Harbor Villa Care Center

Review of Resident 5's MDS dated [DATE], showed Resident 5 was cognitively intact, and required substantial/ maximal assistance with bed mobility.

• On 1/8/25 at 1101 hours, during the Resident Council meeting, the residents were asked regarding

the call light being placed within reach. Resident 35 stated when the CNAs provided her incontinence care, they would forget to clip her call light within her reach. Resident 35 stated she just waited for someone to come to her room, so she could ask for assistance.

Medical record review for Resident 35 was initiated on 1/7/25. Resident 35 was readmitted to the facility on [DATE].

Review of Resident 35's MDS dated [DATE], showed Resident 35 was cognitively intact and required partial/ moderate assistance with bed mobility.

On 1/10/25 at 1530 hours, an interview was conducted with the DSD.

When asked about the residents' call light, the DSD stated when the resident was in the room, whether in bed or wheelchair, the call light should be within the resident's reach at all times.

• On 1/7/25 at 1026 hours, an observation was conducted for Resident 48. Resident 48 was observed

lying in bed with the call light hanging on the wheelchair, away from Resident 48.

Medical record review for Resident 48 was initiated on 1/7/25. Resident 48 was admitted to the facility on [DATE].

Review of Resident 48's MDS dated [DATE], showed Resident 48 had no impairment with the use of his upper extremities and was independent on the use of the manual wheelchair.

On 1/7/25 at 1035 hours, an observation and concurrent interview was conducted with CNA 2 for Resident 48. CNA 2 verified the call light was hanging on Resident 48's wheelchair, and not within Resident 48's reach. CNA 2 stated the call light should be on the resident's bed and close to the resident so he could call for help if he needed. Resident 48 was able to move his upper extremities and wheel himself on the wheelchair.

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Harbor Villa Care Center 861 S.

Harbor Blvd Anaheim, CA 92805

resident council had concerns with.

The Activities Staff stated the resolution of the resident council

she would not be able to show what facility administrative actions were taken to address the resident

On 1/8/25 at 1611 hours, a concurrent interview and facility document review was conducted with the DON.

When asked if the nursing department was made aware of the concerns from the resident council meeting dated 7/11/24, regarding a resident not getting pain medication, the DON stated he was not made aware about this concern, and he did not get a response form from the Activities Director.

When asked if the nursing department was made aware of the concerns from the resident council meeting dated 9/11/24, regarding residents' medications not being ordered on time and not having all of the residents' medications, the DON stated the Activities Staff gave him the response form today (1/8/25), and the DON stated he wrote the department response on the form.

When asked what was documented as the nursing department's response to concerns from the resident council meeting dated 9/11/24, the DON was not able to read his handwriting.

When asked if the nursing department was made aware of the concerns from the resident council meeting dated 10/10/24, regarding the CNAs talking to the residents in a childish tone, the DON stated he was not informed of this concern.

On 1/8/25 at 1643 hours, a concurrent interview and facility document review was conducted with the DSD.

When asked if the nursing department was made aware of the concerns from the resident council meeting dated 10/10/24, regarding the CNAs talking to the residents in a childish tone, the DSD stated she was not informed of this concern.

On 1/9/25 at 1430 hours, a concurrent interview and facility document review was conducted with the CDM.

When asked if the dietary department was made aware of the concerns by the resident council meeting dated 9/12/24, regarding the residents wanting more snacks, the CDM stated she was not informed of this concern.

055742 01/10/2025

Harbor Villa Care Center 861 S.

Harbor Blvd Anaheim, CA 92805

limited to receiving treatment and supports for daily living safely.

minimal harm Based on observation, interview, and medical record review the facility failed to provide the clean, sanitary, and homelike environment for one of 19 final sampled residents (Resident 64).

This failure

Findings

On at 1/8/25 at 0918 hours, during the initial tour of the facility, the wall by Resident 64's head of bed was observed to have scattered chipped paint.

On 1/9/25 at 0754 hours, an observation and concurrent interview was conducted with the Maintenance Director.

