Harbor Villa Care Center

F-F756.

50787

5. Medical record review for Resident 64 was initiated on 1/9/25. Resident was initially admitted to the facility

on [DATE REDACTED] and readmitted on [DATE REDACTED].

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 63 055742 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Review of Resident 64's Psychiatric Progress Note dated 12/6/24, showed with Seroquel and Depakote medications use. Level of Harm - Minimal harm or potential for actual harm Review of Resident 64's Informed Consent - Psychoactive Medications showed effective date of 11/20/24, with the following listed medications: mirtazapine, quetiapine fumarate and valproic acid, including Residents Affected - Some interventions and assessment of psychoactive medications, possible side effects of the 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 63 055742 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50953 potential for actual harm Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure Residents Affected - Few the medication error rate was below 5%.

* The facility's medication error rate was 23.33%. Three of three licensed nurses (LVNs 1, 2, and 3) were found to have made errors during the medication administration observation for one sampled resident (Resident 745) and two non-sampled residents (Residents 29 and 32). This failure had the potential to negatively impact the resident's heal outcomes.

Findings:

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

Review of the facility's P&P titled Administering Medication through a Metered Dose Inhaler revised 10/2010 showed the purpose of this procedure is to provide guidelines for the safe administration of inhaled medication. Assess the resident, if indicated :

a. Lung sounds;

b. Respiratory rate and depth;

c. Cough (amount, color, and character of expectorate);

d. Presence of dyspnea.

1. On 1/7/27 at 0801 hours, a medication administration observation for Resident 32 was conducted with LVN 1. LVN 1 prepared the following medications for Resident 32:

- acidophilus probiotic (supplement) one billion probiotic cultures one capsule

- amiodarone (antiarrythmic) 200 mg one tablet

- amlodipine (calcium channel blocker) 5 mg one tablet

- artificial tears lubricant (eye drop, use for dry eye)

- budesonide (steroid) 0.5 mg/2 ml suspension one unit dose via handheld nebulizer

- eliquis (blood thinner) 5 mg one tablet

- Lasix (diuretic) 40 mg one tablet hold for systolic blood pressure below 110

- namenda (medication to treat moderate to severe dementia) 10 mg one tablet

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 63 055742 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 - metoprolol tartrate (beta blocker) 25 mg one tablet

Level of Harm - Minimal harm or - modafinil (stimulant) 100 mg one tablet potential for actual harm - multi vitamins with minerals (supplement) one tablet Residents Affected - Few - potassium chloride (supplement) 20 meq give one packet

LVN 1 crushed the lasix during the medication administration, however there was still some medication residual observed in the medicine cup. LVN 1 also did not assess the resident's apical pulse and did not check for lung sounds prior to the medication administration.

Medical record review for Resident 32 was initiated on 1/7/25. Resident 32 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED].

Review of Resident 32's Order Summary Report dated 1/7/25, showed the following physician's orders:

- dated 10/24/23 for Lasix oral tablet 40 mg give one tablet via GT two times a day for hypertension to hold

the medication for systolic blood pressure below 110.

- dated 2/26/24 for budesonide inhalation suspension 0.5 mg/2 ml, 2 ml inhale orally two times a day for COPD, monitor blood pressure, apical pulse, lung sound (C-clear, W-wheezing, R-rhonchi) pre and post administration.

On 1/7/25 at 1131 hours, a concurrent interview and medical record review was conducted with LVN 1. LVN 1 verified they did not check Resident 32's apical pulse and lung sounds prior to administration of budesonide inhalation, and verified there was lasix residual left in the medicine cup.

2. On 1/7/25 at 0913 hours, a medication administration observation for Resident 29 was conducted with LVN 2. LVN 2 prepared the following medications for Resident 29:

- Augmentin (antibiotic) 500-125 mg one tablet. The bubble pack had instructions to take this medication with food to lessen chance of stomach upset.

- aspirin (anti-inflammatory) chewable 81 mg one tablet

- Plavix (antiplatelet) 75 mg one tablet

- docusate sodium (stool softener) 100 mg two tablet

- ferrous sulfate (iron supplement) 325 mg one tablet

- folic acid (supplement) 1 mg one tablet

- lisinopril (ACE inhibitor) 40 mg one tablet

- multivitamins with minerals (supplement) one tablet

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 63 055742 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 - nifedipine extended release (calcium channel blocker) 60 mg one tablet

Level of Harm - Minimal harm or - Systane (eye drop, use for dry eyes) 0.6% eyedrop instill one drop to both eye potential for actual harm LVN 2 did not give the Augmentin and ferrous sulfate medications with food to Resident 29. Residents Affected - Few Medical record review for Resident 32 was initiated on 1/7/25. Resident 32 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED].

Review of Resident 32's Order Summary Report dated 1/7/25, showed the following physician's orders:

- dated 1/6/25 for Augmentin oral tablet 500-125 mg one tablet by mouth three times a day for cellulitis left antecubital for 10 days.

- dated 1/2/25, for ferrous sulfate oral tablet 325 mg give one tablet by mouth two times a day to take with food

On 1/7/25 at 1138 hours, a concurrent interview and medical record review was conducted with LVN 2. LVN 2 verified they did not give the Augmentin and ferrous sulfate with food and stated the order for giving Augmentin with food needed to be clarified with the physician since the bubble pack label instruction was to take the antibiotic medication with food.

3. On 1/7/27 at 0954 hours, a medication administration observation for Resident 745 was conducted with LVN 3. LVN 3 prepared the following medications for Resident 745:

- gabapentin (anticonvulsant) 300 mg one capsule

- depakote (anticonvulsant) two capsules

- acetaminophen (pain reliever) 325 mg two tablet

- multi vitamins with minerals (supplement) one tablet

- Vitamin D (supplement) 1000 IU two tablet

LVN 3 did not administer tamsulosin, duloxetine, and quietapine to Resident 745.

Medical record review for Resident 745 was initiated on 1/7/25. Resident 745 was admitted to the facility on [DATE REDACTED].

