Anaheim Terrace Care Center

of the MDS showed Resident 55 was able to make self-understood and usually understands others.

able to call for help. CNA 7 verified the call light was not within Resident 55's reach and was clipped

056076 06/13/2024

Anaheim Terrace Care Center 141 South Knott Avenue Anaheim, CA 92804

Review of the facility's P&P titled Medicare Advanced Beneficiary Notice dated 4/2021 showed the residents are informed in advance when changes will occur to their bills.

Review of the SNF ABN Form CMS-10055 dated 2018 showed the SNF ABN Form CMS-10055 provided information to allow beneficiaries to decide whether to receive care that may not be paid for by Medicare and allow for the beneficiary to assume the financial responsibility.

• Medical record review for Resident 394 was initiated on 6/10/24. Resident 394 was admitted to the

facility on [DATE].

On 6/13/24 at 0910 hours, an interview and concurrent medical record review was conducted with the Business Office Manager (BOM).

Review of Resident 394's SNF Beneficiary Protection Notification Review Form CMS-20052 completed by the BOM showed Resident 394's Medicare Part A skilled services episode start date was 11/29/23, with the last covered day of Part A service on 12/20/23.

The facility initiated the discharge from Medicare Part A services when the benefit days were not exhausted.

The BOM was asked if the SNF ABN Form CMS-10055 was provided to Resident 394 or Resident 394's representative.

The BOM stated the SNF ABN Form CMS-10055 was not provided to Resident 394 or Resident 394's representative due to an oversight.

• Medical record review for Resident 395 was initiated on 6/10/24. Resident 395 was admitted to the

facility on [DATE].

On 6/13/24 at 0910 hours, an interview and concurrent medical record review was conducted with the BOM.

Review of Resident 395's SNF Beneficiary Protection Notification Review Form CMS-20052 completed by the BOM showed Resident 395's Medicare Part A skilled services episode start date was 11/24/23, with the last covered day of Part A service on 12/12/23.

The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted.

The BOM was asked if the SNF ABN Form CMS-10055 was provided to Resident 395 or Resident 395's representative.

The BOM stated the SNF ABN Form CMS-10055 was not provided to Resident 395 or Resident 395's representative due to an oversight.

056076 06/13/2024

Anaheim Terrace Care Center 141 South Knott Avenue Anaheim, CA 92804

verified the computer screen was left on unattended with no privacy screen with Resident 244's

056076 06/13/2024

Anaheim Terrace Care Center 141 South Knott Avenue Anaheim, CA 92804

- The wall close to the entrance of Resident 75's room had missing paint and scrapes.

On 6/13/24 at 0958 hours, a concurrent observation and interview was conducted with the Administrator.

The Administrator acknowledged the above findings.

• On 6/11/24 at 0934 hours, during the medication pass observation in Resident 8's room, the

window on the right side of the resident's bed had missing 17 vertical blind slats showing a walkway outside of the window.

On 6/11/24 at 958 hours, post medication administration, LVN 3 was asked if she was aware of the missing window vertical blind slats. LVN 3 stated she was not aware and did not notice the missing blind slats until today and it should have been replaced to provide full privacy to Resident 8. LVN 3 stated she would notify the management ASAP.

• On 6/10/24 at 0936 hours, during the initial tour of the facility and concurrent interview with CNA 8

and Resident 71, Resident 71's room was observed with curtains not properly hooked on the window curtain railings. CNA 8 was inside Resident 71's room and verified the findings. Resident 71 stated the curtains had been like that for a couple of months and it was reported to someone who took the trash out; however, that staff only cleaned and did not fix the curtains. Resident 71 stated the curtains made her feel a little uncomfortable because it was not in the right place.

056076 06/13/2024

Anaheim Terrace Care Center 141 South Knott Avenue Anaheim, CA 92804

notification of transfer and discharge provided to the resident's representatives.

The MRD stated it

transfer date identified.

056076 06/13/2024

Anaheim Terrace Care Center 141 South Knott Avenue Anaheim, CA 92804

Review of the facility's P&P titled Transfer or Discharge, Facility Initiated dated 10/2022 showed the notice of facility bed-hold and returns policies are provided to the resident and representative within 24 hours of emergency transfers.

• Medical record review for Resident 55 was initiated on 6/10/24. Resident 55 was admitted to the

facility on [DATE], transferred to the acute care hospital on 5/23/24, and readmitted to the facility on [DATE].

