire bed area to provide the resident privacy during activities of daily living such as hygiene care. Residents 5 and 6 was attempted to be interviewed but refused to be interviewed. During an interview on 5/16/23 at 11:17 AM, the Director of Nursing (DON) stated it was important for the facility to provide privacy to all residents. The DON stated she informed the Administrator (ADM) months ago that the privacy curtains around the resident ' s bed were not long enough to provide full privacy to the residents, but she did not receive a response from the ADM and the curtains were not changed. A review of the facility ' s policy titled, Dignity and Privacy, with no date , indicated, the facility will take into consideration maximum safety, dignity and privacy for residents at all times. Page 1 of 17 555755 555755 05/19/2023 Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide treatment and services to one of two sampled residents (Resident 1) who had a gastrostomy tube GT (GT, a tube surgically inserted into the stomach or small intestines used to deliver fluids and medications) in accordance with current professional standard of practice that was newly placed and inserted on 4/11/23 and dislodged (pulled out) after two days on 4/13/23 by failing to: Residents Affected - Few 1. The Director of Nursing (DON) inserting an indwelling catheter (a rubber tube used inserted into the urethra to drain urine from the bladder) into the GT stoma site (opening in the body) and flushing the catheter tubing with 30 cc (cubic centimeter- a unit of measurement) of water after Resident 1's GT had dislodged. 2. The Licensed Vocational Nurses (LVN 1, LVN 2 ) and Registered Nurse (RN 2) flushing fluids and enteral feeding (the delivery of a nutritionally complete feed directly into the stomach and small intestine via tube) on 4/13/2023 after Resident 1's GT had dislodged. 3. The DON and LVN 1 had sufficient skills and competency of the current standard of practice for a GT care after it was dislodged. This deficient practice resulted in Resident 1 being placed at high risk for enteral feeding complications which can (a life-threatening infection of the lining in the abdomen), and perforation (hole made by piercing or boring) in the peritoneal (lining of the abdominal cavity) and spillage of gastric (acidic fluid in the stomach) contents in the abdominal tissue). On 4/14/23 at 6:45 AM, Resident 1 was found unresponsive by facility staff with oxygen saturation (level of oxygen in the blood) of 40% (normal level 90-100%), and no blood pressure (a pressure of the blood in the circulatory system). CPR (Cardiopulmonary Resuscitation - an emergency procedure consists of chest compression and artificial and artificial ventilation to preserve brain function, breathing and blood circulation to the body) was initiated by the facility staff and 911 emergency services was called. Resident 1 was pronounced dead by the paramedics at 7:40 AM on 4/14/23. On 5/17/2023 at 4:21 PM, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the Administrator (ADM), director of nursing (DON), clinical Director of Quality Assurance (QA) and Quality Assurance Nurse (QAN) regarding the facility's failure to follow the standards of practice for GT care and Physician Notification. On 5/19/2023 at 6:12 PM, the IJ situation was removed after the ADM and the QAN submitted an acceptable IJ Removal Plan (interventions to correct the deficient practices). The surveyor verified and confirmed the implementations of the POA while onsite by observation, interview, and record review. The IJ was removed in the presence of the ADM, QAN, Regional Consultant (RCN)1 and RCN 2. The acceptable IJ Removal Plan included the following actions: 1. On 5/17/2023 the QAPI (Quality Assurance Program Improvement) and Resident Care Policy Committee of the findings stated in the IJ template dated 5/17/2023 and the need to update Policy: Re-insertion of Gastrostomy Tubes. 555755 Page 2 of 17 555755 05/19/2023 Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770

F 0658 Level of Harm - Immediate jeopardy to resident health or safety 2. The Medical Director was communicated and updated on 5/19/23, policy titled, Re-insertion of Gastrostomy Tubes. The policy has stated that the facility will not reinsert the GT and will transfer the resident to the acute hospital for GT reinsertion. 3. The DON was formally terminated on 5/19/23 and the facility submitted a formal report to the Board of Nursing upon completion of the investigation. Residents Affected - Few 4. The Acting DON/QA nurse will provide education and in-services on the policies regarding standard of practice. 5. LVN 1 was suspended for 5 days and disciplinary action, including termination considered upon completion of the investigation. 6. During in-services, instructors educated license nurses and explained that all GT reinsertions will be done at the hospital only. 7. On 5/17/2023 CEO (Chief Operating Officer), MD (Medical Director) of the specialized GT services, contracted by the facility for GT care, provided training to all available licensed nurses regarding GT dislodgement. 8. On 5/19/2023 Medical Director participated in QAPI (Quality Assurance Program Improvement-team of staff that plan how to improve the care and quality of life of residents in the facility) and Resident Care Policy Committee to update policy titled Re-insertion of Gastrostomy Tubes to ensure licensed nurses properly follow policy and procedures to obtain the proper care and treatment for residents' with GT care and treatment according to the current standard of practice for residents with dislodged GT. 9. The facility has notified the licensed nurses of the updated policy via in services and on-shift (during the working time) communication. Cross Reference to F693 Findings: A review of Resident 1's Face Sheet (admission Record) indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted in the facility on 4/12/2023, with diagnoses that included aphasia (unable to speak), blindness, adult failure to thrive (characterized by unexplained weight loss, malnutrition and disability), with gastrostomy tube (a surgical procedure for inserting a tube through the abdomen wall and into the stomach) and chronic duodenal ulcer (a sore that forms in the lining of the duodenum, the first part of your small intestine). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 4/13/2023, indicated Resident 1 had severely impaired cognition (ability to think, understand and reason) with moderate difficulty of hearing and sometimes could express ideas and wants, and understand others. The MDS indicated Resident 1 was totally dependent with one person assistance on dressing, eating, toilet use and personal hygiene. A review of the GACH record, Resident 1 was admitted to the hospital on [DATE] due to failure to thrive and weakness. On 4/11/23 Resident 1 had an EGD (Endo gastroduodenoscopy- a procedure in which a 555755 Page 3 of 17 555755 05/19/2023 Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770

F 0658 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few tube is inserted into the mouth to visualize the gastrointestinal tract) and placement of the GT. The GACH Physician Discharge Summary Report, dated 4/12/23, indicated Resident 1 was clinically stable and improved with no signs and symptoms of respiratory distress (difficulty breathing), vital signs (measurement of the heart rate, blood pressure, body temperature) were stable and was cleared for discharge. A review of Resident 1's Order Summary Report, dated 4/12/2023, timed at 9 PM, Enteral Feed Order indicated: 1. Insert indwelling catheter into the GT site PRN (as needed), if GT becomes displaced (dislodged) temporarily, cover with dry dressing until pending reinsertion of GT. 2. Replace GT (if removed/displaced) by specialized GT services. 3. Transfer the resident to the hospital emergency room (ER) if GT becomes displaced/removed. 4. Administer enteral feeding: Jevity (a nutritional formula) 1.2 calorie (unit of energy) bolus feeding (instilling fluid in a fast rate) 400 cc (cubic centimeter-unit of measurement) three times a day to provide 1200cc/kcal (kilo calorie) per day. 5. Flush the enteral tube with 30 cc of water every shift three times a day. A review of Resident 1's Change of Condition (COC) report, dated 4/13/2023, timed at 9 AM, indicated the Charge Nurse reported to the primary physician (PHY 1) that Resident 1 pulled out his GT. The COC indicated PHY1 ordered to re-insert the GT with an indwelling catheter PRN while waiting for the GT to be replaced by the wound specialist. A review of Resident 1's COC report, dated 4/14/2023, timed at 11AM, indicated (Register Nurse) RN 1 made rounds (tour the facility) at 6:45 AM, and Resident 1 was found unresponsive, without vital signs, oxygen saturation was 40%, and CPR was started by the facility staff. The COC report indicated the paramedic arrived within ten minutes after the 911 emergency services were called. At 7:40 AM, Resident 1 was pronounced dead by the paramedics on 4/14/23. A review of the Medication Administration Record (MAR) for April 2023, indicated, Resident 1 received 30 cc water flush before and after medication administration on 4/13/23 at 8AM, 12PM, 4PM and 5 PM, a total of more than 240 cc of fluid and medications. During an interview with the Director of Nursing (DON) on 5/16/2023 at 10:04 AM, the DON stated, she inserted an indwelling catheter on 4/13/23 between 8 AM to 9 AM, into Resident 1's GT stoma site, when the resident's GT was found dislodged on 4/13/23. The DON also stated she flushed the indwelling catheter at the stoma site with 50 ml (milliliter, a unit of measurement) of water without verifying if there was a physician's order to insert an indwelling catheter into the stoma site when the GT was dislodged and flush the tubing. During an interview with the Licensed Vocational Nurse (LVN) 1 on 5/16/2023 at 12:31 PM, LVN 1 validated the DON inserted an indwelling catheter on 4/13/23 between 8 AM to 9 AM, when Resident 1's GT dislodged and that an X-ray (images or pictures inside of the body using) was not done to check the GT placement after she had inserted the catheter. LVN 1 explained, he contacted the specialized GT services the morning of 4/13/23 to have the resident's GT replaced after it had been dislodged, 555755 Page 4 of 17 555755 05/19/2023 Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770

F 0658 however the GT services were unable to see the Resident 1 until 4/14/23. Level of Harm - Immediate jeopardy to resident health or safety During an interview with the Director of Staff Development (DSD) on 5/16/23 at 1:08 PM, DSD stated as a facility's practice, The DON and any licensed nurse can re-insert a G Tube. Residents Affected - Few A review of Resident 1's Baseline Care Plan (initial care plan developed during admission), dated 4/12/2023, verified with the DON on 4/16/23 at 2:50 PM, indicated, Resident 1 had nutritional/fluid impairment (poor nutrition and fluid intake) and was placed on GT feeding. To ensure Resident 1 remained adequately nourished and hydrated (absorption of fluid) without unplanned weight loss, the facility would monitor the resident for aspiration (inhalation of fluid and food in the lungs) and tolerance to GT feeding. The resident's care plan did not indicate nursing interventions on how to address or handle the resident's GT site in the event the GT tube becomes dislodged. During a concurrent interview and record review of the Medication Administration Record (MAR) on 5/16/2023 at 5 PM, LVN 1 stated after the indwelling catheter was inserted by the DON, he