Health inspection·February 10, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to enhance a resident's dignity and respect by failing to ensure for one of eight residents (13) that Resident 13's wet clothes and bedding were changed timely to prevent strong urine odors. This deficient practice had the potential to negatively affect the resident's psychosocial and physical wellbeing by feelings of being neglected and possible skin breakdown. Findings: During a review of Resident 13's admission record, the record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of, but not limited to overactive bladder (a condition that causes a frequent and sudden urge to urinate that may be difficult to control), stress incontinence (happens when physical movement or activity - such as coughing, laughing, sneezing, running or heavy lifting - puts pressure (stress) on your bladder, causing you to leak urine), major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning) and schizoaffective (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania. During a review of Resident 13's Minimum Data Set (MDS - a standardized assessment and screening tool) dated January 24, 2022, the MDS indicated the resident had intact cognition (ability to think, understand and make decisions of daily living). The MDS indicated Resident 13 required supervision with personal hygiene and bathing. During concurrent observation and interview on February 8, 2022, at 9:45 a.m. in room [ROOM NUMBER] B., Resident 13's room had a strong urine odor. Resident 13 was lying in bed covered all over underneath blanket showing part of under pad sheet. Resident 13 stated that she was not wet (with urine), speaking in soft voice, however Resident 13 smelled of urine and her under pad, linen and pants had a yellow to brown stain. During a concurrent observation and interview on February 8, 2022, 10:45 a.m., Certified Nurse Assistant (CNA) 5 stated that Resident 13 was scheduled for a shower that day. CNA 5 stated that she comes to work before 7 a.m. and she said that all residents occupying the B bed (in every room) were scheduled for showering. CNA 5 stated that since she started her shift at 7:00 a.m. until 11:00 a.m., she had not seen Resident 13, and she has no idea what was going on with the resident. CNA 5 then checked Resident 13's pants by hand touching and she stated that it was dry, however Resident 13 still Page 1 of 25 555780 555780 02/10/2022 Villa Del Rio Gardens 7004 East Gage Avenue Bell Gardens, CA 90201

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few smelled of urine. CNA 5 stated that Resident 13 had possibly been wet, but is dry now. CNA 5 stated she did not know how long it would take for Resident 13 clothing to dry out after she had an incontinent episode. CNA 5 stated that she should have checked Resident 13 at the start of the shift, during her morning rounds, since Resident 13 is schedule for showering. CNA 5 stated that leaving Resident 13 in urine-soaked undergarments and bedding, placed her at risk for skin breakdown due to prolong period of being wet with urine. CNA 5 acknowledged that an overactive bladder means resident cannot control their urination making them incontinent. During a review of the Resident 13's shower schedule, the schedule indicated Tuesdays and Saturdays as shower days for Resident 13. During a review of the care plan dated January 26, 2021, the care plan indicated Resident 13 had a potential for skin breakdown due to episodes of urinary incontinence secondary to diagnosis of overactive bladder. The care plan goal indicated the resident skin integrity will continue to be intact daily, developing skin impairment will be detected and treated upon onset if any by 90 days. The care plan intervention indicated to assess incontinence and clean after each episode of incontinence, remind to turn and reposition every 2 hours, assess skin condition daily, administer medication as prescribed and assess for effectiveness, and anticipate need to use the bathroom to void. During a review of facility's policy and procedure (P/P) undated, titled Certified Nursing Assistant, the P/P indicated that the primary purpose of your job description is to provide each of your assigned residents with routine daily nursing care and service in accordance with the resident's assessment and care plan and as may you be directed by supervisors. As CNA, you are delegated the administrative authority, responsibility, accountability necessary for carrying out your assigned duties. Such duties and responsibilities: making resident comfortable, keep residents dry (i.e., change gown, clothing, linen, etc., when wet and soiled and assist with bowel and bladder functions. During a review of facility's P/P undated, titled Activities of Daily Living (ADLs), the P/P indicated that the facility ensures a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. This includes the resident's ability to bathe, dress and groom, toilet use. A review of facility's P/P undated titled Quality of Life-Dignity, indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Treated with dignity means the resident will be assisted in maintain and enhancing his or her self-esteem and self-worth. 555780 Page 2 of 25 555780 02/10/2022 Villa Del Rio Gardens 7004 East Gage Avenue Bell Gardens, CA 90201

F 0636 Level of Harm - Minimal harm or potential for actual harm Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: Residents Affected - Few a. Ensure the facility offered/implemented non-pharmacological interventions for one of one Residents 33, before starting Anti-Psychotic (a type of psychiatric medication which is used to treat psychosis [a mental disorder characterized by a disconnection from reality]) medication. b. Ensure that Residents 33 was assessed for the appropriateness of anti-psychotic medication before starting the medications. These deficient practices had the potential to result in Resident 33 receiving unnecessary medications, and adverse effects from those medications. Findings: During a review of the admission record, the record indicated Resident 33 was originally admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included diabetes mellitus (irregular levels of blood sugar), hepatic failure (loss of liver function), Depression (a mood disorder resulting in feelings of sadness that can affect quality of daily life), and schizophrenia (a mental condition resulting in a break from reality, disorganized thoughts and speech). During a review of the MDS dated [DATE], the MDS indicated Resident 33 has clear speech usually understood and understand by others. Resident 33 required supervision with set up help for bed mobility and eating, limited assistance with one person assists on transfer, personal hygiene, locomotion (how resident moves) on/off unit, walking in the room and corridor, getting dressed, transfers, and toilet use. During a review of Resident 33's physicians orders dated 12/7/2021, the orders indicated: a. Lexapro (medication used to treat depression), 20 milligrams (m.g a unit of measure), 1 tablet daily for depression manifested by negative statements about self, complaints of sadness. b. Abilify (a medication used to treat disorders involving breaks with reality), 15 m.g, 1 tablet daily for schizophrenia manifested by hearing voices. During an interview on 02/10/2022 at 9:07 a.m., with Licensed Vocational Nurse (LVN4), LVN 4 confirmed that there was no evidence of non-pharmacological interventions in Resident 33's clinical records, before residents were medicated with antipsychotics. LVN 4 stated that since staff were familiar with every resident, when a resident had behavioral changes, LVN's let the psychiatrists know, then it was up to the Psychiatrist if he/she wanted to initiate a pharmacological approach. During an interview and record review on 2/10/2022 at 10:10 a.m. with LVN1, LVN 1 stated that they do not assess Resident 33 before start of psychotropic medication, LVN 1 stated that she was not familiar with the psychotropic assessment form that was indicated in the medical chart. LVN 1 added there was no documentation that non- pharmacological interventions were documented on the medical record prior to start of the anti- psychotic medication. 555780 Page 3 of 25 555780 02/10/2022 Villa Del Rio Gardens 7004 East Gage Avenue Bell Gardens, CA 90201