Review of Resident 55's H&P examination dated 5/28/24, showed Resident 55 had fluctuating capacity to understand and make decisions.

Review of Resident 55's Physician Orders showed an order dated 5/23/24, to transfer the resident to the acute care hospital.

Further review of Resident 55's medical record failed to show the written bed hold notice was provided to the resident's representative for the above transfer.

• Medical record review for Resident 72 was initiated on 6/11/24. Resident 72 was admitted to the

facility on [DATE], transferred to the acute care hospital on 5/2/24, and readmitted to the facility on [DATE].

Review of Resident 72's H&P examination dated 5/21/24, showed Resident 72 had the capacity to understand and make decisions.

Review of Resident 72's Physician Orders showed an order dated 5/2/24, to transfer the resident to the acute care hospital.

Further review of Resident 72's medical record failed to show the written bed hold notice was provided to the resident's representative for the above transfer.

On 6/11/24 at 1635 hours, an interview and concurrent medical record review was conducted with the MRD.

The MRD verified the physician's orders for Residents 55 and 72's transfers to the acute care hospital.

The MRD also verified Residents 55 and 72's medical records failed to show the written bed hold notice was provided to the resident's representative for the above transfer.

The MRD stated it was the Medical Records Department's responsibility to send the bed hold notice to the resident's representatives; however, the MRD was not able to send the written notice for the transfer date identified.

056076 06/13/2024

Anaheim Terrace Care Center 141 South Knott Avenue Anaheim, CA 92804

Review of Resident 15's History and Physical examination dated 4/24/24, showed Resident 15 had no diagnosis of mental illness.

Review of Resident 15's level I PASRR dated 4/20/24, showed Resident 15 had no diagnosis of mental illness and had not been prescribed of a psychotropic medications.

Review of Resident 15's Order Summary Report dated June 2024 showed a physician's order dated 4/30/24, for quetiapine fumarate (antipsychotic medication) 50 mg by mouth at bedtime for psychosis manifested by sudden change in mood from pleasant to anger.

Review of Resident 15's Order Summary Report dated June 2024 showed a physician's order dated 4/30/24, for olanzapine (antipsychotic medication) 5 mg by mouth two times a day for psychosis manifested by inconsolable screaming.

Further review of the medical record showed no documented evidence of coordination for a level II assessment when the resident was started on the antipsychotice medication for psychosis on 4/30/24.

On 6/11/24 at 1414 hours, a concurrent interview and medical record review was conducted with RN

• RN 1 stated she was one of the staff members responsible for coordinating the PASRR

assessments. RN 1 verified the above findings and stated a level II assessment should have been coordinated when Resident 15 received a new diagnosis of psychosis and was prescribed antipsychotic medications on 4/30/24.

056076 06/13/2024

Anaheim Terrace Care Center 141 South Knott Avenue Anaheim, CA 92804

Review of Resident 65's Level I PASRR Screening dated 4/3/24, showed Resident 65 had a diagnosed mental illness and had been prescribed psychotropic medications.

However, Resident 65's Level 1 Screening was negative and a Level II mental health evaluation referral was not required due to an exempted acute care hospital discharge. Resident 65's Level 1 PASRR Screening dated 4/3/24, showed if Resident 65 remained in the facility longer than 30 days, the facility should resubmit a new Level 1 PASRR Screening on the 31st day. RN 1 reviewed Resident 65's PASRR submissions and verified the facility failed to resubmit a new Level 1 PASRR Screening when Resident 65 had remained in the facility longer than 30 days as evidenced by Resident 65 having resided in the facility for approximately two months after the Level 1 PASRR Screening was conducted on 4/3/24.

056076 06/13/2024

Anaheim Terrace Care Center 141 South Knott Avenue Anaheim, CA 92804

Review of the facility's P&P titled High Risk Medications - Anticoagulant revised 2/2023 showed the resident's plan of care shall alert staff to monitor for adverse consequences.

Risks associated with anticoagulants include a. bleeding and hemorrhage (bleeding gums, nose bleed, unusual bruising, blood in urine or stool); b. fall in hematocrit or blood pressure; and c. thromboembolism (obstruction of a blood vessel by a blood clot that has become dislodged from another site in the circulation).

Medical record review for Resident 55 was initiated on 6/10/24. Resident 55 was admitted to the facility on [DATE], and readmitted on [DATE].