Review of Resident 745's H&P examination dated 12/20/24, showed the resident was not competent and not able to enter into a contract, including admission agreement.

Review of Resident 745's Order Summary Report dated 1/7/25 showed the following physician's orders:

-dated 12/19/24 for tamsulosin (to treat symptom of enlarged prostate) oral capsule 0.4 mg, two capsule by mouth one time a day.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 63 055742 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 -dated 12/19/24, for duloxetine (antidepressant) oral capsule 60 mg one capsule by mouth two times a day for depression manifested by verbalization of traumatic experience when he was a firefighter. Level of Harm - Minimal harm or potential for actual harm -dated 12/19/24, for quetiapine fumarate (antipsychotic) oral tablet 25 mg one tablet by mouth two times a day for manic disorder manifested by auditory hallucination. Residents Affected - Few

On 1/7/25 at 1136 hours, a concurrent interview and medical record review for Resident 745 was 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 63 055742 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50953 potential for actual harm Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure Residents Affected - Few one of three sampled residents (final sampled resident, Resident 745) was free from the significant medication errors. This failure placed Resident 745 at risk for medical complications.

Findings:

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.

Review of the facility's P&P titled Medication Ordering and Receiving from Pharmacy date 4/2008 showed to reorder medication five days in advance of the need to assure for an adequate supply is on hand.

Medical record review for Resident 745 was initiated on 1/7/25. Resident 745 was admitted to the facility on [DATE REDACTED].

Review of Resident 745's Order Summary Report dated 1/7/25, showed the following physician orders:

- dated 12/19/24, for duloxetine (antidepressant medication) oral capsule 60 mg one capsule by mouth two times a day for depression manifested by verbalization of traumatic experience when he was a firefighter.

- dated 12/19/24, for quetiapine fumarate (antipsychotic medication) oral tablet 25 mg one tablet by mouth two times a day for manic disorder manifested by auditory hallucination

- dated 12/19/24, for tamsulosin (to treat symptom of enlarged prostate) oral capsule 0.4 mg, two capsule by mouth one time a day.

On 1/7/27 at 0954 hours, a medication administration observation for Resident 745 was conducted with LVN 3. LVN 3 did not administer the tamsulosin, duloxetine, and quietapine fumarate medications to Resident 745.

On 1/7/25 at 1136 hours, a concurrent interview and medical record review for Resident 745 was conducted with LVN 3. LVN 3 verified they did not administer the tamsulosin, duloxetine, and quetiapine fumarate medications. LVN 3 further verified all the medications were signed as given on the MAR.

On 1/7/25 at 1212 hours, a concurrent interview and medical record reviewed was conducted with the Pharmacy Consultant. The Pharmacy Consultant stated the tamsulosin, duloxetine and quetiapine fumarate medications were filled on 12/19/24 for 14 days supply. There was a refill request on 12/26/24, not able to refill. According to the pharmacy's calculation on 1/2/25, the last dose of medication to administered was on 1/2 and 1/3/25, and there were no more medications available. Review of the MAR for 12/2024 and 1/2025 showed no documentation Resident 745 had refused any of the above medications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 63 055742 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 On 1/7/25 at 1334 hours, an interview was conducted with DON and Administrator. The DON and Administrator verified and acknowledged above findings. Level of Harm - Minimal harm or potential for actual harm Cross reference to

F-F758, example #4.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 63 055742 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50953 potential for actual harm Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of five Residents Affected - Few final sampled residents (Residents 84) reviewed for unnecessary medications was properly monitored related to the use opioid medication.

* The facility failed to ensure Resident 84 was monitored for the side effects of receiving Norco (narcotic) medication. This failure had the potential for Resident 84 to receive unnecessary medications and develop significant side effects.

Findings:

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 REDACTED] and was readmitted on [DATE REDACTED].

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 63 055742 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic Level of Harm - Minimal harm or medications are only used when the medication is necessary and PRN use is limited. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50953 Residents Affected - Some Based on interview, medical record review, and facility P& P review, the facility failed to ensure five of five final sampled residents (Residents 5, 19, 64, 84, and 745) reviewed for unnecessary medications were free from the unnecessary psychotropic medications.

* There was no evidence of non-pharmacological interventions for Resident 745's use of quetiapine (antipsychotic medication), Ativan (antianxiety medication), duloxetine (antidepressant medication) and divalproex sodium (mood stabilizer medication). Additionally, the facility failed to monitor behavior and side effects for the use of Ativan and failed to reassess the resident for use of quetiapine as needed more than 14 days.

* The facility failed to show the Xanax (antianxiety medication) medication was only limited to 14 days for Resident 84. Additionally, the informed consent for the use of the Xanax medication was not completed prior to administration, and there was no evidence of non-pharmacological interventions for use of Remeron (antidepressant medication).

* The facility failed to ensure the PRN order for the psychotropic medication was limited to 14 days for Residents 5 and 19.

* Resident 64's informed consent for antidepressant medication, mood stabilizer and psychotropic medication was signed by the resident who was deemed not to have capacity to make decisions.

These failures had the potential to result in unnecessary use of, ineffective and/ or lack of monitoring or interventions for the use of the psychotropic medications that could negatively affect Residents 5, 19, 64, 84, and 745's highest practicable mental, physical, and psychosocial well- being.

Findings:

Review of the facility's P&P titled Psychotropic Drug Use revised 3/2024 showed:

- Nonpharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medication when possible.

- Before prescribing a psychotherapeutic drug, the prescriber must personally examine the resident obtain informed written consent sign by the resident or the resident's representative along with, the signature of the health care professional declaring the required material information has been provided.

- PRN orders for psychotropic medication are limited to 14 days.