The Maintenance Director touched the chipped paint on Resident 64's wall and stated, I have not seen this before.

The Maintenance Director acknowledged the findings.

On 1/9/25 at 0807 hours, an observation and concurrent interview was conducted with CNA 5.

When ask about the chipped paint on Resident 64's wall, CNA 5 stated it's been there for a week, but I always forget to report it, my focus was on the resident. CNA 5 verified the above findings.

On 1/10/25 at 1501 hours, an interview was conducted with the Administrator and DON.

The Administrator and DON were informed and acknowledged the above findings.

055742 01/10/2025

Harbor Villa Care Center 861 S.

Harbor Blvd Anaheim, CA 92805

acknowledged the above findings.

minimal harm

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Harbor Villa Care Center 861 S.

Harbor Blvd Anaheim, CA 92805

Review of Resident 52's PASARR Level 1 Screening Form dated 6/21/24, showed Resident 52 had no prescribed psychotropic medications for mental illness.

However, review of Resident 52's Order Summary Report dated 1/9/25, showed Resident 52 had the physician's orders dated 6/21/24, to administer Zyprexa (antipsychotic medication) 5 mg by mouth two times a day for agitation, and lorazepam (anti-anxiety medication) 0.5 mg one tablet by mouth two times a day for anxiety (mental health condition involving repeated episodes of sudden feelings of fear, dread and uneasiness).

Review of Resident 52's admission Record dated 1/9/25, showed Resident 52 had diagnoses which included major depressive disorder (persistent low mood and loss of interest in activities), bipolar disorder (mood disorder), and anxiety.

On 1/9/25 at 0830 hours, an interview and concurrent medical record review for Resident 52 was conducted with the MDS Coordinator.

The MDS Coordinator verified the above findings and stated there was an error in completing the PASARR Level 1 assessment for Resident 52.

The MDS Coordinator further stated if the PASARR Level 1 was not accurately completed, the facility must do the screening again and refer accordingly.

The MDS Coordinator verified Resident 52 had diagnoses of major depressive disorder, bipolar disorder (mood disorder), and anxiety and had been receiving psychotropic medication.

The MDS Coordinator stated Resident 52's PASARR Level 1 was not completed accurately.

On 1/9/25 at 1445 hours, an interview and medical record review for Resident 52 was conducted with the DON.

The DON was informed and verified the above findings.

055742 01/10/2025

Harbor Villa Care Center 861 S.

Harbor Blvd Anaheim, CA 92805

Review of the facility's P&P titled Care Plans - Baseline revised 3/2022 showed the baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident.

Medical record review for Resident 75 was initiated on 1/7/25. Resident 75 was admitted to the facility on [DATE].

Review of Resident 75's MDS dated [DATE], showed Resident 75 was cognitively intact.

Review of Resident 75's Order Summary Report for January 2025 showed a physician's order dated 11/22/24, for FC FR #16/30 cc to BSD due to diagnosis of urinary retention (difficulty urinating and completely emptying the bladder) and obstructive uropathy (a condition in which the flow of urine is blocked) every shift.

Review of Resident 75's plan of care failed to show a care plan was developed to address Resident 75's use of indwelling urinary drainage catheter.

On 1/9/25 at 1046 hours, an interview and concurrent medical record review was conducted with LVN

• LVN 1 verified there was no care plan for Resident 75's indwelling urinary drainage catheter use.

LVN 1 stated Resident 75's care plan should have been inititated by the licensed nurse to make sure there was no complication with Resident 75's indwelling urinary drainage catheter.

On 1/10/25 at 1631 hours, an interview was conducted with the DON.

The DON was informed and acknowledged the above findings.

055742 01/10/2025

Harbor Villa Care Center 861 S.

Harbor Blvd Anaheim, CA 92805

Review of the Activity Calendar for January 2025 showed the Bingo game was at 1400 hours on

Review of the Smoking Supervisor Schedule showed the Activities department was to supervise the residents who smoked on Fridays at 1530 hours, and on Saturdays and Sundays at 1330 and 1530 hours.

The Activities Director and Activities Staff verified the above findings.