Review of Resident 55's H&P examination dated 5/28/24, showed Resident 55 had fluctuating capacity to understand and make decisions.

Review of Resident 55's Physician Orders as of 6/10/24, showed a physician order dated 5/28/24, to administer heparin sodium (a medication used to prevent and treat blood clots in the lungs or the legs) injection solution 5000 units every 8 hours for 30 days.

Review of Resident 55's MAR for the Month of June 2024 showed Resident 55 received heparin sodium injection solution 5000 units every eight hours since 5/29/24.

Further review of Resident 55's plan of care failed to identify the resident's care plan for use of heparin sodium, individualized goal, and interventions for staff to monitor for and prevent adverse consequences.

On 6/11/24 at 1530 hours, a concurrent interview and medical record review was conducted with LVN

• LVN 7 verified Resident 55 was receiving heparin sodium injection solution 5000 units every eight

hours. LVN 7 verified Resident 55's medical record failed to show a care plan for the resident's use of heparin sodium.

On 6/13/24 at 1445, an interview was conducted with the DON.

The DON was informed and acknowledged the above findings.

056076 06/13/2024

Anaheim Terrace Care Center 141 South Knott Avenue Anaheim, CA 92804

Review of the facility's P&P titled Care Plan Comprehensive dated 8/25/21, showed the purpose of an individualized comprehensive care plan includes measurable objectives and timetables to meet the resident's medical, physical, mental, and psychosocial needs, and shall be developed for each resident.

The comprehensive care plan includes the services that are to be furnished to attain or maintain the resident's highest practicable physical well-being.

Medical record review for Resident 393 was initiated on 6/10/24. Resident 393 was admitted to the facility on [DATE].

Review of Resident 393's Order Summary Report showed a physician's order dated 6/5/24, for oxygen to be administered at 2 to 3 liters per minute as needed to keep the oxygen saturation levels above 90%.

On 6/10/24 at 0948 hours, an observation and concurrent interview was conducted with LVN 1. Resident 393's nasal cannula was observed lying on the floor. LVN 1 verified the findings and stated Resident 393's nasal cannula needed to be stored in a clean bag for infection control and not on the floor.

On 6/12/24 at 0920 hours, an interview and concurrent medical record review was conducted with the MDS Coordinator.

Review of Resident 393's Medication Administration Record dated 6/5/24 at 1650 hours, showed Resident 393 received the oxygen therapy which was administered at 2 to 3 liters per minute to maintain the oxygen saturation levels above 90%.

Review of Resident 393's medical record failed to show a comprehensive care plan was developed for the use of the oxygen.

The MDS Coordinator verified the findings and stated the nurse who obtained the oxygen order should have initiated a comprehensive care plan to ensure Resident 393's plan of care was comprehensive, accurate, and included the monitoring of the oxygen usage.

056076 06/13/2024

Anaheim Terrace Care Center 141 South Knott Avenue Anaheim, CA 92804

Review of Resident 25's weekly progress notes with LVN 6 failed to show documented evidence of any injuries or changes of skin integrity.

On 6/11/24, at 1520 hours, an interview was conducted with Resident 25's assigned CNA (CNA 4).

CNA 4 verified Resident 25's last shower was on 6/11/24.

When asked about Resident 25's skin, CNA 4 stated she did not see any changes to Resident 25's skin integrity.

Medical record review for Resident 25 was initiated on 6/11/24. Resident 25 was readmitted to the facility on [DATE].

Review of Resident 25's History and Physical examination dated 10/9/23, showed Resident 25 had no cognitive impairment.

Further review of this examination form showed Resident 25's diagnoses included peripheral vascular disease for the bilateral lower extremities.

Review of Resident 25's progress notes showed a medical specialist note dated 6/3/24, with Resident 25's diagnoses including left knee contracture, post status stroke with left side paralysis, tremors, and cellulitis of left lower extremity. Resident 25's plan of care included to perform daily skin checks.

On 6/13/24 at 1630 hours, an interview and concurrent medical record review was conducted with the DON.

The DON verified the changes of Resident 25's skin were not documented to show they were observed and assessed and reported to Resident 25's physician for further follow up.

There was no documented evidence a weekly skin head to toe assessment was completed for the resident and identified the impairment in the resident's skin integrity.

056076 06/13/2024

Anaheim Terrace Care Center 141 South Knott Avenue Anaheim, CA 92804

with no bruising, redness, or any marks noted.