signed and confirmed that he instilled Jevity 1.2 calorie, 400cc bolus feeding to Resident 1 and flushed 30cc of water into the indwelling catheter tubing on 4/13/23 between 8 AM and 9 AM. During an interview with the DON and LVN 1 on 5/16/2023 at 5:54 PM and concurrent record review of the Physician's Order Summary Report, dated from 4/12/23 to 4/14/23, the DON and LVN 1 validated there was no physician's order to instill bolus feeding, administer medications, into the Resident 1's tubing after inserting the indwelling catheter into the GT stoma. During an interview with the DON and LVN 1 on 5/16/2023 at 5:55 PM and concurrent record review of the facility's policy and procedure for reinsertion of gastrostomy tubes, (dated 1/24/2017) indicated the facility does not allow licensed nurse to re-insert gastrostomy tubes that become displaced or removed. The procedure indicates if a GT becomes dislodged, removed, or displaced, the GT site will be covered with a clean dressing. If physician orders insertion of indwelling catheter to keep G-Tube orifice open, this will be done; however, no flushing or enteral feedings will be attempted/provided. During an interview on 5/16/23 at 5:57 PM, the DON stated, it's, common sense to continue the feeding without a physician's order, because Resident 1 will get hungry. During an interview on 5/16/2023 at 7:01 PM, the DON stated, she did not get training or certification for inserting an indwelling catheter in the GT site, because she has been a nurse for many years. The DON stated she flushed the indwelling catheter with 50 cc of water and aspirate (to draw in or out using a sucking motion) after she inserted the indwelling catheter on 4/13/23 at around 8AM to 9AM. The DON stated she does recall how far she advanced the catheter tubing into the Resident 1's stomach and the placement was not verifying by X ray. During an interview on 5/17/2023 at 9 AM, PHY 1 stated, he was not informed that Resident 1's GT was dislodged on 4/13/23. PHY 1 stated he did not order the nurses to insert an indwelling catheter into the resident's stoma when the GT site had dislodged. The physician stated, if the GT was pulled out or became dislodged, he would always order the facility to transfer the resident to emergency room so that the resident can be seen by the gastroenterologist (a physician specialized in GT placement) to have the GT reinserted safely and validate GT placement by doing X ray. PHY 1 further stated he did not place the order to start bolus feeding or instill medications into the tube. PHY 1 stated the risk for inserting an indwelling catheter is the tubing could go to a different area of the 555755 Page 5 of 17 555755 05/19/2023 Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770

F 0658 stomach that could lead to peritonitis. Level of Harm - Immediate jeopardy to resident health or safety During an interview on 5/17/2023 at 2:23 PM, CNA 3 stated, he informed the charge nurse (LVN 3) on 4/14/2023 at 5AM, that during the night shift (10 PM to 6:30 AM), Resident 1 was observed getting irritated and tried to pull out his GT. Residents Affected - Few During an interview on 5/17/2023 at 2:36 PM, LVN 3 stated she took care of Resident 1 during the night shift of 4/13/2023 and 4/14/2023. Resident 1 was swinging his arm and told us to go away. During an interview 5/17/2023 3:20 PM, Registered Nurse 2 (RN 2) stated, a check mark and initials in the MAR means she administered the medications and fluid were administered. RN 2 stated the night of 4/13/23, the day shift nurse did not endorse to him that Resident 1's GT had come out and was replaced by a foley catheter. RN 2 was not informed the foley should not be used to administer the medications. During a concurrent interview and record review of the MAR on 5/17/2023 at 3:30 PM, Registered Nurse (RN 2) stated, he signed the MAR that indicated he administered the medications on 4/13/2023 at 4PM, that included Cranberry capsule (helps reduce the frequency of urinary tract infections) 425mg (milligramsa unit of measurement) 1 tablet, Docusate Sodium (a stool softener) 250 mg 1 capsule, Ferrous Sulfate (iron supplement used treat or prevent low levels of iron in the blood) 1 tablet, Fish Oil ( dietary supplement) 1000mg 1capsule, Rena Vite (B complex with C and Folic Acid, multivitamin used to treat nutritional deficiency) 1 tablet, Carbamazepine (used to treat seizure disorder [a sudden, uncontrolled burst of electrical activity in the brain]) 200 mg 1 tablet given and sodium chloride (supplement used to prevent and treat low levels of sodium in your body), and on 4/13/23 at 8PM, he administered Mirtazapine (used to treat major depression [a feeling of severe sadness and hopelessness] manifested by inability to sleep at night causing stress) 7.5mg 1 tablet and Carbamazepine 200 1 tablet. During a review of a declaration report, dated 5/19/2023 and timed at 11:30 AM, written by LVN 3 indicated, she contacted the DON if there was a physician's order for Resident 1's GT dislodgement that occurred in the morning shift on 4/13/2023, but the DON informed her Do not worry, we will take care of it in the morning. LVN 3 asked, who is he? DON stated, Me and LVN 1. During a concurrent interview and record review of the MAR on 5/19/2023 at 2:25 PM, LVN 2 stated she signed the MAR that indicated on 4/13/2023 at 8AM, she administered Nifedipine (a medication used to treat hypertension [a condition of having a high blood pressure]) tablet 10 mg via GT one time a day, Lexapro 5 mg 1 tablet (used to treat depression), Phenobarbital (use to treat seizure disorder) 32.4 mg 1 tab and sodium chloride (supplement used to prevent and treat low levels of sodium in your body). A review of the Journal of Parenteral and Enteral Nutrition related to ASPEN Safe Practices for Enteral Nutrition Therapy, dated 1/15/2017, indicated if the gastrostomy tube dislodges in the first 7-10 days after insertion the inserting provider needs to be contacted as soon as possible for further intervention. A dislodged gastrostomy tube can become a medical emergency, as stomach contents are likely to leak into the peritoneum. The tube should not be reinserted blindly at this stage because it may be repositioned into the peritoneum. https://aspenjournals.onlinelibrary.[NAME].com/doi/full/10.1177/0148607116673053 555755 Page 6 of 17 555755 05/19/2023 Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770