On 1/10/25 at 0836 hours, an interview was conducted with the Activities Assistant.

The Activities Assistant stated the Bingo game for the residents were scheduled on every Friday, Saturday, and Sunday from 1400 hours to 1530 hours.

The Activities Assistant stated on Fridays, the other department supervised the residents who smoke and did not have any issue; however, on the weekends (Saturday and Sunday), the activity department was assigned to monitor the residents who smoked.

The Activities Assistant stated she could not remember the exact dates, but when she worked on the weekends, there were times she had to start the Bingo game late for about 10 to 15 minutes because she had to supervise the residents who smoked.

The Activities Assistant further stated the residents who wanted to play Bingo on time would get upset.

The Activities Assistant stated she brought up the issue to the Activities Director but nothing had been done.

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Harbor Villa Care Center 861 S.

Harbor Blvd Anaheim, CA 92805

64's liquid consistency order was changed to thin liquid.

1/2/25, to change Resident 64's liquid consistency order from nectar thickened liquid to thin

Further review of the resident's medical record showed Resident 64's care plan was not revised to reflect the change from nectar to thin liquid consistency as per the physician's order on 1/2/25.

On 1/10/25 0926 hours, interview was conducted with the DON.

The DON verified Resident 64's liquid consistency order was changed from nectar to liquid consistency.

On 1/10/25 1520 hours, an interview was conducted with the Administrator and DON.

The Administrator and DON verified the above findings.

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Harbor Villa Care Center 861 S.

Harbor Blvd Anaheim, CA 92805

was observed on the nightstand located on the left side of the Resident 20's bed and not stored in a

On 1/7/25 at 0942 hours, an observation and concurrent interview was conducted with RN 1. RN 1

a clean set up bag to prevent environmental contamination. RN 1 then stated she would replace the nebulizer mask and tubing for Resident 20.

On 1/9/24 at 1445 hours, an interview was conducted with the DON.

The DON was informed and acknowledged above findings.

055742 01/10/2025

Harbor Villa Care Center 861 S.

Harbor Blvd Anaheim, CA 92805

Review of Resident 394's average daily intake and output in the MAR did not match the documentation in the Weekly Intake and Output Evaluation. RN 2 verified the above findings.

When asked about Resident 394's average 24-hour output of 1000 ml documented on 12/29/24, and an average 24-hour output of 100 ml documented on 1/5/25, as per the Weekly Intake and Output Evaluation, RN 2 stated the nursing staff member estimated Resident 394's output based on the incontinent brief changes. RN 2 stated if the pad was soaked, then it would be estimated as 100 ml.

When asked about Resident 394's average 24-hour intake of 1100 ml as per the Weekly Intake and Output Evaluation which did not match the documentation of Resident 394's intake and output in the MAR, RN 2 stated the documentation in the MAR was for nursing, and the CNA documented the dietary intake on another record.

Review of the POC Response History dated 12/19/24 to 1/8/25, showed documentation of Resident 394's amount of food eaten as 0 to 25%, 26 to 50%, 51 to 75%, and 76 to 100%.

There was no documentation of the actual fluid intake amount of Resident 394's dietary intake. In addition, there was no documentation of Resident 394's output.

RN 2 verified the above findings.

When asked about Resident 394's fluid intake from the dietary, RN 2 stated the nursing staff member estimated the fluid amount based on the percentage of Resident 394's food intake. RN 2 stated if Resident 394's food amount eaten was 76 to 100 %, it would be assumed Resident 394 had consumed 100 % of fluid which would be 120 ml from that meal. RN 2 stated the facility followed the dietary fluid allowance as per the physician's order. RN 2 verified Resident 394's intake and output was assumed and not accurately monitored.

055742 01/10/2025

Harbor Villa Care Center 861 S.

Harbor Blvd Anaheim, CA 92805

Review of the facility's document titled Lesson Plan on Enhanced Standard Precautions dated 4/10, 4/24, and 8/10/24, did not show CNA 8 and LVN 6 were provided with the in-service training on the EBP.

The DSD verified the above findings.