Today offered again and had finally agreed [to go to

On 6/10/24 at 1009 hours, an interview was conducted with Resident 25. Resident 25 stated he was

Resident 25 stated the CNA was transferring him to the bed, after a shower, when Resident 25 hit the corner of the bedside drawer.

When asked, Resident 25 stated there was only one CNA in the room during the transfer.

On 6/13/24 at 0848 hours, an interview and concurrent medical record review for Resident 25 was conducted with RN 1. RN 1 was asked about the facility's policy for operating the mechanical lift. RN 1 stated mechanical lifts should be operated with two-people assistance.

For transfers from bed to shower chair and back, there should be two-people to assist for resident safety and to prevent any injuries. RN 1 was asked about the incident surrounding Resident 25's acute care hospital transfer on 12/19/23.

Concurrent record review of Resident 25's nursing documentation on 11/30/23 at 1940 hours, was conducted with RN 1. RN 1 reviewed the nurse's documentation and stated Resident 25 claimed he fell and was transferred for evaluation. RN 1 stated the nurse's documentation showed on the interview, the CNA stated only one person (the CNA) transferred Resident 25 using the mechanical lift.

On 6/13/24 at 1032 hours, an interview and concurrent medical record review for Resident 25 was conducted with the DON.

The DON verified the above findings.

The DON further stated she expected there to always be two staff members present for transfers using a lift for the residents' safety.

On 6/13/24 at 1130 hours, the DON and Administrator were informed and acknowledged the above findings.

056076 06/13/2024

Anaheim Terrace Care Center 141 South Knott Avenue Anaheim, CA 92804

Review of the facility's P& P titled Administering Medications through Enteral Tube revised 11/2018 showed to verify the placement of the feeding tube.

Review of the facility's document titled Gastrostomy and Jejunostomy Placement and Patency Check, dislodging: Pulling Out undated showed using a 60 ml syringe, pull syringe plunger back and fill with 10-20 ml of air, connect the syringe to the end of the feeding tube, put on the stethoscope and place bell or diaphragm of the stethoscope over the left upper quadrant of the abdomen while rapidly injecting the air.

On 6/11/24 at 0943 hours, during the medication administration observation of LVN 3, LVN 3 was in the process of administering the GT medications and stated she was putting 10 ml of air to check for patency, then pushed the air to the GT without using the stethoscope (stethoscope was on her right shoulder).

Thereafter, LVN 3 checked for residual feeding/gastric contents, none was noted.

On 6/11/24 at 0958 hours, an interview was conducted with LVN 3. LVN 3 stated the process of checking the GT placement was to palpate the abdomen, inspect visually, listen with stethoscope for bowel sounds and palpate with hand for tenderness and then push air into GT to check for patency, auscultate to hear the air go in with or without stethoscope, would hear the swish once you input the air. LVN 3 clarified it was the facility's policy to use a stethoscope during auscultation to check for the GT placement. LVN 3 verified she did not use the stethoscope and acknowledged she failed to ensure Resident 8's GT placement was confirmed prior to its use.

056076 06/13/2024

Anaheim Terrace Care Center 141 South Knott Avenue Anaheim, CA 92804

acknowledged the above findings.

056076 06/13/2024

Anaheim Terrace Care Center 141 South Knott Avenue Anaheim, CA 92804

Review of Resident 393's Order Summary Report showed a physician's order dated 6/5/24, for oxygen to be administered at 2 to 3 liters per minute as needed to keep the resident's oxygen saturation levels above 90%.

On 6/10/24 at 0922 hours, an observation was conducted of Resident 393. Resident 393 was observed lying in bed. Resident 393's nasal cannula was observed wrapped around the call light cord.

On 6/10/24 at 0948 hours, an observation and concurrent interview was conducted with LVN 1. Resident 393's nasal cannula was observed lying on the floor. LVN 1 verified the findings and stated Resident 393's nasal cannula needed to be stored in a clean bag for infection control and not on the floor.

Cross reference to F-F656.

056076 06/13/2024

Anaheim Terrace Care Center 141 South Knott Avenue Anaheim, CA 92804

verified and acknowledged the missing signatures.

056076 06/13/2024

Anaheim Terrace Care Center 141 South Knott Avenue Anaheim, CA 92804

of opioid addiction, abuse and misuse, which could lead to overdose and death.

methadone, Dilaudid, Percocet, and Tylenol for pain. Resident 25 stated he had chronic pain

On 6/12/24 at 1047 hours, an interview and concurrent medical record review for Resident 25 was conducted with LVN 2. LVN 2 verified the above findings and stated the physician's order should have been clarified with the physician.

