Other·April 24, 2020

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the Department of Public Health of a Complaint investigation during an Abbreviated Standard Survey. Complaint number: CA00665153 Representing the Department of Public Health: Health Facilities Evaluator Nurse ID: 16282 The inspection was limited to the specific Complaint investigation and does not represent the findings of a full inspection of the facility. Two deficiencies were issued for CA00665153

F580 SS=G Notify of Changes (Injury/Decline/Room, etc.) CFR(s): 483.10(g)(14)(i)-(iv)(15)

F580 09/01/2020 §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RV8311 Facility ID: CA940000072 If continuation sheet 1 of 23 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056234 (X3) DATE SURVEY COMPLETED 03/25/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARLORA POST ACUTE REHABILITATION HOSPITAL 3801 E Anaheim St Long Beach, CA 90804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is(A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c) (9). This REQUIREMENT is not met as evidenced by: Based on record review and interview, the facility failed to notify a resident's physician when there was a continuous change of condition (COC) with difficulty in breathing and adhere to its policy and procedure which FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RV8311 Facility ID: CA940000072 If continuation sheet 2 of 23 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056234 (X3) DATE SURVEY COMPLETED 03/25/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARLORA POST ACUTE REHABILITATION HOSPITAL 3801 E Anaheim St Long Beach, CA 90804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated that the attending physician would be notified immediately in the event a resident had a change of condition and if the condition continued to deteriorate to call 911 (emergency services) for one of three sampled residents (Resident 1). (Crossed referenced to F684). This deficient practice of not reporting Resident 1's continuous COC resulting in a delay in diagnosis, care and treatment and the resident's family member (FM 1) calling 911 (emergency services) for Resident 1 to be transfer red to a general acute care hospital (GACH). Resident 1 was readmitted to the GACH within 24 hours of admission to the skilled nursing facility (SNF) after experiencing a change of condition (COC). In the emergency department (ED) Resident 1 required an emergency intubation ([ET] a tube placed in the trachea for air exchange) and was admitted into the intensive care unit ([ICU] a unit for residents who requires a higher level of care [critical care]) for further care and treatment. Findings: A review of Resident 1's GACH Discharge Summary prior to admission to the SNF, dated 11/15/19 indicated Resident 1 had an acute hypoxic respiratory failure (fluid build-up in the air sacs of the lungs), septic shock (wide spread infection), obstructive sleep apnea (complete or partial obstruction during sleep) requiring continuous positive airway pressure ([CPAP] continuous positive airway pressure a treatment for moderate to severe obstructive sleep apnea) and morbid obesity (excessive body fat). A review of Resident 1's GACH medications FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RV8311 Facility ID: CA940000072 If continuation sheet 3 of 23 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056234 (X3) DATE SURVEY COMPLETED 03/25/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARLORA POST ACUTE REHABILITATION HOSPITAL 3801 E Anaheim St Long Beach, CA 90804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and treatments indicated the following were administered at the GACH: 1. Duoneb (a medication that relax muscles in the airway to increase air flow to the lungs) 3 milliliters (ml-a unit of measure) nebulizer ([neb]-a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) every 4 to 6 hours while awake and when necessary for shortness of breath (SOB) or wheezing (a whistling sound made when breathing). 2. Mucomyst (a drug that loosens and thins mucus) 10% 2 ml neb every 4 hours while awake. 3. BiPAP (positive airway pressure breathing device to treat sleep apnea/ delivers pressurized air to regulate the breathing pattern). A review of Resident 1's skilled nursing facility (SNF) Admission Record indicated Resident 1 was admitted to the facility on 11/15/19, with diagnoses of acute hypoxic respiratory failure, obstructive sleep apnea (OSA) receiving CPAP, septic shock (severe and potentially fatal condition that occurs when sepsis leads to life-threatening low blood pressure , high blood pressure and diabetes (high blood sugar). Resident 1's admission vital signs included a blood pressure (BP) of 130/70 [unit of measurement] (normal reference range [NRR] is 139/70-120/70), heart rate 84 beats per minute [bpm] (NRR is 60-100 bpm) and respiratory rate of 21 breaths per minute [bpm] (NRR is 12-20 bpm). Resident 1's pulse oximeter (an electronic device that measures the saturation of oxygen carried in the red blood cells) measured at 95% (NRR is 95100%) on room air with clear breath sounds in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RV8311 Facility ID: CA940000072 If continuation sheet 4 of 23 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056234 (X3) DATE SURVEY COMPLETED 03/25/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARLORA POST ACUTE REHABILITATION HOSPITAL 3801 E Anaheim St Long Beach, CA 90804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE both lungs, no cough and regular respirations. Resident 1 was alert and oriented to person and place with verbal coherent communication and the ability to understand others. Resident 1's neurological status (mental state) was within normal limits. The medication list was obtained from the GACH transfer form and the admission orders were verified by Resident 1's physician. A review of Resident 1's SNF Order Summary Report dated 11/15/19 indicated the following orders: 1. Oxygen 2-3 liter per minute (LPM) via nasal cannula (a plastic tube for oxygen infusion) continuous. 