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview and record review on 2/11/2022 at 9:56 a.m. with Infection Preventionist(I/P), I/P stated that residents that are on Anti- Psychotic medication does not have an assessment prior to start of medication, when asked if non- pharmacologic interventions are documented in the chart, IP stated that staff do it but don't document anywhere in the chart. During an interview on 2/10/2022 at 11:15 a.m., with Director of Nursing (DON), DON stated that there is no psychotropic assessment done with any of the resident that are taking anti- psychotic medications, DON added that evaluation is made by the psychiatrist if medication is necessary for the resident to continue or discontinue medication. During a record review of policy and procedure(p/p) dated 01/22 title Medication monitoring medication management indicated when selecting medications and non-pharmacological approaches members of the IDT, including the resident participate in the care process to identify, assess address, advocate for, monitor and communicate the residents needs and changes in condition. Medication management is based on the care process and includes recognition or identification of the problem/need, assessment, diagnosis/cause identification, management/treatment, monitoring and revising interventions, as warranted as well as documenting management steps. During a review of the undated policy and procedure(P/P) titled admission assessment and follow up: Role of the nurse indicated, conduct supplemental assessment, activity level, pain assessment, fall risk assessment, neurological assessment, skin assessment, functional assessment, behavioral assessment. The following information should be recorded in the resident's medical record, the date and time the assessment was performed. 555780 Page 4 of 25 555780 02/10/2022 Villa Del Rio Gardens 7004 East Gage Avenue Bell Gardens, CA 90201

F 0641 Ensure each resident receives an accurate assessment. 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 accurately assess two of eight sampled residents' skin integrity (Residents 76 and 179). Cross Referenced F686. Residents Affected - Some This deficient practice resulted in Resident 179 developing an unstageable pressure ulcer (localized areas of injury that occur when skin and underlying tissue are compressed between a bony prominence and an external surface such as a mattress) on the sacrococcygeal (base of the spine, tailbone) area and Resident 76 developing a deep tissue injury ([DTI] an injury to a residents underlying tissue below the skin's surface that results from prolonged pressure in an area of the body) on the left heel. Findings: a. A review of Resident 179's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 179's diagnoses included status post left hip surgery, diabetes mellitus (high levels of sugar in the blood), polyneuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet), Alzheimer's disease (brain disorder that causes problems with memory, thinking and behavior), dementia (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), anemia (a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues), and muscle weakness. A review of Resident 179's Quarterly Minimum Data Set (MDS), a standardized assessment and screening tool, dated January 24, 2022, indicated the resident had severe cognitive (ability to think and reason) impairment. The MDS indicated Resident 179 required limited assistance with transfer, dressing, toilet use, personal hygiene and bathing. The MDS indicated Resident 179 was at risk for pressure ulcer development. A review of Resident 179's Braden Scale for Predicting Pressure Ulcers dated January 29, 2022 indicated Resident 179 was a high risk for pressure ulcer development. A review of Resident 179's admission Body assessment dated [DATE], indicated Resident 179 had a surgical wound to the left hip, otherwise the resident's skin integrity was intact. A review of Resident 179's Physician's admission Order dated January 29, 2022, indicated that there were no pressure injury/ulcer preventative measures ordered. A review of the facility's Change of Condition logbook dated from January 29, 2022, to February 6, 2022, indicated that there were no reported records that Resident 179 had skin breakdown. A review of the facility's Treatment Monitoring logbook dated February 2022, indicated that there was no treatment monitoring recorded for Resident 179's sacrum and coccyx areas. During a concurrent observation and interview on February 9, 2022, at 11:46 a.m., in Resident 179's room, Resident 179 was lying in bed in a supine (face up) position with an abduction pillow (a device used to prevent your hip from moving out of the joint) in between the legs. Licensed Vocational Nurse (LVN) 1 and LVN 4 were observed performing a routine body skin assessment for Resident 179. 555780 Page 5 of 25 555780 02/10/2022 Villa Del Rio Gardens 7004 East Gage Avenue Bell Gardens, CA 90201

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 179 was observed to have an unstageable wound (full thickness tissue loss) covered with slough (dead, separated tissue) and eschar (collection of dry, dead tissue within a wound) to the sacrococcygeal area measuring approximately three (3) centimeters (cm) by 3 cm. LVN 1 and LVN 4 stated they did not know Resident 179 had developed a pressure ulcer. LVN 4 stated a skin assessment should have been performed properly and thoroughly on a daily basis for Resident 179 who was at risk for developing pressure ulcers. During an interview on February 10, 2022, at 10:23 a.m., LVN 1 stated certified nurse assistants (CNAs) were supposed to inform the licensed nurses of any skin changes on the residents. LVN 1 stated the registered nurses (RNs) performed a resident skin assessment on admission, and CNAs performed skin assessments on every shower day and reported any abnormal findings to the charge nurse. During an interview on February 10, 2022, at 2:30 p.m., Certified Nurse Assistant (CNA) 8 stated it was Resident 179's shower day but confirmed he did not shower Resident 179 on that day (2/10/22). CNA 8 stated the charge nurse and the supervisor told him not to touch Resident 179 because of the surgical wound on the resident's left hip. CNA 8 stated there were no other wounds on Resident 179 per his knowledge. CNA 8 stated the facility had a resident turning schedule that staff followed, but there was no documentation indicating Resident 179 was turned every two (2) hours. A review of Resident 179's Care Plan dated January 30, 2022, and titled Pressure Ulcer Risk, indicated a goal for Resident 179 was to minimize pressure ulcer risk daily for 3 months. The staff's interventions included to check skin for presence of sores, breakdowns, impairment, and skin trauma, notify physician if reddened areas, change in weight, change in intake or abnormal laboratory, assist with position changes, and use pressure reducing devices. A review of the Nurse Assistant Notes logbook dated February 1, 2022, to February 10, 2022, indicated there was no documentation Resident 179 had been repositioned every 2 hours and had no pressure reducing devices used during that timeframe. A review of the facility's Daily Skin Inspection Tool dated from January 29, 2022, to February 10, 2022, used by CNAs during the residents shower day indicated that Resident 179's skin integrity was not inspected. There was no record Resident 179 received a shower during this period. During an interview on February 10, 2022, at 11:24 a.m., the Director of Nursing (DON) stated for newly admitted and readmitted residents the licensed nurses were expected to perform a resident admission assessment which included a body assessment. The DON stated all licensed nurses were expected to perform a daily skin assessment during the residents' shower days. The DON was not able to explain why Resident 179's unstageable pressure ulcers at the sacrum and coccyx areas was not identified timely during the earlier stage. b. A review of Resident 76's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 76's with diagnoses included bronchitis (an inflammation of the lining of your bronchial tubes, which carry air to and from your lungs), diabetes mellitus, Alzheimer's disease, dementia, and muscle weakness. A review of Resident 76's Quarterly Minimum Data Set (MDS - a standardized assessment and screening tool) dated January 24, 2022, indicated the resident has Brief Interview for Mental Status (BIMS) score was 0 with interpretation of severe impaired cognition. The MDS indicated Resident 76 required extensive assistance with bed mobility, dressing, personal hygiene and total dependence with eating, 555780 Page 6 of 25 555780 02/10/2022 Villa Del Rio Gardens 7004 East Gage Avenue Bell Gardens, CA 90201