On 6/13/24 at 1054 hours, an interview and concurrent medical record review for Resident 25 was conducted with the DON.

The DON acknowledged the above finding and stated the nurse should have clarified the orders with the physician.

On 6/13/24 at 1130 hours, the DON and Administrator were informed and acknowledged the above findings.

056076 06/13/2024

Anaheim Terrace Care Center 141 South Knott Avenue Anaheim, CA 92804

process for informed consent for the use of psychotropic medications, the DON stated it should be the

Administration Disclosure was not signed by the physician and not verified by the nurse.

056076 06/13/2024

Anaheim Terrace Care Center 141 South Knott Avenue Anaheim, CA 92804

During the medication administration observation on 6/11/24, the following prescribed medications were not available for administration: amlodipine besylate, hydralazine hydrochloride, lisinopril, Enulose solution, and magnesium oxide.

On 6/11/24 at 0918 hours, during an interview conducted with LVN 3, LVN 3 stated the medications were not available and stated she did not know why the above medications due to be administered at 0900 hours, were not available.

On 6/11/24 at 1215 hours, interview conducted with the DON, the DON stated the delivery process for the medications for new admission and for IV medications and antibiotics, the medications should have been delivered within four hours, and for routine medications, they should have been delivered the following day.

The DON was informed and acknowledged the above findings.

The DON stated Resident 8's missed medications during the medication observation were stored in the bed hold medications bin inside the medication room and LVN 3 did not know because she worked part-time.

056076 06/13/2024

Anaheim Terrace Care Center 141 South Knott Avenue Anaheim, CA 92804

Review of Resident 8's Nursing Documentation Evaluation dated 6/10/24, showed weakness to both upper extremities in the musculoskeletal system review.

Review of Resident 8's Order Summary Report as of: 6/11/24, showed the following orders: - amlodipine besylate (antihypertensive, medication to control blood pressure) oral tablet 5 mg one tablet daily - hydralazine hcl (antihypertensive) oral tablet 25 mg one tablet enterally two times a day - lisinopril (antihypertensive) oral tablet 20 mg enterally one time a day - enulose (laxative, medication to treat constipation) solution 10 gm/15 ml give 30 ml one time a day - magnesium oxide (supplement for bowel management) 400 oral packet 1 tablet enterally one time a day During the medication administration observation on 6/11/24 at 0914 hours, the above medications were not available for administration: amlodipine besylate, hydralazine hydrochloride, lisinopril, Enulose solution, and magnesium oxide.

On 6/11/24 at 1215 hours, an interview was conducted with the DON.

The DON stated Resident 8's medications were in the bed hold medication storage.

On 6/11/24 at 1220 hours, an interview was conducted with LVN 3. LVN 3 showed Resident 8's bubble packed medications from the bed hold medication storage: lisinopril, amlodipine, hydralazine, and the enulose bottle. LVN 3 stated the magnesium oxide packet was not available. LVN 3 verified she had not given the prescribed medications to the resident that were identified earlier as not available.

Cross reference to F-F759.

056076 06/13/2024

Anaheim Terrace Care Center 141 South Knott Avenue Anaheim, CA 92804

Review of the facility's P&P titled Medication Storage in the Facility dated 4/2018 showed orally

On [DATE] at 1415 hours, an inspection of Medication Cart 3 in Station 2 was conducted with LVN 4.

Fluticasone (medication used to treat sneezing and other nasal symptoms) nasal spray was stored with ipratropium bromide inhalation solution. LVN 4 acknowledged the incorrect storage of the nasal spray with the inhalation solution.

056076 06/13/2024

Anaheim Terrace Care Center 141 South Knott Avenue Anaheim, CA 92804

Review of the facility's matrix showed 82 of 87 residents who consumed food prepared in the kitchen.

According to the California Code, Health, and Safety Code - HSC § 1265.4: A licensed health facility shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations.

Review of the untitled facility document provided by the Administrator showed the DSS's scheduled facility assignments for May 2024.

The document showed the DSS was scheduled at the facility on the following dates: 5/8, 5/9, 5/15, 5/22, 5/23, 5/29, and 5/30/24.

On 6/11/24 at 1018 hours, an interview was conducted with the DSS.

The DSS stated she was scheduled at the facility two to three times a week.