2. Furosemide ([Lasix] medication used to remove excess fluid from the body) and Losartan potassium (blood pressure medication) each once a day for hypertension (high blood pressure [HTN]). 3. Lubriprostone (used to treat irritable bowel syndrome) 24 micrograms (mcg) one capsule two times a day for cirrhosis (A degenerative disease of the liver resulting in scarring and liver failure). 4. Metformin HCL (medication to help control blood sugar levels) 1000 milligrams (mg) one tablet two times a day for diabetes (high blood sugar level). 5. Simivastatin (cholesterol lowering medication) 40 mg tablet at bedtime for HLD (hypersensitivity lung disease). 6. Fexofenadine (allergy medication) 1 tablet every 24 hours as needed for allergy. A review of Resident 1's physician telephone orders, dated 11/16/19 and noted at 5:53 a.m., indicated the following orders: 1. Discontinue Lasix, losartan, Lubiprostone and Metformin. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RV8311 Facility ID: CA940000072 If continuation sheet 5 of 23 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056234 (X3) DATE SURVEY COMPLETED 03/25/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARLORA POST ACUTE REHABILITATION HOSPITAL 3801 E Anaheim St Long Beach, CA 90804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2. Accu-check (blood sugar monitoring) before meals and at hour of sleep and cover with regular insulin ([a short acting, form of the hormone] the body uses insulin to process blood sugar). A review of Resident 1's History and Physical (H/P), dated 11/16/19, within 24 hours of admission indicated the resident had decreased breath sounds and the resident did not have the capacity to understand and make decisions. A review of Resident 1's Medication Administration Record (MAR) of the physician's orders for the month of 11/2019 included the following medications: 1. Ipratropium-Albuterol Solution (used to enlarge airways in the lungs) 3 ml inhale orally via nebulizer every 4 hours for shortness of breath (sob)/ wheezing every 4 hours while awake and/or every 6 hours as needed 2. Mucomyst 10% 2 ml neb every 4 hours while awake to loosen secretions 3. Oxygen (O2) 2-3 LPM via nasal cannula continuous three times a day 4. Monitor oxygen saturation (the percentage of oxygen is in the blood) every shift three times a day 5. Prednisone (a synthetic drug used to relieve rheumatic and allergic conditions and to treat leukemia) 20 mg one time a day for respiratory failure 6. Accu-checks (blood sugar monitoring) before meals and at bedtime cover with regular insulin for diabetes mellitus ([DM] high blood sugar) 7. Lantus ([an insulin] a hormone that works by lowering levels of glucose in the blood) Solution 100 units/ml 10 at bedtime for DM 8. Metformin HCL 500 mg two times a day for DM FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RV8311 Facility ID: CA940000072 If continuation sheet 6 of 23 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056234 (X3) DATE SURVEY COMPLETED 03/25/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARLORA POST ACUTE REHABILITATION HOSPITAL 3801 E Anaheim St Long Beach, CA 90804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 9. Furosemide 40 mg one tablet a day for high blood pressure (HTN) 10. Metoprolol (a medication used to treat high blood pressure) extended release (XR-the drug takes longer to clear from the body) 25 mg one time a day for HTN 11. Losartan Potassium) 50 mg one time a day for HTN 12. Midodrine HCL (a medication designed to raise the blood pressure) 2.5 mg every 8 hours for orthostatic (change in position from lying down to standing) low blood pressure 13. Lubiprostone 24 mcg two times a day for cirrhosis (scarring of the liver) 14. Apixaban 2.5 mg two times a day for deep vein thrombosis prophylaxis (blood clot prevention) 15. Simvastatin 40 mg at bedtime for HLD (abnormally high concentration of fats in the blood) 16. Aspirin 81 mg one time a day for stroke prevention A review of Resident 1's Medication Administration Record for the month of November 2019 indicated the following medications and treatments were not administered as prescribed by the physician on 11/15/19 and 11/16/19: Lantus, Aspirin, Losartan, metoprolol, midodrine HCL, prednisone, protonix, simvastatin, apixaban, metformin and lubiprostone. On 11/15/19, there was no oxygen saturation monitored and documented on the MAR for 117 a.m. shift as ordered by the physician. On 11/15/19 and 11/16/19, there was no documentation of Resident 1's blood sugar monitoring as prescribed by the physician. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RV8311 Facility ID: CA940000072 If continuation sheet 7 of 23 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056234 (X3) DATE SURVEY COMPLETED 03/25/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARLORA POST ACUTE REHABILITATION HOSPITAL 3801 E Anaheim St Long Beach, CA 90804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 1's progress nurses notes, dated 11/15/19 and 11/16/19 indicated there was no documentation Resident 1's physician was notified as to why the resident did not receive the prescribed medications and treatments. On 11/16/19, the albuterol and mucomyst breathing treatments were not administered as prescribed at 12 a.m., 4 a.m., 8 a.m. and 12 noon . There was no documentation for the reason the medications and breathing treatments were not administered. A review of Resident 1's nursing progress notes indicated there was no nursing documentation from 11/15/19 at 9 p.m. until 11/16/19 at 8:23 a.m. . A review of a nursing progress note dated 11/16/19 at 8:23 a.m. indicated Resident 1's CPAP machine was delivered without a power adapter (not usable). A review of Resident 1's nursing progress note, dated 11/16/19 at 9:48 a.m., indicated all of Resident 1's admission orders were reviewed by the nurse practitioner ([NP] an advanced practice registered nurse who has additional responsibilities for administering patient care than RN s) with clarifications made. Resident 1's medication list was updated, transcribed (put in written form), and faxed to pharmacy. A review of Resident 1's nursing progress note, dated 11/16/19 at 10:33 a.m. indicated at approximately 9:50 a.m., Resident 1 was noted with increased respirations (breathing) and congestion (stuffiness, or a runny nose is generally caused by increased blood volume to the vessels that line the passages inside the nose [feeling of fullness in the sinuses]). The note indicated Resident 1's oxygen saturation had decreased to 80% (normal range 92 to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RV8311 Facility ID: CA940000072 If continuation sheet 8 of 23 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056234 (X3) DATE SURVEY COMPLETED 03/25/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARLORA POST ACUTE REHABILITATION HOSPITAL 3801 E Anaheim St Long Beach, CA 90804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 100%) and a breathing treatment was provided, and the resident was suctioned. The nursing progress note indicated the NP ordered to increase Resident 1's oxygen to 5 liters, give Lasix 40 mg IVP (intravenous [into the vein] push) and give breathing treatments every 4 hours around the clock (ATC) and a STAT (immediate) chest x-ray. A review of a nurse's progress note dated 11/16/19 at 12 noon indicated Resident 1's family member (FM)1 came to the nursing station stating Resident 1 had troubled or labored breathing (abnormal respiration and an increased effort to breathe). The note indicated Resident 1's oxygen saturation level fluctuated between 88-90%. FM 1 requested the resident be transferred to the GACH. The nursing note indicated the paramedics were called and the oxygen was increased to 10 liters per minute. The paramedics arrived and transferred the resident to the GACH. A review of Resident 1's Paramedic Run Sheet, dated 11/16/19 at 12:05 p.m., indicated Resident 1 was conscious (awake and alert) and coherent (rational). The paramedics documented Resident 1 had been complaining of shortness of breath (SOB) since that morning and was found with a low oxygen saturation that did not get better with increase of oxygen to 10 liters per minute. Resident 1's vital signs were recorded as follows; a low blood pressure (BP- the pressure of the blood in the circulatory system,) of 96/54 (normal range 120/80), an elevated pulse of 108 beats per minute (normal range-80 beats per minute (bpm), respirations of 20 breaths per minute (normal range 16 to 20 breaths per minute) and oxygen saturation at 100%. A review of Resident 1's GACH Emergency Department (ED) documentation, dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RV8311 Facility ID: CA940000072 If continuation sheet 9 of 23 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056234 (X3) DATE SURVEY COMPLETED 03/25/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARLORA POST ACUTE REHABILITATION HOSPITAL 3801 E Anaheim St Long Beach, CA 90804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 11/16/19 at 12:44 p.m. indicated Resident 1 arrived at the ED with tachycardia (increased heart rate) and tachypneic (fast, shallow breathing) with impending (about to happen) respiratory failure. Resident 1's chest x-ray revealed an almost complete whiteout on the left lung field which suggested due to a left lung collapse and/or from a mucus plug (large collection of mucus). Resident 1 required an endotracheal intubation ([ET] a tube placed in the trachea for air exchange) and was admitted into the GACH's intensive care unit ([ICU] a unit for residents who requires a higher level of care [critical care]) for further care and treatment. Resident 1's treatment included mucomyst (breathing treatment), postural drainage (position to encourage drainage by gravity) and chest PT (physiotherapy/clapping of the chest wall to loosen mucus from the lungs). A review of Resident 1's GACH note, dated 11/18/19 indicated the resident was extubated (tube in trachea removed). The note indicated Resident 1 refused to return to the prior SNF but agreed for admission to another SNF 2. On 11/22/19, the resident was transferred to the SNF 2. On 11/27/19 at 11:08 a.m., during an interview, Certified Nurse Assistant (CNA) 1 stated, "After breakfast Resident 1 was observed to