F 0658 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few A review of the facility's policy and procedure titled, Gastrostomy Tube Re- insertion, revised on 1/24/2017, indicated, the facility does not allow licensed nurse to re-insert G-tubes; however, indwelling catheter may be placed to keep G-tube stoma open. A review of the facility's policy and procedure titled, Reinsertion of Gastrostomy Tubes, revised on 1/24/2017, indicated the facility does not allow licensed nurse to re- insert gastrostomy tubes that become dislodged/removed. Procedure indicated, if a gastrostomy tube becomes dislodged, removed, or dislodged, the gastrostomy site will be covered with clean dressing. If physician orders insertion of indwelling catheter to keep G-Tube orifice open, this will be done; however, no flushing or enteral feedings will be attempted/provided. Attending physician will be contacted and orders will be obtained to contact GT Replacement Services, or orders obtained for transfer to outpatient facility or ER for replacement of gastrostomy tube, or orders obtained for NP (Nurse Practitioner), PA (Physician Assistant), or physician to come to facility to re-insert gastrostomy tube. 555755 Page 7 of 17 555755 05/19/2023 Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770

F 0693 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident who had a Gastrostomy Tube (GT, a tube surgically inserted into the stomach or small intestines used to deliver fluids and medications) receive treatment and services to prevent complications such peritonitis (a life threatening infection of the abdominal lining), and perforation (a hole made by boring or piercing) in the peritoneal (lining of the abdominal cavity) and spillage of gastric (acidic fluid in the stomach) contents in the abdominal tissue) for one of two sampled resident (Resident 1), who had a newly inserted GT placed on 4/11/23. On 4/13/23, Resident 1's GT became dislodged (removal or forced out of position) and Director of Nursing (DON) inserted an indwelling catheter (a rubber tube inserted into the bladder to drain urine) in the resident's GT stoma (opening in the abdomen connected to the stomach or intestine). The DON, the Licensed Vocational Nurses (LVN 1 and LVN 2) and Registered Nurse 2 (RN 2) did not implement the facility's policy and procedure for re-insertion of gastrostomy tubes that indicated not to flush the resident's catheter tube with fluids, instilling (put a substance into something in a form of liquid) Jevity (nutritional formula) and medications through the tubing. As a result of this deficient practice, on 4/14/23 at 6:45 AM, Resident 1 was found unresponsive by facility staff with oxygen saturation (level of oxygen in the blood) of 40% (normal level 90-100%), and no blood pressure (a pressure of the blood in the circulatory system). CPR (Cardiopulmonary Resuscitation - an emergency procedure consists of chest compression and artificial and artificial ventilation to preserve brain function, breathing and blood circulation to the body) was initiated by the facility staff and 911 emergency services was called. Resident 1 was pronounced dead by the paramedics at 7:40 AM on 4/14/23. On 5/17/2023 at 4:12 PM, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified, and an IJ template was reviewed in the presence of the Administrator (ADM), DON, clinical Director of Quality Assurance (QA) and Quality Assurance Nurse (QAN) regarding the facility's failure to follow the standards of practice for GT care and Physician Notification by failing to: 1. Notify the physician to obtain an order to transfer Resident 1 to the GACH (general acute hospital), and/or obtain an order for a Nurse Practitioner or Physician Assistant to re-insert GT or obtain an order to contact the GT services in accordance with the facility's policy after Resident 1's GT was dislodged. 2. Verify and confirm with Resident 1's attending physician to have a licensed nurse re-insert an indwelling catheter tube after the resident's GT was dislodged/removed. Re-inserting a GT has been associated with peritonitis. 3. Ensure licensed nurses did not flush Resident 1's GT with water/liquid, enteral feeding (a form of nutrition that is delivered into the digestive system/stomach as a liquid) and administer medications to Resident 1 via indwelling catheter after tube was inserted. On 5/19/2023 at 6:12 PM, the IJ situation was removed after the ADM and the QAN submitted an acceptable IJ Removal Plan (interventions to correct the deficient practices). The surveyor verified and 555755 Page 8 of 17 555755 05/19/2023 Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770