The DSS stated the RD worked at the facility once a week, on Fridays; and the Dietary Manager worked full-time, five days a week.

The DSS further stated the Dietary Manager was not certified.

On 6/12/24 at 1153 hours, an interview was conducted with the Administrator.

The Administrator confirmed the RD and DSS worked part-time, and the Dietary Manager was not certified.

The Administrator stated it was his understanding the Dietary Manager, although not certified, could be overseen by a DSS.

The Administrator was informed of the Health and Safety Code requirement that the facility must employ a full-time qualified individual to oversee the dietetic service operations.

On 6/12/24 at 1640 hours, the Administrator provided the schedule calendar for the DSS for the month of May 2024.

The Administrator verified the DSS was not at the facility on a full-time basis.

On 6/13/24 at 1130 hours, the DON and Administrator were informed and acknowledged the above findings.

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.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

056076 06/13/2024

Anaheim Terrace Care Center 141 South Knott Avenue Anaheim, CA 92804

According to the 2022 FDA Food Code Section 4-202.11, multi-use food contact surfaces shall be

sharp internal angles, corners, and crevices; and finished to have smooth welds and joints.

On 6/10/24 at 0800 hours, during the initial tour of the kitchen, a concurrent interview and observation was conducted with the DM.

Two green cutting boards were observed heavily marred and discolored.

The DM verified the finding and stated the cutting boards should be replaced.

The DM further stated cutting boards should be replaced as needed to prevent cross contamination.

• On 6/10/24 at 0800 hours, during the initial tour of the kitchen, an observation of the cooks'

refrigerator was conducted with the DM. A white bottle of caramel flavored coffee creamer and a bottle of pure leaf black tea were observed in the refrigerator with food used for resident consumption.

The DM verified the above findings and stated the cook's fridge should only be used to store items for residents' consumption.

The DM further stated the beverages were not for the residents and belonged to kitchen staff.

On 6/13/24 at 1130 hours, the DM, DSS, DON and Administrator were informed and acknowledged all of the above findings.

056076 06/13/2024

Anaheim Terrace Care Center 141 South Knott Avenue Anaheim, CA 92804

According to USDA Food Code 2022, Section 5-501.113 Covering Receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered: (b) with tight-fitting lids or doors if kept outside the food establishment.

Review of the facility's P&P titled Food-Related Garbage and Refuse Disposal (undated) showed all garbage and refuse containers are provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use.

Garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pests.

Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter.

On 6/10/24 at 0730 hours, an observation of the garbage disposal was conducted.

One of four dumpster lid (Dumpster 1) was observed not completely covering the dumpster bin.

On 6/10/24 at 1430 hours, a subsequent observation of the garbage disposal was conducted.

Trash from inside Dumpster 1 was observed above the maximum loading level, and above the level of the dumpster bin.

The dumpster lid (left side of the lid) was observed partially open and propped open by garbage inside Dumpster 1, preventing the lid from fully closing.

On 6/11/24 at 0930 hours, an interview and concurrent observation of the dumpster was conducted with the Housekeeping Supervisor.

The Housekeeping Supervisor stated dumpster lids should be closed to cover the trash inside the dumpster, to prevent animals/rodents from getting in.

Concurrent observation of the dumper bins were conducted with the Housekeeping Supervisor.

The Housekeeping Supervisor verified two of four dumper lids were not completely covering the dumpsters.

The Housekeeping Supervisor stated he had informed the Maintenance Director on 6/10/24.

On 6/11/24 at 1000 hours, an interview was conducted with the Maintenance Director.

The Maintenance Director stated he was informed on 6/10/24, that two of four dumpster lids were not completely covering the dumpster bins.

The Maintenance Director stated he had fixed the dumper lids on 6/10/24.

Concurrent observation of the dumpster was conducted with the Maintenance Director.

The Maintenance Director verified the lids of two dumpsters did not completely cover the dumpster bins and stated the lids should completely cover the dumpster bins with no openings.

When asked, the Maintenance Director stated he had not contacted the dumpster company regarding a new lid.

On 6/13/24 at 1130 hours, the DON and Administrator were informed and acknowledged the above findings.

Review of Resident 78's plan of care showed a care plan problem dated 4/8/24, addressing Resident 78's risk for MDRO colonization/infection due to Resident 78's indwelling device and actual colonization/infection with MDRO ESBL.