be short of breath (SOB) and looked tired. Resident 1 was not receiving oxygen at that time" . CNA 1 was unable to recall the resident's mental status at that time. CNA 1 stated Resident 1 was nonverbal and only respond by nodding her head. On 1/23/2020 at 1:45 p.m., during an interview, Licensed Vocational Nurse (LVN) 1 stated on 11/15/19 the CPAP machine was delivered without the power cord. The resident slept FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RV8311 Facility ID: CA940000072 If continuation sheet 10 of 23 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056234 (X3) DATE SURVEY COMPLETED 03/25/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARLORA POST ACUTE REHABILITATION HOSPITAL 3801 E Anaheim St Long Beach, CA 90804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE without the CPAP machine as ordered by the physician. LVN 1 stated Resident 1's condition changed due to SOB. LVN 1 stated he did not give the resident any medications or breathing treatments, as ordered by the physician, but the registered nurse (RN) 1 gave the resident the Lasix. On 1/23/2020 at 3 p.m., during an interview, RN 1 stated LVN 1 notified her of the resident's COC and she notified the NP . RN 1 stated she was in between two emergency situations and could not recall giving Resident 1 the Lasix IVP (intravenous push) and/or the breathing treatment. On 1/24/2020 at 10:45 a.m., during a telephone interview, the facility's contracting pharmacist ([Pharmacist 1] a medication expert) stated the orders for Resident 1 was received on 11/15/19 after 10 p.m. Pharmacist 1 stated LVN 1 called the pharmacy on 11/16/19 and stated Resident 1's orders that were faxed on 11/15/19, which was incorrect. Then a nursing staff member called back on the same day at 1:15 p.m. and informed the pharmacist not to send any medications because the resident went to the GACH. On 2/6/2020 at 10:40 a.m., during an interview, RN 2 stated Resident 1 was tired when she arrived at the facility. The resident's oxygen saturation was 95% on room air and the resident did not need oxygen. On 2/6/2020 at 11:21 a.m., during an interview, Resident 1's primary care physician (PCP) 1) stated he was not called about Resident 1's change of condition (COC) due to difficulty in breathing. On 2/6/2020 at 12:31 p.m., during a telephone interview, FM 1 stated when he arrived to visit FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RV8311 Facility ID: CA940000072 If continuation sheet 11 of 23 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056234 (X3) DATE SURVEY COMPLETED 03/25/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARLORA POST ACUTE REHABILITATION HOSPITAL 3801 E Anaheim St Long Beach, CA 90804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 1 and there was no staff in Resident 1's room. FM 1 stated Resident 1's face was red, and he could hear the noises coming from the resident's lungs. FM 1 stated Resident 1 had on oxygen face mask but was unable to catch her breath. FM 1 stated he immediately ran out to the nurse's station to get the nurse, as he (FM 1) called 911. On 2/7/2020 at 3:45 p.m., during an interview and review of Resident 1's physician's orders and nurse's notes, RN 3 stated on 11/15/19, she reviewed the admission orders from the packet sent over the GACH. RN 3 stated the orders were verified with the resident's physician but could not recall the physician's name. RN 3 stated she missed verifying Resident 1's new medication and treatment orders that was included in the package. RN 3 denied placing oxygen on Resident 1. RN 3 stated she verified Resident 1's admission orders with the medication nurse who was on duty on 11/15/19. On 2/11/2020 at 8:30 a.m. and 3:40 p.m., during the interviews, LVN 2 stated she was Resident 1's medication nurse on 11/16/19. LVN 2 stated there was a delay in receiving Resident 1's medication and that was why she did not administer any medications or breathing treatments to Resident 1. A review of the facility's policy and procedure titled, Change of Condition Notification, revised on 1/1/17 indicated the purpose was to ensure the physicians were informed of changes in the resident's condition in a timely manner. The policy indicated the facility would promptly consult with the resident's attending physician when the resident endures a significant change in the resident's physical, cognitive, functional and behavioral status (example given) e.g., deterioration in health, life threatening FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RV8311 Facility ID: CA940000072 If continuation sheet 12 of 23 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056234 (X3) DATE SURVEY COMPLETED 03/25/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARLORA POST ACUTE REHABILITATION HOSPITAL 3801 E Anaheim St Long Beach, CA 90804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE conditions or clinical complications. The policy also stipulated in emergency situations, e.g., the resident is experiencing unexpected shortness of breath, the Licensed Nurse (LN) would- Immediately call the attending physician, if unable to reach the physician or the physician on-call during emergency situations, he/she would notify the facility's Medical Director. The policy also indicated, "If the resident deteriorates, the symptoms are serious, and the most rapid intervention available by a physician would place the resident in great jeopardy, call 911 for transport to hospital".