- the signed written consent must be recorded in the resident's medical record. Before initiating treatment with psychotherapeutic drugs, facility staff must verify the resident's health record contains written informed consent with the required signatures.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 63 055742 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 - the facility will have the resident sign the consent or if there is a responsible party, the responsible party will either sign the consent or give a verbal consent with the licensed nurses that verbal consent was received or Level of Harm - Minimal harm or declined. potential for actual harm - the informed consents are maintained in the EMR (electronic medical record). Residents Affected - Some

Review of the facility's P&P titled Psychotropic Medication Use dated July 2022 showed the psychotropic medication are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. Further review of the P&P showed the PRN order for psychotropic medication are limited to 14 days. The P&P also showed for psychotropic medication that are not antipsychotic and if prescriber or attending physician believes it is appropriate to extend the PRN medication beyond 14 days, he or she will document the rational for extending the use and include the duration for the PRN order.

1. Medical record review for Resident 745 was initiated on 1/7/25. Resident 745 was admitted to the facility

on [DATE REDACTED].

Review of Resident 745's H&P examination dated 12/20/24, showed the resident was not competent.

Review of Resident 745's Order Summary Report dated 1/7/25, showed the following physician orders:

- dated 12/19/24, for duloxetine oral capsule 60 mg one capsule by mouth two times a day for depression manifested by verbalization of traumatic experience when he was a firefighter.

- dated 12/19/24, for divalproex sodium oral capsule 125 mg two capsule by mouth three times a day for mood stabilizer manifested by mood swings

- dated 12/19/24, for quetiapine fumarate oral tablet 25 mg one tablet by mouth two times a day for manic disorder manifested by auditory hallucination

- dated 12/19/24, for quetiapine fumarate oral tablet 100 mg one tablet by mouth at bedtime for manic disorder manifested by auditory hallucination

- dated 12/19/24, for quetiapine fumarate oral tablet 25 mg two tablet by mouth every 12 hours as needed for manic disorder manifested by auditory hallucination

- dated 1/7/25, for Ativan oral tablet 0.5 mg one tablet by mouth every six hours as needed for anxiety manifested by yelling/agitation.

Review of Resident 745's medical record did not show for nonpharmacological intervention monitoring for the use of the Ativan, divalproex sodium, duloxetine, and quetiapine fumarate medications.

Review of Resident 745's medical record failed to show the resident was monitored for the side effects and behavior monitoring for the Ativan use.

Review of Resident 745's medical record failed to show the resident was reassessed for quetiapine, as it was an as needed medication and had been more than 14 days.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 63 055742 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 On 1/8/25 at 1339 hours, a concurrent interview and medical record review for Resident 745 was conducted with RN 1. RN 1 verified and acknowledged all the above findings. Level of Harm - Minimal harm or potential for actual harm 2. Medical record review for Resident 84 was initiated on 1/7/25. Resident 84 was admitted to the facility on [DATE REDACTED] and was readmitted on [DATE REDACTED]. Residents Affected - Some

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 the following physician's orders:

-dated 12/12/24, for Xanax oral tablet 0.25 mg, one tablet by mouth every eight hours as needed for anxiety manifested by verbalization of anxiousness.

-dated 12/9/24, for Remeron oral tablet 15 mg, one tablet by mouth at bedtime for depression manifested by poor PO intake less than 50% .

Review of Resident 84's medical record failed to show the resident was reassessed for the use of the Xanax medication, as it was an as needed medication and had been more than 14 days.

Review of Resident 84's medical record failed to show an informed consent was obtained for the Xanax medication.

Review of Resident 84's medical record failed to show nonpharmacological intervention monitoring for the use of the Remeron medication.

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 informed consent for the Xanax medication and Resident 84 was not reassessed for the need to continue the as needed order for the Xanax medication, the order was more than 14 days. RN 1 verified no nonpharmacological interventions were monitored for use of the Remeron medication.

On 1/10/25 at 1006 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

44175

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

Review of Resident 5's Order Summary Report showed an order dated 11/21/24, for lorazepam (antianxiety medication) 0.5 mg give one tablet by mouth every six hours as needed for anxiety.

Further review of Resident 5's medical record did not show a documented reason for the extension of the lorazepam medication beyond 14 days.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 63 055742 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 On 1/10/25 at 0932 hours, a conurrent interview and medical record review for Resident 5 was conducted with LVN 4. LVN 4 verified the above findings and stated she was not able to find the documented reason for Level of Harm - Minimal harm or extension of the lorazepam medication beyond 14 days for Resident 5. potential for actual harm 4. Medical record review for Resident 19 was initiated on 1/7/25. Resident 19 was admitted to the facility on Residents Affected - Some [DATE REDACTED].

Review of Resident 19's Order Summary Report showed an order dated 12/15/24, for lorazepam 1 mg to give one tablet by mouth every 12 hours as needed for anxiety manifested by restlessness for 30 days.

Further review of Resident 19's medical record did not show a documented reason for the extension of the lorazepam medication beyond 14 days.

On 1/9/25 at 1359 hours, a concurrent interview and medical record review for Resident 19 was conducted with LVN 1. LVN 1 verified the above findings and stated she was not able to find the documented reason for extension of the lorazepam medication beyond 14 days for Resident 19.

On 1/10/25 at 1030 hours, a concurrent interview and medical record review for Residents 5 and 19 was conducted with the DON. The DON verified the above findings and stated the PRN order for the psychotropic medications should only be limited to 14 days. The DON further stated if the resident required medication more than 14 days, then there should have been a documented reason for extension of the PRN psychotropic medication.

Cross reference to

F-F759.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 63 055742 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50953 Residents Affected - Few Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide

the necessary pharmacy services to ensure proper medication storage.

* The facility failed to ensure the expired medications were removed from the medication cart

* The facility failed to ensure the medications were stored and labeled properly

* The facility failed to ensure a bag containing several wound dressings, a tube of CalProtect topical ointment (medication used to treat minor skin irritations) and two tubes of Triad hydrophilic wound dressing ointment (a zinc-oxide based sterile coating used to manage low to moderate levels of wound exudate) were not left at

the resident's bedside.

* The facility failed to ensure Residents 58 and 494's medications were not left unattended in the residents' rooms.

* The facility failed to maintain the accurate labeling to facilitate consideration of precautions and safe administration, of medications; and safe and secure storage of all medications to Resdient 81.