Interventions showed to implement enhanced barrier precautions: to use gown and gloves when performing high-contact activities: dressing, bathing and showering, transferring, and changing briefs or assisting with toileting.

On 6/12/24 at 0838 hours an observation was conducted outside of Resident 78's room. A sign posted outside or Resident 78's room showed Enhanced Barrier Precautions: everyone must clean their hands before entering and leaving the room.

Providers and staff must also wear gloves and gown for following high contact Resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting.

On 6/12/24 at 1620 hours, CNA 1 was observed inside Resident 78's room assisting Resident 78 to the toilet. CNA 1 was observed wearing gloves and was not wearing a gown. CNA 1 stated Resident 78 was currently on the toilet.

On 6/12/24 at 1625 hours, Resident 78 was standing over the restroom sink. CNA 1 was observed putting a diaper on Resident 78. Resident 78's catheter tubing and drainage bag was observed.

On 6/12/24 at 1630 hours, an interview and concurrent observation was conducted with the DSD.

The DSD verified CNA 1 was not wearing a gown.

The DSD stated, per the Enhanced Barrier Precaution sign on the wall, the staff are expected to don gloves and gown when assisting the residents with transfers and toileting to prevent/minimize the spread of organisms.

On 6/12/24 at 1632 hours, an interview was conducted with CNA 1. CNA 1 verified she assisted Resident 78 to transfer out of bed and to the restroom, to put on his diaper, and transfer back to bed.

CNA 1 verified she did not don a gown and stated she should have worn a gown and gloves.

On 6/13/24 at 1054 hours, an interview was conducted with the DON.

The DON stated Enhanced Standard Precautions was implemented to protect the residents, visitors and staff from the transmission of multi drug resistant organism.

The DON stated she expected the staff to don PPE when going into resident rooms to provide care and when assisting the residents with transfers.

On 6/13/24 at 1130 hours, the DON and Administrator were informed and acknowledged the above findings.

056076 06/13/2024

Anaheim Terrace Care Center 141 South Knott Avenue Anaheim, CA 92804

Review of the facility's Antibiotic Surveillance Data Collection forms (which contained the McGeer's criteria) for Residents 38 and 595 was conducted with the IP.

The IP verified Residents 38 and 595 were prescribed antibiotics; however, they did not meet McGeer's criteria for a true infection.

Further review of Residents 38 and 595's medical records failed to show documented evidence the residents' physicians were notified that these residents did not meet the McGeer's criteria (thus potentially preventing the physicians from discontinuing the antibiotics for these residents).

Review of Residents 63, 71, 593, and 594's medical records was conducted with the IP.

The IP verified Residents 63, 71, 593, and 594 were prescribed antibiotics; however, antibiotic surveillance information was not collected. b.

Further review of the facility's monthly Infection Prevention and Control Surveillance Logs failed to show documented evidence of outcomes and any adverse events from antibiotic use for January 2024 through May 2024.

The IP verified and acknowledged the above findings.

056076 06/13/2024

Anaheim Terrace Care Center 141 South Knott Avenue Anaheim, CA 92804

Review of Resident 75's Order Summary Report dated 6/11/24, showed a physician's order dated 6/4/24, may have Prevnar 20 (PCV20) for prophylaxis.

Review of Resident 75's Immunization Record showed Resident 75 received the PCV 20 vaccine at the facility on 6/5/24.

However, review of Resident 75's Pneumococcal Vaccine Informed Consent form dated 6/4/24, showed the following sections were left blank: - PCV 15 or PCV20 vaccine history - Information provided to patient/representative and questions answered - Potential side effects - Benefits and risks of vaccine On 6/12/24 at 0948 hours, a concurrent interview and resident medical record review was conducted with the Infection Preventionist.

The IP stated within her role as the facility's infection preventionist, she was responsible for the immunizations of the residents.

The IP verified and acknowledged the above findings.

056076 06/13/2024

Anaheim Terrace Care Center 141 South Knott Avenue Anaheim, CA 92804

Based on interview, facility document review, and facility P&P review, the facility failed to maintain

regarding the benefits and risks of COVID-19 vaccines, and were offered to receive the COVID-19 vaccine.

This failure placed the staff and residents at risk of COVID-19.

Findings

Review of the facility's P&P titled Coronavirus Disease (COVID-19) Vaccination of Staff revised June 2022 showed all staff are required to be fully vaccinated for COVID-19.