055742 01/10/2025

Harbor Villa Care Center 861 S.

Harbor Blvd Anaheim, CA 92805

Review of the facility's P&P titled Medication Administration dated 4/2019 showed the medications are administered in a safe and timely manner and as prescribed.

The medications are administered in accordance with prescriber orders, including any required time frame.

Medical record review for Resident 794 was initiated on 1/7/25. Resident 794 was admitted to the facility on [DATE], and readmitted on [DATE].

Review of Resident 794's H&P examination dated 12/28/24, showed the resident was competent and able to make decisions.

Review of Resident 794's Order Summary Report dated 1/8/25, showed an order dated 12/27/24, for methylphenidate oral tablet 10 mg, give 0.5 tablet by mouth two times a day for depression manifested by feeling sad.

Review of Resident 794's MAR for January 2025 showed the methylphenidate medication was administered to the resident on 1/4/25 at 1700 hours.

On 1/8/25 at 1040 hours, a concurrent observation of Medication Cart A, interview, and medical record review was conducted with LVN 6. Resident 794's Controlled Drug Record failed to show the methylphenidate medication was signed as given on 1/4/25 at 1700 hours.

The emergency kit was observed not to have the methylphenidate medication available. LVN 6 verified the methylphenidate was not signed on the Controlled Drug Record on 1/4/25 at 1700 hours. LVN 6 verified the emergency kit did not contain the methylphenidate.

On 1/10/25 at 1006 hours, an interview was conducted with the DON.

The DON was informed and acknowledged the above findings.

055742 01/10/2025

Harbor Villa Care Center 861 S.

Harbor Blvd Anaheim, CA 92805

Review of the facility's document titled Executive Summary of Consultant Pharmacist's Medication Regimen Review dated 12/11/24, showed Resident 19's medication regimen was reviewed by Pharmacy Consultant during the period of 12/1/24 to 12/11/24.

Further review of the Resident 19's medical records failed to show if the monthly MRR for Resident 19 for December 2024 had recommendations or if the MRR for Resident 19 was completed with no recommendations.

On 1/10/25 at 1543 hours, a concurrent interview and facility document review was conducted with RN 2. RN 2 verified the monthly MRR was conducted for Resident 19 during the period of 12/1/24 to 12/11/24. RN 2 was not able to provide whether the facility had followed up on whether Resident 19's MRR for December 2024 had any recommendations from the Pharmacy Consultant.

On 1/10/25 at 1644 hours, a concurrent interview and facility document review was conducted with the DON.

The DON stated he was not able to provide documented evidence if the MRR for Resident 19 for December 2024 was completed with recommendations or if the MRR completed was with no recommendations.

The DON acknowledged the findings.

Cross reference to F-F758, example #4.

055742 01/10/2025

Harbor Villa Care Center 861 S.

Harbor Blvd Anaheim, CA 92805

Review of the facility's P&P titled Pain - clinical protocol dated 10/2022 showed the staff and physician will monitor for adverse effects of pain medications such as gastrointestinal bleeding from NSAIDs, and anorexia, confusion, lethargy, and severe constipation related to opioids.

Medical record review for Resident 84 was initiated on 1/7/25. Resident 84 was admitted to the facility on [DATE] and was readmitted on [DATE].

Review of Resident 84's H&P examination dated 12/2/24, showed the resident had capacity to make medical decisions.

Review of Resident 84's Order Summary Report showed an order dated 11/26/24, for Norco oral tablet 5-325 mg, one tablet by mouth every four hours as needed for moderate to severe pain, not to exceed three grams in 24 hours.

Review of Resident 84's medical record did not show for the monitoring of the side effects related to the use of Norco medication, as per the facility's P&P.

On 1/9/25 at 1328 hours, a concurrent interview and medical record review for Resident 84 was conducted with RN 1. RN 1 verified there was no documentation to show for the side effect monitoring of Resident 84's Norco medication.

On 1/10/25 at 1006 hours, an interview was conducted with the DON.

The DON was informed and acknowledged the above findings.

055742 01/10/2025

Harbor Villa Care Center 861 S.