F 0693 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few confirmed the implementations of the IJ removal plan while onsite by observation, interview, and record review. The IJ was removed in the presence of the ADM, QAN, Regional Consultant (RCN 1) and RCN 2. The acceptable IJ Removal Plan included the following actions: 1. The Medical Director was communicated and updated on 5/19/23, policy titled, Re-insertion of Gastrostomy Tubes. The policy has stated that the facility will not reinsert the GT and will transfer the resident to the acute hospital for GT reinsertion. 2. During in-services, instructors educated the license nurses and explained that all GT reinsertions will be done at the hospital only. 3. On 5/17/2023 CEO (Chief Operating Officer), MD (Medical Director) of the specialized GT services, contracted by the facility for GT care, provided training to all available licensed nurses regarding GT dislodgement. 4. Medical Director was informed on 5/19/2023 of the deficiency and participated in QAPI (Quality Assurance Program Improvement-team of staff that plan how to improve the care and quality of life of residents in the facility) and Resident Care Policy Committee to update the policy, titled Re-insertion of Gastrostomy Tubes, and to ensure licensed nurses properly follow policy and procedures to obtain the proper care and treatment for residents' with GT care and treatment according to the current standard of practice for residents with dislodged GT. 5. The facility has notified the licensed nurses of the updated policy via in services and on-shift (during the working time) communication. Cross Reference to F658 Findings: A review of Resident 1's admission record indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included aphasia (unable to speak), blindness, adult failure to thrive (characterized by unexplained weight loss, malnutrition (poor food intake), and disability), with GT and chronic duodenal ulcer (a sore that forms in the lining of the duodenum, the first part of your small intestine). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 4/13/2023, indicated Resident 1 had severely impaired cognition (ability to think, understand and reason) with moderate difficulty of hearing and sometimes could express ideas and wants, and understand others. The MDS indicated Resident 1 was totally dependent with one person assistance on dressing, eating, toilet use and personal hygiene. A review of the GACH (General Acute Care Hospital) record, Resident 1 was admitted to the hospital on [DATE] due to failure to thrive and weakness. On 4/11/23 Resident 1 had an EGD (Endo gastroduodenoscopy- a procedure in which a tube is inserted into the mouth to visualize the gastrointestinal tract) and placement of the GT. The GACH Physician Discharge Summary Report, dated 4/12/23, indicated Resident 1 was clinically stable and improved with no signs and symptoms of respiratory distress (difficulty breathing), vital signs (measurement of the heart rate, blood pressure, body temperature) were stable and was cleared for discharge. 555755 Page 9 of 17 555755 05/19/2023 Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770

F 0693 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few A review of Resident 1's Baseline Care Plan (initial care plan developed during admission), dated 4/12/2023, indicated, Resident 1 had nutritional/fluid impairment (poor nutrition and fluid intake) and was placed on GT feeding. To ensure Resident 1 remained adequately nourished and hydrated (absorption of fluid) without unplanned weight loss, the facility would monitor the resident for aspiration (inhalation of fluid and food in the lungs) and tolerance to GT feeding. The resident's care plan did not indicate nursing interventions on how to address or handle the resident's GT site in the event the GT tube becomes dislodged. A review of Resident 1's Order Summary Report, dated 4/12/2023, Enteral Feed Order indicated: 1. Insert indwelling catheter into the GT site PRN (as needed), if GT becomes displaced (dislodged) temporarily, cover with dry dressing until pending reinsertion of GT. 2. Replace GT (if removed/displaced) by specialized GT services. 3. Transfer the resident to the hospital emergency room (ER) if GT becomes displaced/removed. 4. Administer enteral feeding: Jevity (a nutritional formula) 1.2 calorie (unit of energy) bolus feeding (instilling fluid in a fast rate) 400 cc (cubic centimeter-unit of measurement) three times a day to provide 1200cc/kcal (kilo calorie) per day. 5. Flush the enteral tube with 30 cc of water every shift three times a day. A review of Resident 1's Change of Condition (COC) report, dated 4/13/2023, timed at 9 AM, indicated the Charge Nurse reported to the primary physician (PHY 1) that Resident 1 pulled out his GT. The COC indicated PHY1 ordered to re-insert the GT with an indwelling catheter PRN while waiting for the GT to be replaced by the wound specialist. A review of Resident 1's COC report, dated 4/14/2023, timed at 11AM, indicated (Register Nurse) RN 1 made rounds (tour the facility) at 6:45 AM, and Resident 1 was found unresponsive, without vital signs, oxygen saturation was 40%, and CPR was started by the facility staff. The COC report indicated the paramedic arrived within ten minutes after the 911 emergency services were called. At 7:40 AM, Resident 1 was pronounced dead by the paramedics. During an interview with the Director of Nursing (DON) on 5/16/2023 at 10:04 AM, the DON stated, she inserted an indwelling catheter into Resident 1's GT stoma site, when the resident's GT was found dislodged on 4/13/23. The DON also stated she flushed the indwelling catheter at the stoma site with 50 ml (milliliter, a unit of measurement) of water without verifying if there was a physician's order to insert an indwelling catheter into the stoma site when the GT was dislodged and flush the tubing. During an interview with the Licensed Vocational Nurse (LVN) 1 on 5/16/2023 at 12:31 PM, LVN 1 validated the DON inserted an indwelling catheter when Resident 1's GT dislodged and that an X-ray (images or pictures inside of the body using) was not done to check the GT placement after she had inserted the catheter. LVN 1 explained, he contacted the specialized GT services the morning of 4/13/23 to have the resident's GT replaced after it had been dislodged, however the GT services were unable to see the resident until 4/14/23. During a concurrent interview and record review of the Medication Administration Record (MAR) on 555755 Page 10 of 17 555755 05/19/2023 Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770