* The facility failed to ensure a packet of Vitamin A&D (skin moisturizer) was not left at Resident 56's bedside table

These failures had the potential to negatively impact the residents' well-being, and medication errors.

Findings:

Review of the facility's P&P titled Administering Medications revised 4/2019 showed the expiration/beyond

the use date on the medication is checked prior to administering.

1a. On 1/8/25 at 0803 hours, an inspection for Medication Cart C was conducted with LVN 5. 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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 63 055742 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 - 11 individual packs of Curad oil emulsion dressing sealed with expiration date of 9/8/24

Level of Harm - Minimal harm or - two individual packs of open Medi-strip reinforced wound closure potential for actual harm - one individual pack of bordered gauzed with adhesive border cut and open Residents Affected - Few - one individual pack of Aquacel (a hydrofiber wound dressing used to treat wounds that are moderately to heavily exuding)10 x 12 cm open and cut

- two individual packs of open and cut Medi strip reinforced wound closure, with package's description showed it was a single use only dressing

- one individual pack of Collagen wound dressing open, with package's description showed it was a single use only dressing

- one individual pack of calcium alginate dressing (a non-toxic, absorbent wound dressing made from seaweed) 10 x 10, sealed, with expiration date of 8/28/23

- one individual pack of calcium alginate dressing 10 x 10, sealed, with expiration date of 10/21/24

- one individual pack of open Opti foam gentle silicone faced foam and border (used for for partial and full-thickness wounds that are moderately to severely draining)

On 1/8/25 at 0833 hours, an interview was conducted with LVN 5. LVN 5 was asked the process of opening

an individual pack supply. LVN 5 stated individual pack is single use only and needs to be discarded after single use. The LVN 5 verified all the above findings.

b. On 1/8/25 at 1023 hours, an inspection for Medication Cart A was conducted with LVN 6. During the inspection of Medication Cart A, one bottle of Active liquid Protein Concentrated nutrition sealed was noted with an expiration date of 12/1/24.

On 1/8/25 at 1040 hours, an interview was conducted with LVN 6. LVN 6 verified and confirmed above findings.

c. On 1/8/25 at 1052 hours, an inspection of Medication Cart C and interview was conducted with LVN 4. One bottle of Active liquid Protein Concentrated nutrition was observed open with an expiration date of 12/1/24. LVN 4 verified the findings.

d. On 1/7/25 at 1232 hours, an inspection of Medication Room A and interview was conducted with RN 1. One Covid self-test was observed with an expiration date of 12/20/23. RN 1 showed extended expiration date for the Covid test for one year 12/20/24. RN 1 verified the findings.

e. On 1/7/25 at 1251 hours, an inspection of Medication Room B was conducted with RN 1. There was one Amjevita auto injection (used to treat inflammatory diseases) 40 mg/0.4 ml medicine without a label of the resident's name and open date. RN 1 verified the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 63 055742 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 On 1/10/25 at 1006 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. Level of Harm - Minimal harm or potential for actual harm 39453

Residents Affected - Few 2. On 1/7/25 at 0834 hours, during the initial tour of the facility, a bag containing several wound dressings, a tube of CalProtect topical ointment and two tubes of Triad hydrophilic wound ointment was observed on Resident 82's nightstand. Resident 82 stated she did not know anything about the wound dressing and wound care ointments, and the nurse applied those to her right leg wound.

Medical record review for Resident 82 was initiated on 1/7/25. Resident 82 was admitted to the facility on [DATE REDACTED].

Review of Resident 82's Order Summary Report dated 1/8/25, showed the following physician's orders:

- dated 12/13/24, for the left lower leg with dry and scaly skin, cleanse with normal saline, apply with moisturizing cream and leave open to air;

- dated 12/13/24, for the right lower leg with dry and scaly skin, cleanse with normal saline, apply with moisturizing cream and leave open to air;

- dated 12/26/24, for the right posterior/ lateral lower leg peripheral arterial disease wound, cleanse with normal saline, apply collagen then cover with rolled gauze.

- dated 12/26/24, for the left foot second two peripheral arterial disease wound, to paint with betadine (an antiseptic) and leave open to air;

- dated 12/26/24, for the left foot third two peripheral arterial disease wound, to paint with betadine and leave open to air; and

- dated 12/26/24, for left foot fourth two peripheral arterial disease wound, to paint with betadine and leave open to air.

On 1/7/25 at 1013 hours, a concurrent observation for Resident 82 and interview was conducted with LVN 5.

A bag containing several wound dressings, a tube of CalProtect topical ointment and two tubes of Triad hydrophilic wound ointment was observed on Resident 82's nightstand. LVN 5 verified the above findings. LVN 5 stated the bag containing the wound dressings and ointments may have been from when Resident 82 was admitted .

44175

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 63 055742 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 3. Review of the facility's P&P titled Storage of Medications revised 2/2023 showed the drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls Level of Harm - Minimal harm or and only persons have access to locked medications. The medications and biologicals are stored in the potential for actual harm packaging, containers, or other dispensing systems in which they are received. Compartments containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are Residents Affected - Few not left unattended if open or otherwise potentially available to others. Further review of the P&P showed the nursing staff was responsible for maintaining medication storage and preparation areas clean, safe, and sanitary manner.

a. On 1/7/25 at 0929 hours, a concurrent observation and interview was conducted with Resident 58. Two medication cups containing white pasty cream with wooded spatula were observed on top of the nightstand

on the left side of the Resident 58's bed. Resident 58 was observed lying in bed with the night stand next to her. There was no licensed staff inside the room. Resident 58 stated the medication cream was for her back and the staff applied the medication on her back.

Medical record review for Resident 58 was initiated on 1/7/25. Resident 58 was admitted to the facility on [DATE REDACTED].

Review of Resident 58's H&P examination dated 9/20/24, showed Resident 58 was competent and able to make decisions.

b. On 1/7/25 at 0931 hours, a concurrent observation and interview was conducted with Resident 494. A medication cups containing white pasty cream with wooded spatula was observed on top of the nightstand

on the right side of the Resident 494's bed. Resident 494 was observed lying in bed with the night stand next to her. There was no licensed staff inside the room. Resident 494 stated she did not know about the medication that was left at her nightstand.