F684 SS=G Quality of Care CFR(s): 483.25

F684 09/01/2020 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on record review and interview, the facility failed to ensure a resident received medications and breathing treatment, as prescribed by the physician for one of three sampled residents (Resident 1). Resident 1 did not receive the medications and respiratory treatments as prescribed by the physician, which resulted in a change of condition (COC). This deficient practice of not reporting Resident 1's continuous change of condition which FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RV8311 Facility ID: CA940000072 If continuation sheet 13 of 23 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056234 (X3) DATE SURVEY COMPLETED 03/25/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARLORA POST ACUTE REHABILITATION HOSPITAL 3801 E Anaheim St Long Beach, CA 90804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resulted in a delay in diagnosis, care and treatment and the resident's family member (FM 1) calling 911 (emergency services) for Resident 1 to be transferred to a general acute care hospital (GACH). Resident 1 was readmitted to the GACH within 24 hours of admission to the skilled nursing facility (SNF) after experiencing a COC due to not receiving the prescribed medications, oxygen and treatments. In the emergency department (ED) Resident 1 required an emergency intubation ([ET] a tube placed in the trachea for air exchange) and was admitted into the intensive care unit ([ICU] a unit for residents who requires a higher level of care [critical care]) for further care and treatment. Findings: A review of Resident 1's GACH Discharge Summary prior to admission to the SNF, dated 11/15/19 indicated Resident 1 had an acute hypoxic respiratory failure (fluid build-up in the air sacs of the lungs), septic shock (wide spread infection), obstructive sleep apnea (complete or partial obstruction during sleep) requiring continue positive airway pressure ([CPAP] continuous positive airway pressure a treatment for moderate to severe obstructive sleep apnea) and morbid obesity (excessive body fat). A review of Resident 1's GACH medications and treatments indicated the following were administered at the GACH: 1. Duoneb (a medication that relaxes muscles in the airway to increase air flow to the lungs) 3 milliliters (ml-a unit of measure) nebulizer ([neb]-a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) every 4 to 6 hours while awake and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RV8311 Facility ID: CA940000072 If continuation sheet 14 of 23 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056234 (X3) DATE SURVEY COMPLETED 03/25/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARLORA POST ACUTE REHABILITATION HOSPITAL 3801 E Anaheim St Long Beach, CA 90804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE when necessary for shortness of breath (SOB) or wheezing (a whistling sound made when breathing). 2. Mucomyst (a drug that loosens and thins mucus) 10% 2 ml neb every 4 hours while awake. 3. BiPAP (positive airway pressure breathing device to treat sleep apnea/ delivers pressurized air to regulate the breathing pattern). A review of Resident 1's skilled nursing facility (SNF) Admission Record indicated Resident 1 was admitted to the facility on 11/15/19 , with diagnoses of acute hypoxic respiratory failure (not enough oxygen in your blood), obstructive sleep apnea ([OSA] throat muscles relax and block airway during sleep) receiving CPAP, septic shock (severe and potentially fatal condition that occurs when sepsis leads to lifethreatening low blood pressure [sepsis develops when the body has an overwhelming response to infection]), high blood pressure and diabetes (high blood sugar). Resident 1's admission vital signs included a blood pressure (BP) of 130/70 (normal reference range [NRR] is 139/70-120/70), heart rate 84 beats per minute [bpm] (NRR is 60-100 bpm) and respiratory rate of 21 breaths per minute [bpm] (NRR is 12-20 bpm). Resident 1's pulse oximeter (an electronic device that measures the saturation of oxygen carried in the red blood cells) measured at 95% (NRR is 95-100%) on room air with clear breath sounds in both lungs, no cough and regular respirations. Resident 1 was alert and oriented to person and place with verbal coherent communication and the ability to understand others. Resident 1's neurological status (mental state) was within normal limits. The medication FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RV8311 Facility ID: CA940000072 If continuation sheet 15 of 23 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056234 (X3) DATE SURVEY COMPLETED 03/25/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARLORA POST ACUTE REHABILITATION HOSPITAL 3801 E Anaheim St Long Beach, CA 90804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE list was obtained from the GACH transfer form and the admission orders were verified by Resident 1's physician. A review of Resident 1's SNF Order Summary Report dated 11/15/19 indicated the following orders: 1. Oxygen 2-3 liter per minute (LPM) via nasal cannula (a plastic tube for oxygen infusion) continuous. 