F 0693 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 5/16/2023 at 5 PM, LVN 1 stated after the indwelling catheter was inserted by the DON, he signed and confirmed that he instilled Jevity 1.2 calorie, 400cc bolus feeding to Resident 1 and flushed 30cc of water into the indwelling catheter tubing on 4/13/23 at 8 AM. During an interview with the DON and LVN 1 on 5/16/2023 at 5:54 PM and concurrent record review of the Physician's Order Summary Report, dated from 4/12/23 to 4/14/23, the DON and LVN 1 validated there was no physician's order to instill bolus feeding, administer medications, into the Resident 1's tubing after inserting the indwelling catheter into the GT stoma. During an interview with the DON and LVN 1 on 5/16/2023 at 5:55 PM and concurrent record review of the facility's policy and procedure for reinsertion of gastrostomy tubes, (dated 1/24/2017) indicated the facility does not allow licensed nurse to re-insert gastrostomy tubes that become displaced or removed. The procedure indicates if a GT becomes dislodged, removed, or displaced, the GT site will be covered with a clean dressing. If physician orders insertion of indwelling catheter to keep G-Tube orifice open, this will be done; however, no flushing or enteral feedings will be attempted/provided. During an interview on 5/16/23 at 5:57 PM, the DON stated, It is a common sense to continue the feeding without a physician's order, because Resident 1 will get hungry. During an interview on 5/16/2023 at 7:01 PM, the DON stated, she did not get training or certification for inserting an indwelling catheter in the GT site, because she has been a nurse for many years. The DON stated she flushed the indwelling catheter with 50 cc of water and aspirate (to draw in or out using a sucking motion) after she inserted the indwelling catheter on 4/13/23 at around 8AM to 9AM. The DON stated she does recall how far she advanced the catheter tubing into the Resident 1's stomach and the placement was not verifying by X ray. During an interview on 5/17/2023 at 9 AM, PHY 1 stated, he was not informed that Resident 1's GT was dislodged on 4/13/23. PHY 1 stated he did not order the nurses to insert an indwelling catheter into the resident's stoma when the GT site had dislodged. The physician stated, if the GT was pulled out or became dislodged, he would always order the facility to transfer the resident to emergency room so that the resident can be seen by the gastroenterologist (a physician specialized in GT placement) to have the GT reinserted safely and validate GT placement by doing X ray. PHY 1 further stated he did not place the order to start bolus feeding or instill medications into the tube. PHY 1 stated the risk for inserting an indwelling catheter is the tubing could go to a different area of the stomach that could lead to peritonitis. A review of the National Library of Medicine, article titled Gastrostomy Tube Replacement dated January 2023, indicated once the tube is placed, a fistulous gastrocutaneous tract (a skin tract that form to connect the stomach and the skin) is formed in about 2-4 weeks. If a percutaneous endoscopic gastrostomy (PEG, a feeding tube inserted through the skin and the stomach wall) tube is dislodged within a month after placement, then endoscopic (a procedure that allows a doctor to view inside of a person's body using a specialized tube with camera) replacement is recommended. If the tube is dislodged within 4 weeks of initial placement, residents are at significant risk of peritonitis and perforation due to peritoneal spillage of gastric (stomach) contents through the immature track, and replacement should not be attempted without surgical consultation. A blind attempt (inserting a tube into the stomach without camera) to re-insert the tube or even indwelling catheter placement in an immature tract can lead to inadvertent placement of the tube into the peritoneal cavity (the space within the abdomen that contains the intestines, stomach, and liver. 555755 Page 11 of 17 555755 05/19/2023 Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770

F 0693 https://pubmed.ncbi.nlm.nih.gov/29494029/ Level of Harm - Immediate jeopardy to resident health or safety A review of the Journal of Parenteral and Enteral Nutrition related to ASPEN Safe Practices for Enteral Nutrition Therapy. If the gastrostomy tube dislodges in the first 7-10 days after insertion the inserting provider needs to be contacted as soon as possible for further intervention. A dislodged gastrostomy tube can become a medical emergency, as stomach contents are likely to leak into the peritoneum. The tube should not be reinserted blindly at this stage because it may be repositioned into the peritoneum. Residents Affected - Few https://aspenjournals.onlinelibrary.[NAME].com/doi/full/10.1177/0148607116673053 A review of the facility's policy and procedure titled, Gastrostomy Tube Re- insertion, revised on 1/24/2017, indicated the facility does not allow licensed nurse to re-insert GT. However, indwelling catheter may be placed to keep G-Tube stoma open. A review of the facility's policy and procedure titled, Re-Insertion of Gastrostomy Tubes, revised on 1/24/2017, indicated, the facility does not allow licensed nurse to re-insert gastrostomy tubes that become displaced/removed. Procedure indicated, if a gastrostomy tube becomes dislodged, removed, or displaced, the gastrostomy site will be covered with clean dressing. If physician orders insertion of indwelling catheter to keep G-Tube orifice open, this will be done; however, no flushing or enteral feedings will be attempted/provided. 