Medical record review for Resident 494 was initiated on 1/7/25. Resident 494 was admitted to the facility on [DATE REDACTED].

Review of Resident 494's H&P examination dated 12/20/24, showed Resident 494 had the capacity to understand and make medical decisions.

On 1/7/25 at 0942 hours, a concurrent observation and interview was conducted with RN 1. RN 1 verified the above observations and stated the white pasty substance in the medication cup on the nighstand of Resident 58 and 494 looked like zinc oxide. RN 1 further stated the nursing staff should not have left the medication at

the bed side of Resident 58 and 494 unattended.

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

50787

c. On 1/7/25 1147 hours, a concurrent observation of Resident 81's room and interview was conducted with CNA 1. A white cream was observed inside a small cup with a tongue depressor on top of Resident 81's bedside stand. CNA 1 was asked what the white cream was. CNA 1 stated it was for Resident 81, and the treatment nurse used it on the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 63 055742 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Medical record review of Resident 81 was initiated on 1/9/24. Resident 81 was initially admitted on [DATE REDACTED] and readmitted on [DATE REDACTED]. Level of Harm - Minimal harm or potential for actual harm On 1/8/25 at 1008 hours, a concurrent interview and medical record review was conducted with LVN 5. LVN 5 identified the cream as zinc oxide cream and verified it was used. Review of Resident 81's physician's Residents Affected - Few orders and treatment administration record did not show an order for the zinc oxide cream. LVN 5 verified there was no order to use the cream for the resident and need one.

On 1/10/24 at 1520 hours, an interview was conducted with the Administrator and DON. The Administrator and DON acknowledged and verified the above findings.

49644

4. On 1/8/25 at 0902 hours, a concurrent observaation and interview was conducted with Resident 56. Resident 56 was observed lying in bed and using her cellphone. One Vitamin A&D packet was observed on Resident 56's bedside table. Resident 56 stated the nurses applied the Vitamin A&D ointment to her skin.

Medical record review for Resident 56 was initiated on 1/7/25. Resident 56 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED].

Review of Resident 56's Order Summary Report for January 2025 showed the following physician's orders:

- dated 12/11/2024, LLE Dryness: Apply Vitamin A&D and leave open to air every day for 30 days; and

- dated 12/11/2024, RLE Dryness: Apply Vitamin A&D and leave open to air every day for 30 days.

On 1/7/25 at 1019 hours, a concurrent observaation and interview was conducted with LVN 1. LVN 1 verified

the Vitamin A&D ointment packet was on Resident 56's bedside table. LVN 1 stated the Vitamin A&D packet should not be left on Resident 56's bedside table.

On 1/10/25 at 1631 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 63 055742 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Potential for **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44175 minimal harm Based on observation, interview, and facility document review, the facility failed to ensure the food served to Residents Affected - Some the residents was palatable.

* The cooked broccoli was mushy in texture. This failure had the potential for the residents to not eat the food served and could affect their nutritional status.

Findings:

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 REDACTED].

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 63 055742 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 44175

Residents Affected - Few Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure

the food safety and sanitation guidelines were followed when:

* The facility failed to ensure two coffee pots were not stored wet.

* The facility failed to ensure the kitchen equipment and utensils were maintained in a sanitary condition.

* The facility failed to ensure the food preparation sink had a back flow prevention in place.

These failures had the potential to result in foodborne illnesses for residents receiving kitchen services in the facility.

Findings:

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.

1. According to the USDA Food Code 2022, Section 4-901.11, Equipment and Utensils, Air-Drying Required, items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items prevents them from drying and may allow an environment where microorganism can begin to grow.

On 1/7/25 at 0800 hours, an observation and concurrent interview was conducted with the CDM. Two coffee pots were observed stored wet in the coffee station inside the kitchen. The CDM verified the observation and stated the staff should have air dried the coffee pots before storing.

2. According to the USDA Food Code 2022, Section 4-601.11 Equipment, Food- Contact Surfaces, Nonfood Contact Surface, and Utensils. Equipment food - contact surfaces and utensils shall be clean to sight and touch.

a. On 1/7/25 at 0800 hours, an observation and concurrent interview was conducted with the CDM. The following were observed:

- A white freezer was observed with a brownish black discoloration on the Styrofoam lining inside the freezer. Food was observed stored in the freezer.

- Four small red bowls with dried food crumbs were observed stored in a clean dish storage area.

The CDM verified the above observations and stated the white freezer needed to be cleaned and the four small red bowls should have been thoroughly cleaned before the bowls were stored in a clean dish storage area. The CDM was observed taking the four small red bowls with dry food crumbs to the dishwashing area for cleaning.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 63 055742 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 b. Review of the facility's P&P titled Ice Machine and Ice Storage Chests dated November 2022 showed the ice machines and ice storage distribution containers will be used and maintained to assure a safe and Level of Harm - Minimal harm or sanitary supply of ice. potential for actual harm

On 1/8/25 at 0953 hours, an observation of the ice machine and concurrent interview was conducted with the Residents Affected - Few Maintenance Director. When the Maintenance Director was asked to open the metal cover of the ice machine, the inside lining of the door of the ice machine was observed peeling off with sticky brown discoloration. The Maintenance Director verified the observation and acknowledged the peeling of the inside lining of the ice machine was not a cleanable surface and needed to be fixed.

3. 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 63 055742 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49644

Residents Affected - Some Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records for one of 19 final sampled residents (Resident 24) and one of three closed record residents (Resident 92) were complete and accurately documented.

* The facility failed to ensure Resident 24's POLST was signed by the legal decisionmaker.

* The facility failed to ensure Resident 92's Vital Signs Summary was accurate.

These failures had the potential for the residents' needs not being met as the medical information were incomplete and inaccurate.

Findings:

Review of the facility's P&P titled Charting and Documentation revised ,d+[DATE REDACTED] showed all the services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The Policy Interpretation and Implementation section showed documentation

in the medical record will be objective (not opinionated or speculative), complete, and accurate.