Harbor Blvd Anaheim, CA 92805

Depakote medications use.

11/20/24, with the following listed medications: mirtazapine, quetiapine fumarate and valproic acid,

medications, black box warnings, informed consent, and informed consent verification.

The document showed the date and time the licensed nurse verified the verbal or telephone consent was received as 11/20/24 at 0700 hours and the name of the person who gave the verbal or telephone consent was Resident 64.

On 1/09/24 at 1500 hours, a concurrent interview and medical record review of Resident 64's four paged informed consent to psychoactive medication was conducted with LVN 4. LVN 4 stated she obtained the consent for mirtazapine, quetiapine and valproic acid use from Resident 64's family with no specifics. Resident 64 had two listed contacts, Resident 64's wife and daughter however, the name of the person who gave the consent showed the name of Resident 64.

On 1/10/25 at 1003 hours, a concurrent interview and medical record review of Resident 64's informed consent was conducted with the DON.

The DON verified and acknowledged Resident 64's name as the person who gave the consent and stated this should have been the family member's name the staff member that was notified.

On 1/10/25 1520 hours, an interview was conducted with the Administrator and DON.

The Administrator and DON verified the above findings.

055742 01/10/2025

Harbor Villa Care Center 861 S.

Harbor Blvd Anaheim, CA 92805

conducted with LVN 3. LVN 3 verified did not administer tamsulosin, duloxetine, and quetiapine fumarate medications. LVN 3 further verified all the medications were signed as given on MAR.

On 1/7/25 at 1334 hours, an interview was conducted with DON and Administrator.

The DON and Administrator verified and acknowledged findings.

055742 01/10/2025

Harbor Villa Care Center 861 S.

Harbor Blvd Anaheim, CA 92805

Administrator verified and acknowledged above findings.

055742 01/10/2025

Harbor Villa Care Center 861 S.

Harbor Blvd Anaheim, CA 92805

expiration date for the Covid test for one year 12/20/24. RN 1 verified the findings.

one Amjevita auto injection (used to treat inflammatory diseases) 40 mg/0.4 ml medicine without a

On 1/10/25 at 1006 hours, an interview was conducted with the DON.

The DON was informed and acknowledged the above findings.

055742 01/10/2025

Harbor Villa Care Center 861 S.

Harbor Blvd Anaheim, CA 92805

Review of the facility's document titled Diet Type Report dated 1/7/25, showed 89 of 92 residents were receiving food prepared from the kitchen.

Review of the facility's Menu showed on 1/8/24, the noon meal selection included Seas Broccoli Florets (edible flower-shaped pieces of a brocolli).

Review of the facility's document titled Seas Broccoli Florets (undated) showed to place the broccoli in a steamer or stockpot with water and to cook until tender but not mushy.

On 1/7/25 at 1022 hours, an interview was conducted with Resident 5. Resident 5 stated the food in the facility did not taste good.

Medical record review for the Resident 5 was initiated on 1/7/25. Resident 5 was admitted to the facility on [DATE].

Review of Resident 5's H&P examination dated 11/20/24, showed Resident 5 was competent and able to make decisions.

On 1/8/25 at 1318 hours, a test tray inspection was conducted with the CDM, RNA 1, and LVN 4.

The regular diet tray included the broccoli.

The broccoli was observed mushy and overcooked. RNA 1 verified the observation and stated broccoli was cooked a little more. LVN 4 stated the broccoli was softer than it should have been.

On 1/9/25 at 1445 hours, the DON was informed and acknowledged the above findings.

055742 01/10/2025

Harbor Villa Care Center 861 S.

Harbor Blvd Anaheim, CA 92805

According to the USDA Food Code 2022 Section 5-402.11 Backflow Prevention, (A) .a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed.

On 1/8/25 at 0953 hours, an observation and concurrent interview was conducted with the Maintenance Director. An observation of the plumbing of the food preparation sink located adjacent to the CDM's office was conducted.

The drain pipe of the food preparation sink did not have a backflow prevention in place.