555755 Page 12 of 17 555755 05/19/2023 Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to: Residents Affected - Some 1. Ensure discharged Resident 9 and Resident 10 prescribed medication was removed from one of one inspected Treatment Cart (Treatment Cart 1) upon resident discharge. 2. Ensure the expired house supply medication were removed from one of one inspected Treatment Cart (Treatment Cart 1)on expiration dates indicated. 3. Ensure the label on the bottle of one prescribed medication were legible to identify the medication and the resident ' s name. These deficient practices of failing to store or label medications per the manufacturer ' s requirements or remove expired medications from the medication cart increased the risk that Residents 11, 53 and 69 could have received medication that had become ineffective or toxic due to improper storage or labeling possibly leading to health complications resulting in hospitalization or death. Findings: During an inspection of Treatment Cart 1 and concurrent interview with Licensed Vocational Nurse (LVN) 1 on 5/16/2 at 10:48 AM, the following medications and house supplies were found either expired, stored in a manner contrary to their respective manufacturer ' s requirements, or not labeled with an open date as required by their respective manufacturer ' s specifications: 1. For Resident 9, who had been discharged from the facility on 4/11/23, an open tube of Ciclopirox cream 0.77% (a medication used to treat fungal skin infections, such as ringworm, athlete's foot) was found stored and kept in Treatment Cart 1. 2. For Resident 10, who had been discharged from the facility on 4/8/23, an open tube of Triamcinolone Acetonide (a medication used to treat certain skin diseases, allergies, and rheumatic disorders among others) 0.1% cream was found stored and kept in Treatment Cart 1. 3. An opened betadine (a solution used to help prevent infection in minor cuts, scrapes, and burns) bottle was observed with no open date stored and kept in Treatment Cart 1. 4. An opened anti-dandruff shampoo was observed with no open date and expiration date of 3/2022 stored and kept in Treatment Cart 1. 5. An opened Ammonium lactose (medication is used to treat dry, scaly skin conditions) 12% lotion was observed with no open date and unreadable resident name label stored and kept in Treatment Cart 1. LVN 1 stated the medications above were either stored improperly, expired, and unlabeled with the required open date. LVN 1 stated it was his responsibility to check the treatment cart for expired medications routinely, identify and remove medications that were present in the Treatment Cart for longer than they should be based on their expiration dates. LVN 1 stated as soon as a resident is discharged , the medications should be removed from the Treatment Cart and placed in the medication return bin. LVN 1 stated if a medication is expired and given to a resident, there is a chance it might 555755 Page 13 of 17 555755 05/19/2023 Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770

F 0760 not work as intended and could cause harm to the resident. Level of Harm - Minimal harm or potential for actual harm A review of the facility ' s policy titled, Disposal of Medications and medication-related supplies, dated December 2018, indicated: When medications are expired, discontinued by a prescriber, a resident is transferred or discharged and does not take medications with him/her, or in the event of a resident ' s death, the medications are marked as discontinued, stored in a separate location and later destroyed. Residents Affected - Some 555755 Page 14 of 17 555755 05/19/2023 Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770

F 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to conduct and document a Facility Assessment (a facility wide assessment is a facility plan that define the process of strategizing, or directing, and making decisions on allocating its resources to enable each nursing home to thoroughly assess the needs of its resident population and the required resources to provide the care and services the residents need) to ensure the staffs have sufficient competencies (a measurable knowledge and skills) necessary to provide the care level and types of care needed for residents with GT (a tube inserted into the stomach to deliver fluids, medications and nutritional formula) and GT dislodgement (forced out of position) on a day-to-day operations and emergencies. For one of two sampled residents (Resident 1), had a newly inserted GT was dislodged and was reinserted by DON and was flushed with fluids by the LVN and the DON without confirmation that the GT was in the right position. The DON and the LVN did not have evidence of sufficient competency to perform such task. This deficient practice had resulted in Resident 1 not to recieve the emergency intervention needed to when the resident's GT was dislodgement and placed the resident at high risk for complications related to GT such as peritonitis (a life-threatening infection of the lining in the abdomen), and perforation (hole made by piercing or boring) in the peritoneal (lining of the abdominal cavity) and spillage of gastric [acidic fluid in the stomach] contents in the abdominal tissue). This deficient practice also had the potential for other residents with GT or GT dislodgement to be at risk for similar complications. Cross reference to F693 and F658 Findings: A review of Resident 1's Face Sheet (admission Record) indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted in the facility on 4/12/2023, with diagnoses that included aphasia (unable to speak), blindness, adult failure to thrive (characterized by unexplained weight loss, malnutrition and disability), with gastrostomy tube (a surgical procedure for inserting a tube through the abdomen wall and into the stomach) and chronic duodenal ulcer (a sore that forms in the lining of the duodenum, the first part of your small intestine). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 4/13/2023, indicated Resident 1 had severely impaired cognition (ability to think, understand and reason) with moderate difficulty of hearing and sometimes could express ideas and wants, and understand others. The MDS indicated Resident 1 was totally dependent with one person assistance on dressing, eating, toilet use and personal hygiene. A review of the Medication Administration Record (MAR) for April 2023, indicated, Resident 1 received 30 cc water flush before and after medication administration on 4/13/23 at 8 AM, 12 PM, 4 PM and 5 PM, a total of more than 240 cc of fluid and medications. During an interview with the Director of Nursing (DON) on 5/16/2023 at 10:04 AM, the DON stated, she inserted an indwelling catheter into Resident 1's GT stoma site, when the resident's GT was found dislodged on 4/13/23. The DON also stated she flushed the indwelling catheter at the stoma site with 555755 Page 15 of 17 555755 05/19/2023 Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770

F 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 50 ml (milliliter, a unit of measurement) of water without verifying if there was a physician's order to insert an indwelling catheter into the stoma site when the GT was dislodged and flush the tubing. During an interview with the Licensed Vocational Nurse (LVN) 1 on 5/16/2023 at 12:31 PM, LVN 1 validated the DON inserted an indwelling catheter when Resident 1's GT dislodged and that an X-ray (images or pictures inside of the body using) was not done to check the GT placement after she had inserted the catheter. LVN 1 explained, he contacted the specialized GT services the morning of 4/13/23 to have the resident's GT replaced after it had been dislodged, however the GT services were unable to see the resident until 4/14/23. During an interview with the Director of Staff Development (DSD) on 5/16/23 at 1:08 PM, DSD stated as a facility's practice, The DON and any licensed nurse can re-insert a GT. During an interview on 5/18/23 at 12:23 PM, the Administrator (ADM) stated upon review of the facility's Facility Assessment dated 4/7/23, indicated the Facility Assessment did not specifically indicate the necessary care and services for the residents with GT and GT dislodgement, or the competency and resources needed by the facility staffs to care for the residents with GT. The ADM stated, he will suggest to the QAPI (Quality Improvement Program Improvement- a program that determines the quality of care and life to be delivered to the residents) to add GT service to the Facility Assessment, and confirmed the facility not to accept residents with GT at this time until the staffs are provided training and competencies about GT and GT dislodgement. A review of the facility's policy and procedure, dated 1/2023, titled Facility Assessment, indicated the facility will conduct a facility assessment annually to determine and update the capacity of the facility to meet the needs of and competently care for the residents during the day to day operations and during an emergency. 555755 Page 16 of 17 555755 05/19/2023 Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review, the facility failed to maintain a safe and functional environment by failing to ensure the latch bolt (a part of a lockset that allows the bolt to retract to prevent the door from swinging open) were in good working condition for two of 6 sampled residents (Residents 3 and 5). Resident 3 and 5's cabinets did not fully closed or remained closed inside the shared residents ' rooms to ensure the residents personal belongings were safely stored. This deficient practice had the potential to have Resident 3 and 5's belongings to be misplaced, or subjet to theft and loss. Findings: During an observation of Resident 5 ' s room on 5/16/23 at 11:45 AM, in the presence of the Director of Nurses (DON), the cabinet in the center of the shared room which belonged to Resident 5 was observed open. Upon closer inspection of the cabinet, the latch bolt used to maintain the cabinet closed was observed not working appropriately. The DON stated all cabinet locks must work for the residents to have a safe space to keep their personal belongings in the shared rooms. The DON stated it is all staff ' s responsibility to report if something in a resident ' s room is not working properly and it must be reported immediately once it is found. During an interview, on 5/16/23 at 11:46 AM, CNA 6 stated she had reported the problem to the Maintenance department the other day and wrote it in the maintenance log. CNA 6 stated when something is broken it should be reported immediately. During an observation of Resident 3 ' s Room on 5/16/23 at 11:59 AM., in the presence of the DON, the cabinet of Resident 3 was observed open. Upon closer inspection, the latch bolt used to maintain the cabinet closed was observed not in working condition. During an interview on 5/16/23 at 12:01 PM, w CNA 7 stated the problem to maintenance department over a week ago and wrote it in the maintenance log. A review of the facility ' s binder titled Daily Maintenance Log problem dated 3/8/23 to 5/16/23, did not indicate that the cabinets lock for Resident 3 and 5 ' s rooms had been reported to the Maintenance Department. A review of the facility ' s policy titled, Physical Environment Policy, indicated 1.Maintain all essential mechanical, electrical and patient care equipment in safe operation condition i.e scales, mechanical lifts, beds, bedrails, wheel locks, bed cranks, night stands, dresser, closets, overbed table, shower curtains, wheelchairs, gerichairs and call lights, and etc. 555755 Page 17 of 17