F 0641 toilet, bathing. The MDS indicated Resident 76 was at risk for pressure ulcer development. Level of Harm - Minimal harm or potential for actual harm A review of Resident 76's readmission Body assessment dated [DATE], indicated the resident's skin integrity was intact. Residents Affected - Some A review of Resident 76's Physician's admission Orders dated January 2, 2022, indicated there was no preventative measures ordered to decrease the resident's risk of pressure ulcer development. A review of the facility's Change of Condition logbook dated from January 7, 2022, to February 6, 2022, indicated Resident 76 was reported to have a DTI with no specific location documented on January 20, 2022. During a concurrent observation and interview with LVN 4 on February 10, 2022, at 9:30 a.m., Resident 76 was observed lying in bed with both knees in a bent position with a pillow underneath his knees and both heels were touching the mattress. Resident 76 was observed with a DTI on the left heel measuring approximately 2 cm by 2 cm. LVN 4 stated there was no care plan initiated for Resident 76's DTI of the left heel. LVN 4 confirmed that a wound specialist had not seen Resident 76 and there was no treatment ordered by the physician. LVN 4 stated the facility had issues with the wound care contractor. LVN 4 stated he followed up with the wound specialist multiple but did not document. LVN 4 stated the facility did not have a wound care nurse at the time and that the charge nurses were responsible for the current wound care of residents. During an interview on February 10, 2022, at 9:48 a.m., CNA 6 stated she followed Resident 76's turning schedule every 2 hours, but she stated that there was no documentation of the repositioning in the resident's chart. A review of Resident 76's Nursing Notes from January 20, 2022, to January 25, 2022, indicated that LVN 6 noted the resident's DTI was reported by a CNA when a shower was given. Physician was notified and referred to a wound specialist, however, no follow up notes with wound specialist was documented. A review of the facility's undated policy and procedure (P/P) titled, Change in a Resident's Condition or Status, indicated that the facility shall promptly notify the resident, his or her attending Physician, and representative of change in the resident's medical/mental condition and/or status. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-call Physician when there has been: 1. An accident or incident involving the resident. 2. A discovery of injuries of an unknown source. 3. A significant change in the resident's physical/ emotional/ mental condition. 4. A need to alter the resident's medical treatment significantly. 5. Refusal of treatment or medications two (2) or more consecutive times. 6. Instructions to notify the physician of changes in the resident's condition. 555780 Page 7 of 25 555780 02/10/2022 Villa Del Rio Gardens 7004 East Gage Avenue Bell Gardens, CA 90201

F 0641 Level of Harm - Minimal harm or potential for actual harm A review of the facility's undated P/P titled, Charge Nurse, indicated that the primary purpose of the job position was to provide direct nursing care to the residents and to supervise the day-to day nursing activities performed by the CNAs. All care and supervision must be in accordance with the current federal, state, local standards, guidelines, regulations and laws that govern out facility. Residents Affected - Some 1. Observe, report and record findings/changes in resident conditions to physician, and nursing personnel. 2. Report changes of condition to physician and families. Follow-up on orders and document. 3. Communicate resident's condition and nursing care to appropriate people (i.e. supervisor, administrator, physician, family, etc. A review of the facility's undated P/P titled, Resident Assessment, indicated that this facility makes a comprehensive assessment of each resident's needs, strengths, goals, life history and preferences using the resident assessment instrument (RAI) specified by CMS. 555780 Page 8 of 25 555780 02/10/2022 Villa Del Rio Gardens 7004 East Gage Avenue Bell Gardens, CA 90201

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop a person- centered care plan for two of two sampled residents (46 and 43), who were taking anti- psychotic (a type of psychiatric medication which is used to treat psychosis [a mental disorder characterized by a disconnection from reality]) medication. This deficiency had the potential to result in a delay in delivery of care and services. Findings: During a review of the admission record, the record indicated Resident 46 was originally admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors) chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe), and schizophrenia (a mood and thought disorder that causes a break from reality). During a review of the Minimum Data Set (MDS- a comprehensive assessment tool) dated 12/22/2021, indicated Resident 46 has unclear speech usually understood and understand by others. Resident 46 required limited assistance with one-person physical assistance for bed mobility and personal hygiene, extensive assistance locomotion (how resident moves) on/off unit, walking in the corridor, dressing, transfer, and toilet use. During a record review of the Physician's order dated February 2022 Resident 46 taking Seroquel 300 mg twice a day, for schizophrenia manifested by striking out with no cause. During a review of the admission record, the record indicated Resident 43 was originally admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe), anxiety disorder( a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome)/ During a review of the Minimum Data Set (MDS- a comprehensive assessment tool) dated 12/20/2021, indicated Resident 43 has unclear speech usually understood and understand by others. Resident 43 required limited assistance with one-person physical assistance for bed mobility and personal hygiene, extensive assistance locomotion (how resident moves) on/off unit, walking in the corridor, dressing, transfer, and toilet use. During a record review of the physician's order dated February 2022, Resident 43's taking Risperadal 2 milligrams by mouth twice a day for schizophrenia manifested by physical aggression without a cause. During an interview on 02/10/2022 at 11:15 a.m. with Director of Nursing (DON), DON stated that care plan should be initiated upon admission, every time there is significant change of condition, or any update with medication or approaches with interventions. During an interview on 02/10/2022 at 3:02 p.m. with I/P, IP stated that Resident 43 was taking risperdal since 8/2/2021 care plan was not done until 9/20/2021, IP added that the care plan should 555780 Page 9 of 25 555780 02/10/2022 Villa Del Rio Gardens 7004 East Gage Avenue Bell Gardens, CA 90201

F 0656 reflect the exact physician order, or it was not resident specific. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 02/10/2022 at 4:27p.m. with I/P, of Resident 43 and 46's medical records, IP stated that Physician's order should match the care plan. The care plan is important to give proper care or interventions for residents. I/P stated that Resident 46 was on psychotropic medication care plan, however the care plan was not initiated and updated when Resident 46 started taking the medications. IP stated that whoever gets the order should update the care plan. Resident 43's care plan did not reflect dosage or route of the psychotropic medication, I/P stated it was not specific for resident. Residents Affected - Few During a review of the undated policy and procedure(P/P) titled Care Plans- Comprehensive, the P/P indicated an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. 555780 Page 10 of 25 555780 02/10/2022 Villa Del Rio Gardens 7004 East Gage Avenue Bell Gardens, CA 90201