The Maintenance Director verified the observation and stated he was not able to show if the food preparation sink had the system to prevent the back flow from the sewage system.

055742 01/10/2025

Harbor Villa Care Center 861 S.

Harbor Blvd Anaheim, CA 92805

minimal harm - Pulse - 74 bpm (regular);

- Respiration - 18 (breaths/min); and - Temperature - 97.8 (forehead, non-contact).

On [DATE] at 1102 hours, an interview and concurrent medical record review for Resident 92 was conducted with LVN 1. LVN 1 stated Resident 92 expired on [DATE]. LVN 1 verified the vital signs were documented on Resident 92's electronic health record on [DATE]. LVN 1 stated the licensed nurse documented the vital signs on the electronic health record.

On [DATE] at 1057 hours, an interview and concurrent medical record review for Resident 92 was conducted with the DON.

The DON acknowledged Resident 92 expired on [DATE].

The DON verified the vital signs were documented on [DATE], one day after the resident expired.

The DON stated it happened due to the licensed staff's carelessness.

The DON stated the staff should have deactivated Resident 92's account and changed the status to discharged so nobody could mistakenly enter unnecessary documentation.

055742 01/10/2025

Harbor Villa Care Center 861 S.

Harbor Blvd Anaheim, CA 92805

Review of hospice calendar for December 2024, for Resident 52, showed a skilled nurse to visit every Thursdays (12/ 5, 12/12, 12/19, and 12/26/2024), hospice aide to visit twice a week on Tuesdays and Fridays (12/3, 12/6, 12/10, 12/13, 12/17, 12/20, 12/24, and 12/27/2024), and a social worker to visit on 12/18/2024.

Review of the facility document titled Hospice Provider A Flowsheet for December 2024 did not show the name of Resident 52, and showed the entries dated 12/5, 12/10, 12/12, 12/13, 12/20, 12/12, and 12/24/2024.

Further review of the entries on the above dates did not show the designation of the person who visited.

Further review of the document did not show if the hopice staffs (skilled nurse, hospice aid, and social worker) visited as scheduled in the calendar for December 2024.

On 1/10/25 at 1319 hours, an interview and concurrent medical record review for Resident 52 was conducted with LVN 6. LVN 6 verified the above findings and stated the Hospice Provider A Flowsheet for December 2024 was for Resident 52. LVN 6 also stated there were no other residents in the facility with the Hospice Provider A. LVN 6 stated she was not able to verify if the hospice staff visited Resident 52 as scheduled in the calendar for December 2024 and if their plan of care was followed.

On 1/10/25 at 1445 hours, an interview and concurrent medical record review for Resident 52 was conducted with the DON.

The DON verified and acknowledged the above findings.

055742 01/10/2025

Harbor Villa Care Center 861 S.

Harbor Blvd Anaheim, CA 92805

should post the EBP sign by the resident's door so the staff would know who was on the EBP.

055742 01/10/2025

Harbor Villa Care Center 861 S.

Harbor Blvd Anaheim, CA 92805

According to the CDC, the antibiotics are some of the most commonly prescribed medications in nursing homes.

Over the course of a year, up to 70% of nursing home residents get an antibiotic.

Roughly 40% to 75% of antibiotics are prescribed incorrectly. In nursing homes, high rates of antibiotics are prescribed to prevent urinary tract infection (UTI) and respiratory tract infection (RTI).

Prescribing antibiotics before there is an infection often contributes to misuse.

Often residents are given antibiotics just because they are colonized with (carrying) bacteria that are not making the person sick.

Prescribing antibiotics for colonization contributes to antibiotic overuse.

When patients are transferred between facilities, for example from a nursing home to a hospital, poor communication between facilities about prescribed antibiotics (e.g., rationale, number of days) plus insufficient infection control practices can result in antibiotic misuse and the spread of antibiotic resistance.

Antibiotic-related harms, such as diarrhea from C. difficile, can be severe, difficult to treat, and lead to hospitalizations and deaths, especially among people over age [AGE].

Review of the facility's P&P titled Antibiotic Stewardship revised 12/2016 showed the antibiotics will be prescribed and administered to the residents under the guidance of the facility's antibiotic stewardship program.