Under the section for Documentation and Reporting showed the Infection Preventionist maintains a tracking worksheet of staff members and their vaccination status.

The tracking worksheet provides the most current vaccination status of all staff who provide any care, treatment, or other services for the facility and/or its residents.

The worksheet includes: staff name (and/or employee ID), initial start of employment or service, termination of employment or service, job title, work area, brief description of how they interact with residents, and vaccination status.

On 6/12/24 at 0948 hours, a concurrent interview and facility document review was conducted with the IP.

The IP stated within her role as the facility's infection preventionist, she was responsible for the tracking of the facility staff's vaccination status for COVID-19.

The IP stated the facility staff vaccination status was tracked on a worksheet.

However, review of the facility's document titled Staff 2023-2024 Vaccination failed to show the COVID-19 vaccination status worksheet to track all working staff members was complete.

The tracking sheet had multiple missing information regarding the staff COVID-19 vaccination status.

The IP verified and acknowledged the findings.

056076 06/13/2024

Anaheim Terrace Care Center 141 South Knott Avenue Anaheim, CA 92804

and sanitize bin or dispenser with remaining sanitizer solution while machine completes sanitizing

On 6/11/24 at 0845 hours, an interview was conducted with the Maintenance Director regarding cleaning and sanitizing of the ice machine.

The Maintenance Director stated he followed the manufacturer's guidelines to clean and sanitize the ice machine monthly.

On 6/11/24 at 0911 hours, an interview and concurrent observation was conducted of the ice machine cleaner and sanitizer used by the Maintenance Director.

The Maintenance Director stated he used Manitowoc Ice Machine Cleaner and Manitowoc Ice Machine Sanitizer to clean and sanitize the ice machine.

On 6/12/24 at 0944 hours, an interview and concurrent review of the Scotsman Ice Systems Installation and User's Manual was conducted with the Maintenance Director.

The Maintenance Director verified the instructions showed to use Scotsman Clear 1 Scale Remover to clean and de-scale, and Nu-calgon Sanitizer to sanitize the ice machine.

The Maintenance Director further stated he had always used the Manitowoc Ice Machine Cleaner and Sanitizer.

On 6/13/24 at 1130 hours, the DON and Administrator were informed and acknowledged the above findings.

056076 06/13/2024

Anaheim Terrace Care Center 141 South Knott Avenue Anaheim, CA 92804

Review of the facility's Controlled Medication Count Reconciliation Sheet showed multiple missing signatures on the following dates and times:

- 4/3/24 1500-2300 hours, for incoming nurse

- 5/8/24 2300 -0700 hours, for outgoing nurse

- 5/31/24 0700 - 1500 hours, for incoming nurse

- 6/6/24, 2300 -0700 hours, for outgoing nurse

056076

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056076 B.

Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Anaheim Terrace Care Center 141 South Knott Avenue Anaheim, CA 92804

Review of the facility's P&P titled Administering Medications revised ,d+[DATE] showed the individual administering the medications checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

On [DATE] at 1449 hours, the treatment cart inspection was conducted with LVN 9. A triamcinolone acetonide cream 0.1% for Resident 85 did not have a clear label. LVN 9 stated she tried to save the label by putting a tape around it and acknowledged she would not be able to verify the information needed from the cream and the cream would be reordered from the pharmacy.

2.

Review of the facility's P&P titled Disposal of Medications and Medication Related Supplies IE3: Discontinued Medications dated ,d+[DATE], showed if a medication expires, discontinued by a prescriber, the medications are marked as discontinued or stored in a separate location and later destroyed.

a. On [DATE] at 1110 hours, the shared medication room for Stations 2 and 3 was inspected with LVN 4.

The refrigerator contained pantoprazole (medication to treat acid reflux) 2 mg/ml date with an open date of [DATE], and an expiration date of [DATE], for Resident 79. LVN 4 verified the pantoprazole had expired.

b.

Medical record review for Resident 80 was conducted on [DATE]. Resident 80 was admitted to the facility on [DATE], with diagnoses including osteomylitis (swelling of bone).

Review of Resident 80's physician's order showed an order dated [DATE], to administer ceftriaxone sodium solution 2 gm intravenously one time a day for right foot osteomyelitis.

The order was discontinued on [DATE].

Review of Resident 80's MAR showed ceftriaxone sodium solution 2 gm was last given on [DATE].

056076

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056076 B.

Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Anaheim Terrace Care Center 141 South Knott Avenue Anaheim, CA 92804