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure Resident 20 received the necessary care and services needed to attain the highest practicable level of physical, mental, and psychosocial well-being. Residents Affected - Few These deficient practices had the potential to result in Residents 20 not receiving the quality of care that was needed. Findings: During a review of Resident 20's Face Sheet (admission record), the Face Sheet indicated Resident 20 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 20's diagnoses included essential hypertension (high blood pressure), history of falling, hyperlipidemia (high level of fat particles in the blood), chronic obstructive pulmonary disease ([COPD] a condition involving constriction of the airways and difficulty or discomfort in breathing, pressure-induced deep tissue damage of left buttock (injury caused by pressure to areas of skin when resting in a position for too long). During a review of Resident 20's Minimum Data Set (MDS a comprehensive assessment and care planning tool) dated 11/25/2021, the MDS indicated Resident 20 had intact cognitive function (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). During review of Resident 20's Care Plan (CP) for compromised mobility, dated 01/22/2022 , the CP indicated to provide assistance with position changes as needed; CP for pain due to sacral wound, dated 01/23/2022 indicated to stay with the resident and provide one on one interaction; CP for assistance with activities of daily living (ADL's), dated 01/22/2022 indicated to keep resident clean and dry as much as possible; CP for wound dehiscence (splitting open of a wound) from previous surgery at the sacral area, dated 12/22/2022 indicated to keep skin clean and dry, protect skin from moisture and reposition every two hours as needed. During an observation on 02/09/2022 at 08:41 a.m., Resident 20 was lying in bed, on the top sheet, with foul smelling wound discharge from his sacral (lowest part of the spine, just above the tailbone) area. During an observation on 02/09/2022 at 10:11 a.m., Resident 20 was still lying in bed, on the top sheet with foul smelling wound discharge from his sacral area . During an observation on 02/09/2022 at 12:03 p.m., Resident 20 was lying to his left side with Sacro coccyx wound dressing saturated with foul smelling drainage and still dripping to the top sheet of the bed. During an observation on 02/09/2022 at 02:41 p.m., Resident 20 was lying to his left side with Sacro coccyx wound dressing saturated with foul smelling drainage and still dripping on the top sheet of the bed. During an interview on 02/10/2022 at 11:17 a.m., the certified nursing assistant (CNA 6) stated 555780 Page 11 of 25 555780 02/10/2022 Villa Del Rio Gardens 7004 East Gage Avenue Bell Gardens, CA 90201

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that Resident 20 must be turned from side to side every two hours as scheduled and ordered, but when CNA 6 were asked why Resident 20 were soaked with foul smelling wound discharges and was not cleaned, CNA 6 replied that she does not have any excuses for the incident. CNA 6 stated that the practice can make the wound get worse and can lead to a deeper wound infection. When CNA 6 were asked why there were small flies all over the wound drainage and top sheet of the bed, CNA 6 replied that foul smelling discharges attracts flies. During an interview on 02/10/2022 at 11:22 a.m., CNA 5 stated that Residents must be repositioned every two hours to prevent the wound from getting worsts and if I was the resident and was soaking with foul smelling wound discharge, it would make me very uncomfortable and affect my psychosocial being. During an interview on 02/10/2022 at 11:34 a.m., the licensed vocational nurse (LVN 1) acknowledged that it was a quality-of-care issue and stated that if the assigned CNA was turning Resident 20 every two hours, then the top sheet should have been clean and not soaked with wound drainage. During an interview on 02/10/2022 at 11:45 a.m., LVN 1 stated that if it was her or a family member then it would affect the psychosocial aspect of the resident, turning the resident every two hours as ordered is one of the ways to help promote wound healing by taking the pressure out of the way so that the wound can breathe. LVN 1 acknowledged that the reason why there's a lot of small flies on the top sheet was due to foul smelling drainage that attracted insects and it was also an infection control issue. During the review of facility's policy and procedure (P/P) titled Provision of Quality Care undated, the P/P indicated: Based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the residents' choices. Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. 555780 Page 12 of 25 555780 02/10/2022 Villa Del Rio Gardens 7004 East Gage Avenue Bell Gardens, CA 90201

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of eight sampled residents (Resident 76 and 179) received care to prevent pressure ulcer (localized areas of injury that occur when skin and underlying tissue are compressed between a bony prominence and an external surface such as a mattress) development, by failing to: Residents Affected - Few 1. Implement Resident 179's care plan which indicated staff were to check the resident's skin for presence of sores, breakdown, impairment, and skin trauma, and use pressure reducing devices. 2. Implement its policy which indicated to initiate a care plan to address Resident 76's newly developed deep tissue injury ([DTI] an injury to a residents underlying tissue below the skin's surface that results from prolonged pressure in an area of the body) to the left heel, obtain treatment orders, and monitor the effectiveness of the treatment. This deficient practice resulted in Resident 179 developing an unstageable pressure ulcer on the sacrococcygeal (base of the spine, tailbone) area and Resident 76 developing a DTI on the left heel. Findings: a. A review of Resident 179's admission Record indicated the resident was admitted to the facility on [DATE], and last readmitted on [DATE]. Resident 179's diagnoses included status post left hip surgery, diabetes mellitus (high levels of sugar in the blood), polyneuropathy (damage to the nerves outside the brain and spinal cord), Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), dementia (disorder affecting memory, thinking and social abilities severely enough to interfere with your daily life), anemia (a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues) and muscle weakness. A review of Resident 179's Quarterly Minimum Data Set (MDS), a standardized assessment and screening tool, dated January 23, 2022, indicated the resident had severe cognitive (ability to think and reason) impairment. The MDS indicated Resident 179 required limited assistance with transfer, dressing, toilet, personal hygiene and bathing. The MDS indicated Resident 179 was at risk for pressure ulcer development. A review of Resident 179's admission Body assessment dated [DATE], indicated Resident 179 had a surgical wound on her left hip, otherwise the resident's skin integrity was intact. A review of Resident 179's Braden Scale for Predicting Pressure Ulcers dated January 29, 2022, indicated the resident scored a 12, indicating a high risk. A review of Resident 179's Physician's admission Order dated January 29, 2022, indicated that there were no pressure ulcer preventions ordered. A review of the facility's Change of Condition logbook dated from January 29, 2022, to February 6, 2022, indicated that there were no reported records that Resident 179 had skin breakdown. A review of the facility's Treatment Monitoring logbook for the month of February 2022, indicated there was no treatment monitoring documented for Resident 179's sacrum (base of the spine) and coccyx 555780 Page 13 of 25 555780 02/10/2022 Villa Del Rio Gardens 7004 East Gage Avenue Bell Gardens, CA 90201