The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents.

On 1/9/25 at 1620 hours, an interview and concurrent record review was conducted with the IP.

The IP was asked to show for the documentation she notified the physician of the residents who were prescribed antibiotics and did not meet the Loeb's Criteria.

The IP was not able to show documentation the physicians were notified of the residents who were prescribed antibiotics and did not meet the Loeb's Criteria.

On 1/10/25 at 1049 hours, an interview and concurrent medical record review was conducted with the DON.

The DON acknowledged the above findings.

The DON stated the IP should have notified the physician of the residents who were prescribed antibiotics but did not meet the Loeb's criteria.

055742 01/10/2025

Harbor Villa Care Center 861 S.

Harbor Blvd Anaheim, CA 92805

minimal harm residents' refrigerator, located in Station B was free of ice buildup.

This failure had the potential for the food stored in the freezer area to not maintain the proper temperature.

Findings

On 1/7/25 at 0846 hours, an observation and concurrent interview was conducted with RN 1.

The only refrigerator in the facility to store the residents' food located in Station B was observed with the ice buildup in the frozen storage area.

The frozen storage area was observed inside residents' refrigerator with no separate door for the frozen storage area.

The food for a resident was observed stored in the refrigerator. RN 1 verified the observations and stated the above refrigerator needed to be defrosted.

On 1/9/25 at 1445 hours, an interview was conducted with the DON.

The DON was informed and acknowledged the above findings.

Review of Resident 64's H&P examination dated 11/20/24, showed Resident 64 was not competent and not able to enter into a contract.

Review of Resident 64's Order Summary Report dated 1/8/25, showed the following:

- to administer mirtazapine (antidepressant medication) 15 mg tablet to give one tablet via GT at bedtime.

- to administer quetiapine fumarate tablet, give 250 mg via GT at bedtime for bipolar disorder manifested by physically aggressive to staff.

- to administer depakote oral solution 250 mg/5 ml to give 250 mg via GT one time a day for bipolar disorder manifested by sudden verbal angry outburst for no apparent reason.

- to administer depakote oral solution 250 mg/5 ml to give 1000 mg via GT one time a day for bipolar disorder manifested by sudden verbal angry outburst for no apparent reason.

055742

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 055742 B.

Wing 01/10/2025

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

Harbor Villa Care Center 861 S.

Harbor Blvd Anaheim, CA 92805

Review of Resident 84's H&P examination dated 12/2/24, showed the resident had capacity to make medical decisions.

Review of Resident 84's Order Summary Report showed an order dated 11/26/24, for Norco oral tablet 5-325 mg, one tablet by mouth every four hours as needed for moderate to severe pain, not to exceed three grams in 24 hours.

Review of Resident 84's medical record did not show for the monitoring of the side effects related to the use of Norco medication, as per the facility's P&P.

On 1/9/25 at 1328 hours, a concurrent interview and medical record review for Resident 84 was conducted with RN 1. RN 1 verified there was no documentation to show for the side effect monitoring of Resident 84's Norco medication.

On 1/10/25 at 1006 hours, an interview was conducted with the DON.

The DON was informed and acknowledged the above findings.

055742

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 055742 B.

Wing 01/10/2025

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

Harbor Villa Care Center 861 S.

Harbor Blvd Anaheim, CA 92805

During the inspection of Medication Cart C, the following was observed:

- seven individual packs of skin integrity Hydrogel impregnated gauze (a medical dressing where a soft, water-based gel (hydrogel) is absorbed into a gauze material), sealed, with expiration date of 12/2024

- five individual packs of skin integrity Hydrogel impregnated gauze, sealed, with expiration date of 9/2023

- seven individual packs of Curad oil emulsion dressing (a nonadherent gauze mesh impregnated with white petrolatum in an oil emulsion blend), sealed, with expiration date of 1/2/24

055742

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 055742 B.

Wing 01/10/2025

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

Harbor Villa Care Center 861 S.

Harbor Blvd Anaheim, CA 92805