1. Medical record review for Resident 24 was initiated on [DATE REDACTED]. Resident 24 was admitted to the facility on [DATE REDACTED].

Review of Resident 24's POLST dated ,d+[DATE REDACTED], failed to show the signature of Resident 24's legal decisionmaker.

On [DATE REDACTED] at 1012 hours, an interview and concurrent medical record review for Resident 24 was conducted with LVN 1. LVN 1 verified Resident 24's POLST had no signature on the space for the Signature of Patient or Legally Recognized Decisionmaker. LVN 1 stated Resident 24's POLST should have been signed so the staff would know if it was valid. LVN 1 stated the licensed nurse or social worker should contact the family to make sure Resident 24's POLST was valid.

On [DATE REDACTED] at 1631 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

2. Closed medical record review for Resident 92 was initiated on [DATE REDACTED]. Resident 92 was admitted to the facility on [DATE REDACTED].

Review of Resident 92's Record of Death (undated), showed Resident 92's date of death was [DATE REDACTED] at 2030 hours.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 63 055742 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Review of Resident 92's Weights and Vital Signs Summary showed the following vital signs documented on [DATE REDACTED] at 0018 hours: Level of Harm - Potential for minimal harm - Blood Pressure - ,d+[DATE REDACTED] mmHg;

Residents Affected - Some - Oxygen Saturation - 98% (room air);

- Pulse - 74 bpm (regular);

- Respiration - 18 (breaths/min); and

- Temperature - 97.8 (forehead, non-contact).

On [DATE REDACTED] 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 REDACTED]. LVN 1 verified the vital signs were documented on Resident 92's electronic health record on [DATE REDACTED]. LVN 1 stated the licensed nurse documented the vital signs on the electronic health record.

On [DATE REDACTED] 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 REDACTED]. The DON verified the vital signs were documented on [DATE REDACTED], 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 63 055742 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44175

Residents Affected - Few Based on interview, medical record review, and facility document review, the facility failed to ensure one of one resident (final sampled, Resident 52) reviewed for hospice services had received the necessary care and services.

* The facility failed to ensure the hospice visit calendar was available in Resident 52's residents' medical record.

* The facility failed to ensure for an accurate documentation of the hospice staff visits were available for Resident 52.

* The facilty failed to ensure the hospice staff visited the resident as scheduled in the hospice calendar for Resident 52.

These failures posed the risk for the delay in communication and provision of hospice care between the hospice provider and facility .

Findings:

Review of the facility's document titled Hospice Services Agreement with Hospice Provider A dated 2/23/23, showed:

- The hospice provider will ensure that patient's visit will be made at a time mutually agreed upon by provider and patient.

- The hospice provider will ensure complete physical assessment will be completed by an RN employee of Hospice Provider A, and ongoing assessment will be done each time that the patient is visited by a skilled nurse.

Medical record review for Resident 52 was initiated on 1/7/25. Resident 52 was admitted to the facility on [DATE REDACTED].

Review of Resident 52's Physician Order Summary dated 1/9/25, showed a physician's order dated 6/21/24, to admit Resident 52 in the facility under Hospice Provider A.

a. Review of the Resident 52's hospice provider Plan of Care dated 12/2/24, showed the following:

- Skilled nurse to visit one time weekly and eight visits as needed;

- Hospice aide to visit two times a week; and

- Social worker to visit one time a month and three visits as needed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 63 055742 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 Review of the Resident 52's medical records did not show a calendar for January 2025, to show the schedule when the hospice staff were visiting Resident 52. Level of Harm - Minimal harm or potential for actual harm On 1/9/25 at 1028 hours, an interview and concurrent medical record review was conducted with LVN 6. LVN 6 verified the above findings and stated the skilled nurse from Hospice Provider A visited Resident 52 every Residents Affected - Few Thursday, and she was not sure about the schedule of hospice aide and which days the hospice aide visited Resident 52. LVN 6 verified the hospice visit calendar for January 2025, was not in Resident 52's medical records.

b. 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 63 055742 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49644 potential for actual harm Based on observation, interview, and facility P&P review, the facility failed to implement the infection control Residents Affected - Some practices designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections.

* The facility failed to ensure the facility had monthly Infection Prevention and Control Surveillance logs for July, September, and December 2024.

* The facility failed to ensure the facility's infection surveillance log for August through November 2024 included if the resident met the Loeb's criteria for true infection.

* The facility failed to ensure the October and November 2024 Infection Prevention and Control QA Reports were accurate.

* The facility failed to ensure the facility had a surveillance log to show the residents who met and not met

the Loeb's criteria.

* The IP failed to include residents with signs and symptoms of infection but were not prescribed with antibiotic on the infection surveillance report.

* The facility failed to ensure Resident 694's Infection Screening Evaluation form showed whether the resident met or not met the Loeb's Criteria.

* The facility failed to ensure staff performed hand hygiene after removing gloves during medication administration for one of three resident (Resident 32).

* The facility failed to ensure the staff performed hand hygiene during the wound care treatment for Resident 19.

* The facility failed to ensure Resident 14's Foley catheter bag was not on the floor.

* The facility failed to ensure the EBP was implemented and the EBP sign was posted outside of resident's door for Resident 82.

These failures posed the risk for not identifying infections and controlling the transmission of communicable disease to other resident through the facility.

Findings:

Review of the facility's P&P titled Policies and Practices - Infection Control revised 10/2018 showed the facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 63 055742 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Review of the facility's P&P titled Surveillance for Infections revised 9/2017 showed the infection preventionist will conduct ongoing surveillance for healthcare-associated (HAIs) and other epidemiologically Level of Harm - Minimal harm or significant infections that have substantial impact on potential resident outcome and that may require potential for actual harm transmission-based precautions and other preventative interventions. The Policy Interpretation and Implementation section showed the purpose of infection surveillance is to identify both individual cases and Residents Affected - Some trends of epidemiologically significant organisms and healthcare-associated infections, to guide appropriate interventions, and to prevent future infections. Nursing staff will monitor residents for signs and symptoms that may suggest infection, according to current criteria and definitions (Loeb's criteria to initiate antibiotics, Revised McGeers for infection), and will document and report suspected infections to the charge nurse as soon as possible. The Gathering Surveillance Data section showed the infection preventionist or designated infection control personnel is responsible for gathering and interpreting surveillance data. The infection control committee and/or QAPI committee may be involved in interpretation of data.