F 0686 areas. Level of Harm - Actual harm During a concurrent observation and interview on February 9, 2022, at 11:46 a.m., in Resident 179's room, Resident 179 was lying in bed in a supine (face up) position with an abduction pillow (a device used to prevent your hip from moving out of the joint) in between the legs. Licensed Vocational Nurse (LVN) 1 and LVN 4 were observed performing a routine body skin assessment for Resident 179. Resident 179 was observed to have an unstageable wound (full thickness tissue loss) covered with slough (dead, separated tissue) and eschar (collection of dry, dead tissue within a wound) to the sacrococcygeal area measuring approximately three (3) centimeters (cm) by 3 cm. LVN 1 and LVN 4 stated they did not know Resident 179 had developed a pressure ulcer. LVN 4 stated a skin assessment should have been performed properly and thoroughly on a daily basis for Resident 179 who was at risk for developing pressure ulcers. Residents Affected - Few During an interview on February 10, 2022, at 10:23 a.m., LVN 1 stated certified nurse assistants (CNAs) were supposed to inform the licensed nurses of any skin changes on the residents. LVN 1 stated registered nurses (RNs) performed resident skin assessment on admission, and CNAs performed skin assessments on every shower day and were to report any abnormal findings. During an interview on February 10, 2022, at 2:30 p.m., Certified Nurse Assistant (CNA) 8 stated it was Resident 179's shower day but confirmed he did not shower Resident 179 on that day (2/10/22). CNA 8 stated the charge nurse and the supervisor told him not to touch Resident 179 because of the surgical wound on the resident's left hip. CNA 8 stated there were no other wounds on Resident 179 per his knowledge. CNA 8 stated the facility had a resident turning schedule that staff followed, but there was no documentation indicating Resident 179 was turned every two (2) hours. A review of Resident 179's Care Plan dated January 30, 2022, and titled Pressure Ulcer Risk, indicated a goal for Resident 179 was to minimize pressure ulcer risk daily for 3 months. The staff's interventions included to check skin for presence of sores, breakdowns, impairment, and skin trauma, notify physician if reddened areas, change in weight, change in intake or abnormal laboratory, assist with position changes, and use pressure reducing devices. A review of the Nurse Assistant Notes logbook dated February 1, 2022, to February 10, 2022, indicated there was no documentation Resident 179 had been repositioned every 2 hours and had no pressure reducing devices used during that timeframe. A review of the facility's Daily Skin Inspection Tool dated from January 29, 2022, to February 10, 2022, used by CNAs during the residents shower day indicated that Resident 179's skin integrity was not inspected. There was no record Resident 179 received a shower during this period. During an interview on February 10, 2022, at 11:24 a.m., the Director of Nursing (DON) stated for newly admitted and readmitted residents the licensed nurses were expected to perform a resident admission assessment which included a body assessment. The DON stated all licensed nurses were expected to perform a daily skin assessment during the residents' shower days. The DON was not able to explain why Resident 179's unstageable pressure ulcers at the sacrum and coccyx areas was not identified timely during the earlier stage. b. A review of Resident 76's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 76's diagnoses included diabetes mellitus, Alzheimer's disease, dementia, and muscle weakness. 555780 Page 14 of 25 555780 02/10/2022 Villa Del Rio Gardens 7004 East Gage Avenue Bell Gardens, CA 90201

F 0686 Level of Harm - Actual harm A review of Resident 76's Quarterly MDS dated [DATE], indicated the resident had severe cognitive impairment. The MDS indicated Resident 76 required extensive assistance with bed mobility, dressing, personal hygiene and total dependence with eating, toilet use, and bathing. The MDS indicated Resident 76 was at risk for pressure ulcer development. Residents Affected - Few A review of Resident 76's readmission Body assessment dated [DATE], indicated the resident's skin integrity was intact. A review of Resident 76's Physician's admission Orders dated January 2, 2022, indicated there was no preventative measures ordered to decrease the resident's risk of pressure ulcer development. A review of the facility's Change of Condition logbook dated from January 7, 2022, to February 6, 2022, indicated Resident 76 was reported to have a DTI with no specific location documented on January 20, 2022. A review of Resident 76's Change of Condition (COC) dated January 20, 2022, indicated a DTI was identified to the resident's left heel. There was no documentation that treatment was ordered. During a concurrent observation and interview with LVN 4 on February 10, 2022, at 9:30 a.m., Resident 76 was observed lying in bed with both knees in a bent position with a pillow underneath his knees and both heels were touching the mattress. Resident 76 was observed with a DTI on the left heel measuring approximately 2 cm by 2 cm. LVN 4 stated there was no care plan initiated for Resident 76's DTI of the left heel. LVN 4 confirmed that a wound specialist had not seen Resident 76 and there was no treatment ordered by the physician. LVN 4 stated the facility had issues with the wound care contractor. LVN 4 stated he followed up with the wound specialist multiple times but did not document. LVN 4 stated the facility did not have a wound care nurse at the time and that the charge nurses were responsible for the current wound care of residents. During an interview on February 10, 2022, at 9:48 a.m., CNA 6 stated she followed Resident 76's turning schedule every 2 hours, but she stated that there was no documentation of the repositioning in the resident's chart. A review of Resident 76's Nursing Notes from January 20, 2022, to January 25, 2022, indicated that LVN 6 noted the resident's DTI was reported by a CNA when a shower was given. Physician was notified and referred to a wound specialist, however, no follow up notes with wound specialist was documented. A review of the facility's undated policy and procedure (P/P) titled, Change in a Resident's Condition or Status, indicated that the facility shall promptly notify the resident, his or her attending Physician, and representative of change in the resident's medical/mental condition and/or status. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-call Physician when there has been: 1. An accident or incident involving the resident. 2. A discovery of injuries of an unknown source. 3. A significant change in the resident's physical/ emotional/ mental condition. 555780 Page 15 of 25 555780 02/10/2022 Villa Del Rio Gardens 7004 East Gage Avenue Bell Gardens, CA 90201