2. Furosemide ([Lasix] medication to remove excess fluids from the body) and Losartan potassium each once a day for hypertension (high blood pressure [HTN]). 3. Lubriprostone 24 micrograms (mcg) one capsule two times a day for cirrhosis (a degenerative disease of the liver resulting in scarring and liver failure). 4. Metformin HCL 1000 milligrams (mg) one tablet two times a day for diabetes (high blood sugar level). 5. Simvastatin 40 mg tablet at bedtime for HLD (hypersensitivity lung disease). 6. Fexofenadine 1 tablet every 24 hours as needed for allergy. A review of Resident 1's physician telephone orders, dated 11/16/19 and noted at 5:53 a.m., indicated the following orders: 1. Discontinue Lasix, losartan, Lubiprostone and Metformin. 2. Accu-check (blood sugar monitoring) before meals and at hour of sleep and cover with regular insulin ([a short acting, form of the hormone] the body uses insulin to process blood sugar). A review of Resident 1's History and Physical (H/P), dated 11/16/19 , within 24 hours of admission indicated the resident had FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RV8311 Facility ID: CA940000072 If continuation sheet 16 of 23 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056234 (X3) DATE SURVEY COMPLETED 03/25/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARLORA POST ACUTE REHABILITATION HOSPITAL 3801 E Anaheim St Long Beach, CA 90804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE decreased breath sounds and the resident did not have the capacity to understand and make decisions. A review of Resident 1's Medication Administration Record (MAR) of the physician's orders for the month of 11/2019 included the following medications: 1. Ipratropium-Albuterol Solution 3 ml inhale orally via nebulizer every 4 hours for shortness of breath (sob)/ wheezing every 4 hours while awake and/or every 6 hours as needed 2. Mucomyst 10% 2 ml neb every 4 hours while awake to loosen secretions 3. Oxygen (O2) 2-3 LPM via nasal cannula continuous three times a day 4. Monitor oxygen saturation (the percentage of oxygen is in the blood) every shift three times a day 5. Prednisone (a synthetic drug used to relieve rheumatic and allergic conditions and to treat leukemia) 20 mg one time a day for respiratory failure 6. Accu-checks (blood sugar monitoring) before meals and at bedtime cover with regular insulin for diabetes mellitus ([DM] high blood sugar) 7. Lantus ([an insulin] a hormone that works by lowering levels of glucose in the blood) Solution 100 units/ml 10 at bedtime for DM 8. Metformin HCL (an oral diabetes medicine that helps control blood sugar levels) 500 mg two times a day for DM 9. Furosemide (a medication that rids excess fluid in the system) 40 mg one tablet a day for high blood pressure (HTN) 10. Metoprolol (a medication used to treat high blood pressure) extended release (XR-the drug takes longer to clear from the body) 25 mg one time a day for HTN 11. Losartan Potassium (a medication used to treat high blood pressure) 50 mg one time a day for HTN FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RV8311 Facility ID: CA940000072 If continuation sheet 17 of 23 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056234 (X3) DATE SURVEY COMPLETED 03/25/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARLORA POST ACUTE REHABILITATION HOSPITAL 3801 E Anaheim St Long Beach, CA 90804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 12. Midodrine HCL (a medication designed to raise the blood pressure) 2.5 mg every 8 hours for orthostatic (change in position from lying down to standing) low blood pressure 13. Lubiprostone 24 mcg two times a day for cirrhosis (scarring of the liver) 14. Apixaban 2.5 mg two times a day for deep vein thrombosis prophylaxis (blood clot prevention) 15. Simvastatin 40 mg at bedtime for HLD (abnormally high concentration of fats in the blood) 16. Aspirin 81 mg one time a day for stroke prevention A review of Resident 1's Medication Administration Record for the month of November 2019 indicated the following medications and treatments were not administered as prescribed by the physician on 11/15/19 and 11/16/19: Lantus, Aspirin, Losartan, metoprolol, midodrine HCL, prednisone, protonix, simvastatin, apixaban, metformin and lubiprostone. On 11/15/19, there was no oxygen saturation monitored and documented on the MAR for 117 a.m. shift. As ordered by the physician . On 11/15/19 and 11/16/19, there was no documentation of Resident 1's blood sugar monitoring as prescribed by the physician. A review of Resident 1's progress nurses notes, dated 11/15/19 and 11/16/19 indicated there was no documentation Resident 1's physician was notified as to why the resident did not receive the prescribed medications and treatments. On 11/16/19, the albuterol and mucomyst FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RV8311 Facility