Review of the facility's P&P titled Healthcare-Associated Infections, Identifying revised 9/2017 showed the healthcare-associated infections (HAIs) are those that are acquired during the delivery of healthcare across settings, in contrast to those that were acquired prior to entering the healthcare setting but may persist after admission to the facility.

Review of the facility's P&P titled Infection Preventionist revised 9/2022 showed the infection preventionist is responsible for coordinating the implementation and updating of the infection prevention and control program.

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.

Review of the facility's P&P titled Enhanced Barrier Precautions revised 8/2022 showed the enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents.

1. Review of the facility's infection control binder failed to show documentation of the monthly Infection Prevention and Control Surveillance log for July, September, and December 2024.

On 1/8/25 at 1151 hours, an interview and concurrent record review of the facility's infection control program was conducted with the IP. The IP verified there was no Infection Prevention and Control Surveillance log for July, September, and December 2024. The IP further stated there was no Infection Prevention and Control Surveillance log for September 2024 because the previous IP left the facility. The IP stated she completed

the surveillance report for October and November 2024.

On 1/9/25 at 1620 hours, a follow up interview was conducted with the IP. The IP stated she just found the Infection Prevention and Control Surveillance log for July 2024 last night in the system (computer).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 63 055742 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 1/9/25 at 1657 hours, an interview and concurrent record review was conducted with the DON. The DON verified there was no Infection Prevention and Control Surveillance log for September and December 2024. Level of Harm - Minimal harm or The DON stated the IP was new and he had no idea why the surveillance log for September and December potential for actual harm 2024 were not done.

Residents Affected - Some 2. On 1/8/25 at 1151 hours, an interview and concurrent record review was conducted with the IP. The IP stated the facility was using the Loeb's criteria to assess for true infection. The IP verified the infection surveillance log for August through November did not include if the resident met the Loeb's criteria for true infection. However, review of the records showed the August 2024 Infection Prevention and Control Surveillance log included residents that met or not met McGeers criteria instead of the Loeb's criteria. The October and November 2024 Infection Surveillance Monthly Report did not show whether the resident met or not met the Loeb's criteria.

On 1/9/25 at 1657 hours, an interview and concurrent record review was conducted with the DON. The DON verified the records for August 2024, Infection Prevention and Control Surveillance log included residents who met or not met McGeers criteria instead of the Loeb's criteria. The October and November 2024 Infection Surveillance Monthly Report did not show whether the resident met or not met the Loeb's criteria.

The DON stated it was his first time to see the October and November 2024 Infection Surveillance Monthly Report.

3. On 1/8/25 at 1151 hours, an interview and concurrent record review was conducted with the IP.

The Infection Prevention and Control October 2024 QA Report showed the following:

- Total infection-62;

- CAI-38; and

- HAI-8.

The Infection Surveillance Monthly Report for October 2024 showed the following:

- Total infection-44;

- CAI-23; and

- HAI-23.

The Infection Prevention and Control November 2024 QA Report showed the following:

- Total infection-31;

- CAI-16; and

- HAI-15.

The Infection Surveillance Monthly Report for November 2024 showed the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 63 055742 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 - Total Infection-18;

Level of Harm - Minimal harm or - CAI-16; and potential for actual harm - HAI 15. Residents Affected - Some

The IP verified the October and November 2024 Infection Prevention and Control QA Report were not accurate. The October and November 2024 Infection Prevention and Control QA Report did not match the October and November 2024 Infection Surveillance Monthly Report. In addition, the total number of infections between HAI and CAI for November and December were not the same count of total infections for both months identified. When asked to explain regarding the difference/inaccuracies between the datas , the IP stated she did not know. The IP verified she was the one who prepared the October and November 2024 Infection Prevention and Control QA Report and the October and November 2024 Infection Surveillance Monthly Report.

On 1/9/25 at 1657 hours, an interview and concurrent record review was conducted with the DON. The DON verified the October and November 2024 Infection Prevention and Control QA Report did not match the October and November 2024 Infection Surveillance Monthly Report. The DON stated he has not seen the Infection Prevention and Control QA Report and the Infection Surveillance Monthly Report before.

4. On 1/8/25 at 1151 hours, an interview and concurrent record review was conducted with the IP. The IP verified she did not have a surveillance log to show the residents who met and not met the Loeb's criteria.

On 1/9/25 at 1620 hours, a follow up interview was conducted with the IP. The IP acknowledged she did not have a log to track those residents who met and not met the Loeb's Criteria.

5. Review of the facility's EBP signage showed everyone must perform hand hygiene before entering the room. Anyone anticipating in any of these six moments must also don gown and gloves. Change and discard gown and gloves and perform hand hygiene between each resident and before leaving room. The EBP six moments were morning & evening care, toileting and changing incontinence briefs, device care or use, wound care, transferring and preparing to leave room, and changing linens.

On 1/8/25 at 1101 hours, an interview was conducted with the IP. When the IP was asked about the six moments of the EBP, the IP was not able to answer the question.

On 1/8/25 at 1151 hours, a follow up interview was conducted with the IP. The IP stated she has been asking

the facility for more training. The IP further stated she had a total of four days training for the IP role. The IP stated she completed an online training but it was different from the actual floor training in the facility.

6. On 1/9/25 at 1620 hours, an interview and concurrent record review was conducted with the IP. The IP stated she only included the residents who were prescribed with the antibiotics on the infection surveillance report. The IP stated she did not include those residents with signs and symptoms of infection and were not prescribed with antibiotics.