F 0686 4. A need to alter the resident's medical treatment significantly. Level of Harm - Actual harm 5. Refusal of treatment or medications two (2) or more consecutive times. Residents Affected - Few 6. Instructions to notify the physician of changes in the resident's condition. A review of the facility's undated P/P titled, Pressure Ulcers Prevention Guidelines, indicated to implement evidenced-based interventions for all residents who are assessed at [NAME] or who have a pressure ulcer present. Preventive skin care: 1. Inspect skin while providing care, paying close attention to bony prominences. 2. Inspect skin underneath medical devices at least twice daily. Keep skin clean and dry underneath. Adjust devices as needed for proper fit. 3. Avoid positioning the resident on an area of redness whenever possible. 4. Keep the skin clean and dry. Manage incontinence with absorptive products. Check every 2 hours, and provide perineal care as needed after incontinent episodes. Diaper usage in bed is not recommended. Protect skin from exposure to excessive moisture with barrier products. 5. Moisturize dry skin. 6. Use positioning devices or folded linens to keep body surfaces from rubbing against one another. Nutrition/Hydration: Consult for nutritional screen for each resident who is at risk for a pressure ulcer or has a pressure ulcer present. Repositioning: Reposition all residents at risk of, or with existing pressure ulcers, unless contraindicated due to medical condition. Utilize small shifts in repositioning, if otherwise contraindicated. Pressure relieving devices: Support surfaces do not eliminate the need for turning and repositioning. Provide alternative support surfaces as needed. Considerations for utilizing specialized support surfaces. A review of the facility's undated P/P titled Wound Treatment Guidelines, indicated to promote wound healing of various types of wounds, the facility must provide evidence-based treatments in accordance with current standards of practice and physician orders. 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing and frequency of dressing change. 2. In the absence of treatments orders the license nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatments nurse. 555780 Page 16 of 25 555780 02/10/2022 Villa Del Rio Gardens 7004 East Gage Avenue Bell Gardens, CA 90201

F 0686 3. Treatments will be documented on the Treatment Administration Record. Level of Harm - Actual harm 4. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Residents Affected - Few 555780 Page 17 of 25 555780 02/10/2022 Villa Del Rio Gardens 7004 East Gage Avenue Bell Gardens, CA 90201

F 0710 Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. 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 the resident's physician took an active role in supervising the skin impairment of one of eight sampled residents (Resident 76), who was admitted to the facility with intact skin integrity, as per their policy. Residents Affected - Few This deficient practice had the potential for delay in necessary services, poor continuity of care and follow up on Resident 76's deep tissue injury ([DTI] an injury to a residents underlying tissue below the skin's surface that results from prolonged pressure in an area of the body) to the left heel. Findings: A review of Resident 76's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 76's diagnoses included diabetes mellitus (high levels of sugar in the blood), Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), dementia (disorder affecting memory, thinking and social abilities severely enough to interfere with your daily life), and muscle weakness. A review of Resident 76's Quarterly MDS dated [DATE], indicated the resident had severe cognitive impairment. The MDS indicated Resident 76 required extensive assistance with bed mobility, dressing, personal hygiene and total dependence with eating, toilet use, and bathing. The MDS indicated Resident 76 was at risk for pressure ulcer development. A review of Resident 76's readmission Body assessment dated [DATE], indicated the resident's skin integrity was intact. A review of Resident 76's History of Present Illness dated January 6, 2022, indicated Resident 76 was dependent on staff for activities of daily living ([ADLs] self-care activities performed daily) including eating, transfers, bed mobility and toileting. A review of the facility's Change of Condition logbook dated from January 7, 2022, to February 6, 2022, indicated Resident 76 was reported to have a DTI with no specific location documented on January 20, 2022. During a concurrent observation and interview with LVN 4 on February 10, 2022, at 9:30 a.m., Resident 76 was observed lying in bed with both knees in a bent position with a pillow underneath his knees and both heels were touching the mattress. Resident 76 was observed with a DTI on the left heel measuring approximately 2 centimeters ([cm] unit of measurement) by 2 cm. LVN 4 stated there was no care plan initiated for Resident 76's DTI of the left heel. LVN 4 confirmed that a wound specialist had not seen Resident 76 and there was no treatment ordered by the physician. LVN 4 stated the facility had issues with the wound care contractor. LVN 4 stated he followed up with the wound specialist multiple times but did not document. LVN 4 stated the facility did not have a wound care nurse at the time and that the charge nurses were responsible for the current wound care of residents. During an interview on February 10, 2022, at 9:48 a.m., CNA 6 stated she followed Resident 76's turning schedule every 2 hours, but she stated that there was no documentation of the repositioning in the resident's chart. 555780 Page 18 of 25 555780 02/10/2022 Villa Del Rio Gardens 7004 East Gage Avenue Bell Gardens, CA 90201

F 0710 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 76's Nursing Notes dated January 20, 2022, indicated LVN 6 noted the resident's DTI was reported by a CNA when a shower was given. Physician was notified and referred to a wound specialist. A review of Resident 76's Nursing notes from January 20, 2022, to January 25, 2022, indicated there was no written notes that a wound specialist saw Resident 76 for her DTI to the left heel. A review of the facility's undated policy and procedure (P/P) titled, Wound Treatment Guidelines, indicated to promote wound healing of various types of wounds, it is the policy of the facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing and frequency of dressing change. 2. In the absence of treatments orders the license nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatments nurse. 3. Treatments will be documented on the Treatment Administration Record. 4. The effectiveness of treatments will be monitored through ongoing assessment of the wound. A review of the facility's undated P/P titled, Physician Visits and Physician Delegation, indicated to ensure the physician takes an active role in supervising the care of residents. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident's immediate care and needs. A resident's attending physician may delegate the task of writing therapy orders to a qualified therapist who is acting within the scope of practice as defined by state of law and is under the supervision of the physician. 555780 Page 19 of 25 555780 02/10/2022 Villa Del Rio Gardens 7004 East Gage Avenue Bell Gardens, CA 90201

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 perform psychotropic assessments and provide non-pharmacological interventions to Residents 6, 33, 43, and 49 prior to start of psychotropic medications (medication that affects brain activities associated with mental processes and behavior) to ensure the use of psychotropics were necessary to treat a specific condition; and perform a gradual dose reduction ([GDR] an attempt to decrease or discontinue psychotropic medication after no more than three months after starting on the psychotropic medication) for Resident 49. These deficient practices had the potential to result in Residents 6, 33, 43, and 49 receiving unnecessary medications. Findings: A review of Resident 43's admission Record indicated Resident 43 was initially admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 43's diagnoses included chronic obstructive pulmonary disease ([COPD] group of lung diseases that block airflow and make it difficult to breathe), anxiety disorder (feeling of worry, nervousness, or unease), and other lack of coordination. During a review of Resident 43's Minimum Data Set (MDS), a resident assessment and care-screening tool), dated 12/20/2021, the MDS indicated Resident 43 was usually understood by others and was able to understand others. The MDS indicated Resident 43 required limited assistance with one-person physical assistance for bed mobility and personal hygiene, and extensive assistance with locomotion (how resident moves) on/off unit, walking in the corridor, dressing, transfer, and toilet use. A review of Resident 49's admission Record indicated Resident 49 was initially admitted to the facility on [DATE]. Resident 49's diagnoses included hyperlipidemia (elevated lipids in the blood), Alzheimer's disease (progressive mental deterioration due to generalized degeneration of the brain), and epilepsy unspecified (neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions). During a review of Resident 49's MDS, dated [DATE], the MDS indicated Resident 49 had unclear speech, was usually understood and able to understand others. The MDS indicated Resident 49 required supervision with set up help for bed mobility and eating, and limited assistance with a one-person physical assistance with transfer, personal hygiene, locomotion on/off unit, walking in the room and corridor, dressing, transfer, and toilet use. A review of Resident 33's admission Record indicated Resident 33 was initially admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 33's diagnoses included diabetes mellitus (high blood sugar), hepatic failure (loss of liver function), and hypertensive heart disease (refers to heart conditions caused by high blood pressure). During a review of Resident 33's MDS, dated [DATE], the MDS indicated Resident 33 had clear speech, was usually understood and able to understand others. The MDS indicated Resident 33 required supervision with set up help for bed mobility and eating, and limited assistance with a one-person physical assist with transfer, personal hygiene, locomotion on/off unit, walking in the room and corridor, 555780 Page 20 of 25 555780 02/10/2022 Villa Del Rio Gardens 7004 East Gage Avenue Bell Gardens, CA 90201