ID: CA940000072 If continuation sheet 18 of 23 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056234 (X3) DATE SURVEY COMPLETED 03/25/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARLORA POST ACUTE REHABILITATION HOSPITAL 3801 E Anaheim St Long Beach, CA 90804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE breathing treatments were not administered as prescribed at 12 a.m., 4 a.m., 8 a.m. and 12 noon. There was no documentation for the reason the medications and breathing treatments were not administered. A review of Resident 1's nursing progress notes indicated there was no nursing documentation from 11/15/19 at 9 p.m. until 11/16/19 at 8:23 a.m. A review of a nursing progress note dated 11/16/19 at 8:23 a.m. indicated Resident 1's CPAP machine was delivered without a power adapter (not usable). A review of Resident 1's nursing progress note, dated 11/16/19 at 9:48 a.m., indicated all of Resident 1's admission orders were reviewed by the nurse practitioner ([NP] an advanced practice registered nurse who has additional responsibilities for administering patient care than RNs) with clarifications made. Resident 1's medication list was updated, transcribed (put in written form), and faxed to pharmacy . A review of Resident 1's nursing progress note, dated 11/16/19 at 10:33 a.m. indicated at approximately 9:50 a.m., Resident 1 was noted with increased respirations (breathing) and congestion (stuffiness, or a runny nose is generally caused by increased blood volume to the vessels that line the passages inside the nose [feeling of fullness in the sinuses]). The note indicated Resident 1's oxygen saturation had decreased to 80% (normal range 92 to 100%) and a breathing treatment was provided, and the resident was suctioned. The nursing progress note indicated the NP ordered to increase Resident 1's oxygen to 5 liters, give Lasix 40 mg IVP (intravenous [into the vein] push) and give breathing treatments every 4 hours around the clock (ATC) and a STAT (immediate) chest x-ray. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RV8311 Facility ID: CA940000072 If continuation sheet 19 of 23 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056234 (X3) DATE SURVEY COMPLETED 03/25/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARLORA POST ACUTE REHABILITATION HOSPITAL 3801 E Anaheim St Long Beach, CA 90804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of a nurse's progress note dated 11/16/19 at 12 noon indicated Resident 1's family member (FM)1 came to the nursing station stating Resident 1 had troubled or labored breathing (abnormal respiration and an increased effort to breathe). The note indicated Resident 1's oxygen level fluctuated between 88-90%. FM 1 requested the resident be transferred to the GACH. The nursing note indicated the paramedics were called and the oxygen was increased to 10 liters per minute. The paramedics arrived and transferred the resident to the GACH. A review of Resident 1's Paramedic Run Sheet, dated 11/16/19 at 12:05 p.m., indicated Resident 1 was conscious (awake and alert) and coherent (rational). The paramedics documented Resident 1 had been complaining of shortness of breath (SOB) since that morning and was found with a low oxygen saturation that did not get better with increase of oxygen to 10 liters per minute. A review of Resident 1's GACH Emergency Department (ED) documentation, dated 11/16/19 at 12:44 p.m. indicated Resident 1 arrived at the ED with tachycardia (increased heart rate) and tachypneic (fast, shallow breathing) with impending (about to happen) respiratory failure. Resident 1's chest x-ray revealed an almost complete whiteout on the left lung field which suggested due to a left lung collapse and/or from a mucus plug (large collection of mucus). Resident 1 required an endotracheal intubation ([ET] a tube placed in the trachea for air exchange) and was admitted into the GACH's intensive care unit ([ICU] a unit for residents who requires a higher level of care [critical care]) for further care and treatment. Resident 1's treatment included mucomyst (breathing treatment), postural drainage (position to encourage drainage by FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RV8311 Facility ID: CA940000072 If continuation sheet 20 of 23 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056234 (X3) DATE SURVEY COMPLETED 03/25/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARLORA POST ACUTE REHABILITATION HOSPITAL 3801 E Anaheim St Long Beach, CA 90804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE gravity) and chest PT (physiotherapy/clapping of the chest wall to loosen mucus from the lungs). A review of Resident 1's GACH note, dated 11/18/19 indicated the resident was extubated (tube in trachea removed). The note indicated Resident 1 refused to return to the prior SNF but agreed for admission to another SNF 2. On 11/22/19, the resident was transferred to the SNF 2. On 11/27/19 at 11:08 a.m., during an interview, Certified Nurse Assistant (CNA) 1 stated, "After breakfast