F 0758 dressing, transfer, and toilet use. Level of Harm - Minimal harm or potential for actual harm A review of Resident 6's admission Record indicated Resident 6 was initially admitted to the facility on [DATE]. Resident 6's diagnoses included epilepsy unspecified, COPD, and hypothyroidism (condition in which the thyroid gland doesn't produce enough thyroid hormone). Residents Affected - Some During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6 had clear speech, was understood by others and was able to understand others. The MDS indicated Resident 6 required supervision with set up help with bed mobility and eating, transfer, locomotion on/off unit, walking in the room and corridor, and a limited assistance with dressing, transfer, personal hygiene, and toilet use. During an interview on 2/10/2022 at 9:07 a.m. with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated the staff did not document non-pharmacological interventions prior to the use of psychotropic medication because staff was familiar with every resident who had behavioral changes. LVN 4 stated the licensed nurses completed a change of condition (COC) form when the resident had behavioral changes, and the psychiatrist was to determine if they want to take a pharmacological approach. During an interview on 2/10/2022 at 10:10 a.m. with LVN 1, LVN 1 stated licensed nurses did not assess the residents before the start of psychotropic medication. LVN 1 stated she was not familiar with the psychotropic assessment form indicated in the resident's medical chart. LVN 1 stated there was no documentation that non- pharmacological interventions were documented in the resident's medical record prior to the start of the psychotropic medication. During an interview and record review of Resident 49's medical chart on 2/11/2022 at 9:56 a.m. with the Infection Preventionist Nurse (IP), IP stated residents that were receiving psychotropic medication did not have an assessment prior to start of the medication. When asked if nonpharmacological interventions were documented in the chart, IP stated that staff did perform nonpharmacological interventions but did not document in the resident's chart. When asked when Resident 49 was last offered a GDR, IP stated there was no GDR since September of 2021. During an interview on 2/10/2022 at 11:15 a.m. with the Director of Nursing (DON), DON stated there were no psychotropic assessments performed with any of the residents receiving psychotropic medication. The DON stated an evaluation was made by the psychiatrist if medication was necessary for the resident to continue or discontinue medication. During a record review of the facility's policy and procedure (P/P) dated January 2022 and titled, Medication Monitoring Medication Management, the P/P indicated when selecting medications and non-pharmacological approaches, members of the IDT included resident participation in the care process to identify, assess, address, advocate for, monitor and communicate the residents needs and changes in condition. The P/P indicated medication management is based on the care process and includes recognition or identification of the problem/need, assessment, diagnosis/cause identification, management/treatment, monitoring and revising interventions, as warranted as well as documenting management steps. 555780 Page 21 of 25 555780 02/10/2022 Villa Del Rio Gardens 7004 East Gage Avenue Bell Gardens, CA 90201

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 food preparation and storage practices were followed in the kitchen when: Residents Affected - Many 1. The foods were not labeled with opened dates, there was no received dates, foods were stored in bins, refrigerator, and freezer without removing from original packaging. 2. The ice machine was not maintained in a clean and sanitary condition to ensure the ice was safe to consume. These failures had the potential to result in harmful bacteria growth and cross contamination that could lead to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) for 80 of 81 medically compromised residents who received food and ice from the kitchen. Findings. a. During a concurrent kitchen observation and interview with Dietary Aide 1 (DA 1) on 2/8/22 at 9:11 a.m., there was one box of orange juice concentrate and one box of grape juice concentrate observed without received and opened dates. DA 1 stated both juice concentrates should be dated with the received date and use by date when they were opened. DA 1 stated he was responsible for labeling the items and missed labeling the two boxes. During a concurrent kitchen observation and interview with the Dietary Service Supervisor (DSS) on 2/8/22 at 9:29 a.m., there was one opened box of baking soda with a received date of 4/22/2021 and a use by date of 12/28/2022. The opened date was 1/22/2022 however the box was left opened and uncovered. The DSS stated the box should have been covered with plastic wrap to prevent the baking soda from being contaminated. During a concurrent kitchen observation and interview with DSS on 2/8/22 at 9:32 a.m., there was a bottle of nutmeg with a date received on 9/30/2021 and opened date on 10/4/2021. The use by date was 5/4/23 however the lid was left opened. The DSS stated the lid should always be kept closed to prevent possible contamination. The DSS stated it was important to ensure foods were free from possible contamination as harmful bacteria may grow that could lead to foodborne illness. During a concurrent kitchen observation and interview with the DSS on 2/8/22 at 9:35 a.m., the white rice, powdered milk, brown sugar, brown rice, oatmeal, and white sugar were observed stored in plastic bins with no label indicating the received date, use by date, and opened date. The white sugar was observed in the plastic bin with its original packaging. The DSS stated all foods should be stored with labels indicating the received date, used by date and open date. The DSS stated the white sugar should have been removed from the original packaging prior to placing in the bin. During a concurrent kitchen observation and interview with the DSS on 2/8/22 at 9:45 a.m., there were boxes of graham crackers, salt, sugar, pepper, chips, and cans of pureed chicken stored with its original packaging in the storage rack. There were also boxes of wheat roll dough, egg rolls, and pork sausages that were stored in its original packaging. The DSS stated the graham crackers, salt, sugar, pepper, chips, pureed chicken cans, wheat roll dough, egg rolls, and pork sausages should have 555780 Page 22 of 25 555780 02/10/2022 Villa Del Rio Gardens 7004 East Gage Avenue Bell Gardens, CA 90201

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many been removed from the original carton boxes or packaging it was delivered in because the carton boxes could possibly be contaminated during transport and might cause the residents to become sick or be source of pest problem. A review of the facility's undated policy and procedure (P/P) titled, Food Receiving and Storage, indicated foods shall be received and stored in a manner that complies with safe food handling practices. The P/P indicated dry foods that are stored in bins will be removed from original packaging, labeled, and dated (use by date). Opened containers must be dated and sealed or covered during storage. b. During an initial tour of the kitchen on 2/8/2022 at 8:34 a.m. with Dietary Aide 1 (DA 1), a black substance approximately 4 (four) inches in length was noted on the plastic in the upper, inner, right corner of the interior of the ice machine. This finding was photographed. During a concurrent interview and record review, on 2/8/2022 at 3:10 p.m., with the Maintenance Manager (MM) and Assistant Maintenance Manager (AM), the photograph taken of the interior of the ice machine was reviewed. The MM acknowledged the black substance noted on the ice machine. The MM stated the ice machine was supposed to be cleaned daily by the dietary aid, but the MM could not verbalize why the ice machine had black dirt in it. The MM stated the ice machine should be clean all the time and cannot have a black substance. During an interview with Dietary Service Supervisor 2 (DSS 2) on 2/8/2022 at 3:45 p.m., DSS 2 stated that it was the responsibility of DA 1 to clean the ice machine daily, but staff did not log who completed the task. DSS 2 stated that it would be obviously dirty because we hold the ice scooper every time which means that it needs cleaning. During a review of the facility's P/P titled, Ice Machines and Ice Storage Chests, revised 2021, indicated ice-making machines, ice storage chest/containers, and ice can all become contaminated by: unsanitary manipulation by employees, residents, and visitors. Waterborne microorganisms naturally occurring in the water source, colonization by microorganisms and/or improper storage or handling of ice. Facility has established procedure for cleaning and disinfecting ice machines and ice storage chests which adhere to the manufacturer's instructions. 555780 Page 23 of 25 555780 02/10/2022 Villa Del Rio Gardens 7004 East Gage Avenue Bell Gardens, CA 90201

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 maintain an infection prevention and control program to prevent the spread of the coronavirus disease ([COVID-19 a disease caused by virus called SARs-CoV-2}) an illness caused by a virus that can easily spread from person to person) by failing to: Residents Affected - Some 1. Ensure housekeeping that was assigned to clean the hallway at the green zone (a room or group of rooms designated for residents who do not have nor were exposed to Covid-19) was wearing an N-95 (a type of mask worn over the face to cover the nose and mouth that provides respiratory protections against aerosols [a suspension of fine solid particles or liquid droplets in air] and prevent infections). 2. Ensure one of one residents (229) was cohorted (creating distinct roommates or small groups of COVID-19 positive residents or Covid-19 exposed residents that stay together to ensure minimal or no interaction with residents who do not have COVID-19) at the yellow zone (an area housing covid 19 suspected, symptomatic or exposed residents) upon return from the hospital( re-admission). 3. Ensure two out of 2 Licensed vocational nurses performed hand hygiene in between resident's contact for three of three Residents (34, 53 and 57). Findings: 1. During an initial tour of the facility on 02/08/2022 at 10:19 am., housekeeping staff (HS) was in the hallway wearing a face shield without face mask. During an interview with HS on 02/08/2022 at 10:38 a.m., HS stated that he was responsible for cleaning all the hallways and he did it early morning. HS stated he usually wears an N95 mask and a face shield as personal protective equipment(PPE- equipment worn to minimize exposure to virus that cause serious infection/Covid-19 ). HS stated he forgot the N95 mask today and just used a face shield. During an interview on 02/08/2022 at 11:06 a.m. with Infection Preventionist (I/P), IP stated that HK should be wearing appropriate PPE like the rest of the staff in the facility, an N95 and face shield to prevent the spread of the virus. IP stated that HK spends more than 15 minutes cleaning the hallways and he cleans every 2 hours all the high touch surfaces in the facility. 2. During a review of the admission record, the record indicated Resident 229 was admitted to the facility on [DATE] and re admitted on [DATE], with diagnoses that included Alzheimer's disease (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain) dementia (a group of thinking and social symptoms that interfere with daily functioning),chronic obstructive pulmonary disease(COPD- a group of lung diseases that block airflow and make it difficult to breathe). During a review of the Resident 229's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 11/15/2021, the MDS indicated Resident 229 had clear speech, made self-understood, and had the ability to understand others, needed limited assistance from one staff for bed mobility, transfer, locomotion, walking in the room, toilet use and personal hygiene, and extensive assistance for dressing and bathing. 555780 Page 24 of 25 555780 02/10/2022 Villa Del Rio Gardens 7004 East Gage Avenue Bell Gardens, CA 90201

F 0880 Level of Harm - Minimal harm or potential for actual harm During an initial tour of the facility on 2/08/2022, around 10:19 a.m., there were no residents in the yellow zone of the facility. During a review of the census (number of residents in the facility) dated 02/06/2022, the census indicated that green zone had 81 residents. Residents Affected - Some During an interview on 02/10/2022 at 4:12p.m. with I/P nurse, IP stated that Resident 229 came to the facility on 2/1/2022 and was assigned to the green zone, when asked about the new California Department of Public health (CDPH) guidance that new admission and re- admissions regardless of the vaccination status, should be placed in the yellow zone, IP stated that she was not aware of the update, IP stated that Resident 229 should have been in the yellow zone when she came to the facility on 2/1/2022. During a review of all facility letter ( AFL 20-87.1), the AFL indicated that regardless of vaccination status, residents who may have prolonged close contact (within 6 feet for a cumulative total of 15 minutes or more over a 24-hour period) with someone with SARS-CoV-2 infection while outside the facility should quarantine in the yellow-observation area for 14 days and be tested immediately, at 5-7 days after exposure, and again prior to return to their usual room in green-unexposed/recovered area. During a review of the CDPH illustration titled, Cohorting dated 12/16/2021, indicated regardless of vaccination status; admissions and re admissions go straight to the yellow zone for 14 days. 3. During a medication administration observation on 02/09/2022 at 09:45 a.m., the licensed vocational nurse (LVN 1) administered oral medication for Residents 34, 53 and 57 and was observed not washing hands in between care of these three residents. During an interview on 02/09/2022 at 09:58 a.m., LVN 1 stated that hand washing must be done in between care, when passing medications and providing direct care to the resident. LVN 1 acknowledged that it was an infection control issue when staff does not wash hands or use hand sanitizer before providing care to the resident and the potential outcome is putting the residents at risk for getting infected with infectious disease such as COVID-19 infection and vice versa. During an interview on 02/11/2022 at 10:19 a.m., the Infection Preventionist (IP) stated that when a licensed nurses are passing medications, staff must wash hands or use hand sanitizer in between resident care to prevent cross contamination, if such practice are not followed, the potential is to spread the infection and putting the resident at risk or the staff for getting infected with any infectious disease the hand carries and IP acknowledged that it was an infection control issues. During a review of the facility policy (P/P) titled, Infection Prevention and Control Program, the P/P indicated all staff will wash their hands when coming on duty, between resident contact, after handling contaminated objects. Staff shall wash their hands before and after performing resident care procedures. Hands shall be washed in accordance with facility's established hand washing procedure. 555780 Page 25 of 25