Resident 1 was observed to be short of breath (SOB) and looked tired. Resident 1 was not receiving oxygen at that time". CNA 1 was unable to recall the resident's mental status at that time. CNA 1 stated Resident 1 was nonverbal and only respond ed by nodding her head. On 1/23/2020 at 1:45 p.m., during an interview, Licensed Vocational Nurse (LVN) 1 stated on 11/15/19 the CPAP machine was delivered without the power cord. The resident slept without the CPAP machine as ordered by the physician. LVN 1 stated Resident 1's condition changed due to SOB. LVN 1 stated he did not give the resident any medications or breathing treatments, as ordered by the physician, but the registered nurse (RN) 1 gave the resident the Lasix. On 1/23/2020 at 3 p.m., during an interview, RN 1 stated LVN 1 notified her of Resident 1's COC and she notified the NP. RN 1 stated she was in between two emergency situations and could not recall giving Resident 1 the Lasix IVP (intravenous push) and/or the breathing treatment. On 1/24/2020 at 10:45 a.m., during a telephone FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RV8311 Facility ID: CA940000072 If continuation sheet 21 of 23 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056234 (X3) DATE SURVEY COMPLETED 03/25/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARLORA POST ACUTE REHABILITATION HOSPITAL 3801 E Anaheim St Long Beach, CA 90804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE interview, the facility's contracting pharmacist ([Pharmacist 1] a medication expert) stated the orders for Resident 1 w ere received on 11/15/19 after 10 p.m. Pharmacist 1 stated LVN 1 called the pharmacy on 11/16/19 and stated Resident 1's orders that were faxed on 11/15/19, which were incorrect . Then a nursing staff member called back on the same day at 1:15 p.m. and informed the pharmacist not to send any medications because the resident went to the GACH. On 2/6/2020 at 10:40 a.m., during an interview, RN 2 stated Resident 1 was tired when she arrived at the facility. The resident's oxygen saturation was 95% on room air and the resident did not need oxygen. On 2/6/2020 at 11:21 a.m., during an interview, Resident 1's primary care physician (PCP) 1) stated he was not called about Resident 1's change of condition (COC) due to difficulty in breathing. On 2/6/2020 at 12:31 p.m., during a telephone interview, FM 1 stated when he arrived to visit Resident 1 and there was no staff in Resident 1's room. FM 1 stated Resident 1's face was red, and he could hear the noises coming from the resident's lungs. FM 1 stated Resident 1 had on oxygen face mask but was unable to catch her breath. FM 1 stated he immediately ran out to the nurse's station to get the nurse, as he (FM 1) called 911. On 2/6/2020 at 2:48 p.m., during an interview, the NP stated she did not see Resident 1 in the facility because she does not go to the facility to see residents. The NP stated she was currently out of town and was unable to continue the interview and abruptly hung up the phone. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RV8311 Facility ID: CA940000072 If continuation sheet 22 of 23 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056234 (X3) DATE SURVEY COMPLETED 03/25/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MARLORA POST ACUTE REHABILITATION HOSPITAL 3801 E Anaheim St Long Beach, CA 90804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 2/7/2020 at 3:45 p.m., during an interview and review of Resident 1's physician's orders and nurse's notes, RN 3 stated on 11/15/19 , she reviewed the admission orders from the packet sent over the GACH . RN 3 stated the orders were verified with the resident's physician but could not recall the physician's name. RN 3 stated she missed verifying Resident 1's new medication and treatment orders that was included in the package. RN 3 denied placing oxygen on Resident 1. RN 3 stated she verified Resident 1's admission orders with the medication nurse who was on duty on 11/15/19. On 2/11/2020 at 6:30 a.m., during an interview, RN 4 stated she provided care to Resident 1 on 11/15/19 during the night shift (11 p.m.-7 a.m.). RN 4 stated she received a report regarding Resident 1's respiratory diagnoses. RN 4 stated there were no medications delivered for Resident 1. RN 4 stated she verified the confusing admission orders with the NP and made the medication order changes in the computer. On 2/11/2020 at 8:30 a.m. and 3:40 p.m., during the interviews, LVN 2 stated she was Resident 1's medication nurse on 11/16/19. LVN 2 stated there was a delay in receiving Resident 1's medication and that was why she did not administer any medications or breathing treatments to Resident 1. A review of the facility's policy and procedure titled, "Physician Orders and Telephone Orders," dated 11/2017 indicated physician's orders shall be obtained prior to initiation of any medication or treatment and followed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RV8311 Facility ID: CA940000072 If continuation sheet 23 of 23