7. Medical record review for Resident 694 was initiated on 1/9/25. Resident 694 was admitted to the facility

on [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 63 055742 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Review of Resident 694's H&P examination dated 12/10/24, showed Resident 694 had the capacity to make medical decisions. The H&P showed a diagnosis of cellulitis of unspecified part of limb. Level of Harm - Minimal harm or potential for actual harm On 1/9/25 at 1620 hours, an interview and concurrent medical record review for Resident 694 was conducted with the IP. When the IP was asked about the Loeb's criteria, the IP showed Resident 694's Infection Residents Affected - Some Screening Evaluation form. Review of the Resident 694's Infection Screening Evaluation form did not show whether the resident met or not met the Loeb's Criteria. The IP stated she should have typed in the comment section of the Infection Screening Evaluation form whether the resident met or not met the Loeb's criteria.

50953

8. Review of the facility P&P titled Personal Protective Equipment - Using Gloves revised 9/2010 showed the facility objectives to prevent the spread of infection. Perform hand hygiene after removing gloves.

On 1/7/25 at 0801 hours, a medication administration observation for Resident 32 was conducted with LVN 1. LVN 1 was observed removing the gloves and putting on another pair of gloves without performing hand hygiene.

On 1/7/25 at 1131 hours, an interview was conducted with LVN 1. LVN 1 verified the findings.

On 1/10/25 at 1006 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

44175

9. Review of the facility's P&P titled Hand Washing/Hand Hygiene dated October 2023, showed the facility considered hand hygiene the primary means to prevent the spread of the health care associated infection. Hand hygiene was indicated for the following situations:

- After contact with blood, body fluids, or contaminated surfaces;

- Immediately after glove removal.

Further review of the facility's P&P showed the use of the gloves does not replace hand washing/hand hygiene.

Medical record review for Resident 19 was initiated on 1/7/25. Resident 19 was admitted to the facility on [DATE REDACTED].

Review of Resident 19's Order Summary Report showed the following physician's orders:

- dated 12/6/24, for the left buttocks extending to left posterior thigh fungal dermatitis related to MASD, to clean with normal saline, pat dry, apply zinc oxide (medicine to treat or prevent minor skin irritations such as burns, cuts, and diaper rash) ointment and leave open to air every shift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 63 055742 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 - dated 12/26/24, for the left thigh (front) fungal dermatitis related to MASD, to cleanse with normal saline, pat dry, apply zinc oxide and leave open to air every shift for 21 days. Level of Harm - Minimal harm or potential for actual harm On 1/10/25 at 0758 hours, a wound care observation for Resident 19 was conducted with LVN 5. Resident 19 was observed being awake in bed. LVN 5 was observed performing a hand hygiene and donning a clean Residents Affected - Some pair of gloves. LVN 5 was then observed cleaning Resident 19's wound on left buttock extending to left posterior thigh with normal saline. LVN 5 then changed to a clean pair of gloves without performing hand hygiene and proceeded to apply zinc oxide to the wound on left buttock extending to left posterior thigh and left the wound open to air. LVN 5 then doffed her gloves and performed hand hygiene. LVN 5 was then observed donning a clean pair of gloves and proceeded to clean wound on left thigh (front) with normal saline. LVN 5 was again observed changing to a clean pair of gloves without performing hand hygiene and proceeded to apply zinc oxide to the wound on the left thigh (front) and left the wound open to air.

On 1/10/25 at 0815 hours, an interview was conducted with LVN 5. LVN 5 verified the above observation and stated she was nervous and forgot to perform a hand hygiene in between glove changes during the wound care for Resident 19. LVN 5 further stated she should have performed a hand hygiene before donning each pair of clean gloves.

On 1/10/25, 1030 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

48332

10. Review of facility's P&P titled: Emptying a Urinary Collection Bag, Nursing Policy and Procedure Manual for Long Term Care; revised August 2022 showed to keep the collection bag and tubing off the floor at all times to prevent contamination and damage.

Medical record review for Resident 14 was initiated on 1/7/25. Resident 14 was admitted to facility on 5/31/24.

Review of the Order Summary Report dated 1/8/25, showed a physician's order dated 10/2/24, for F/C size FR# 16/10 cc to BSD.

On 1/07/25 at 0926 hours, an observation was conducted for Resident 14. Resident 14's bed was observed

on low position and the indwelling urinary catheter bag was observed laying on the floor.

On 1/07/25 at 1033 hours an interview and concurrent observation for Resident 14 was conducted with the DON. The DON verified the findings and stated the indwelling urinary bag should not be directly laying on the floor.

39453

11. On 1/7/25 at 0834 hours and on 1/8/24 at 0948 hours, Resident 82 was observed seating in the wheelchair, in the room. There was no EBP signed posted by the door nor a PPE cart.

Medical record review for Resident 82 was initiated on 1/7/25. Resident 82 was admitted to the facility on [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 63 055742 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Review of Resident 82's Order Summary Report dated 1/8/25, showed the following physician's orders:

Level of Harm - Minimal harm or - dated 12/12/24, for enhanced barrier precautions due to wound care on the right posterior/ lateral lower leg; potential for actual harm and

Residents Affected - Some - dated 12/13/24, for enhanced barrier precautions due to wound care on the right posterior/ lateral lower leg.

a. On 1/8/25 at 0948 hours, an observation for Resident 82 and concurrent interview was conducted with CNA 8. Resident 82 was observed sitting in the wheelchair, in the room. There was no EBP signed posted by the door nor a PPE cart by the resident's door. CNA 8 verified the above findings. When asked about the Enhanced Barrier Precautions, CNA 8 stated there should be a sign posted by the resident's door, and a star next to resident's name so the staff would know who was on isolation.

b. On 1/8/25 at 1004 hours, an observation for Resident 82 and concurrent interview and medical record

review was conducted with LVN 6. Resident 82 was observed sitting in the wheelchair, in the room. There was no EBP signed posted by the door nor a PPE cart by the resident's door. LVN 6 verified the above findings. When asked about the Enhanced Barrier Precautions, LVN 6 stated the IP should post the EBP sign by the resident's door so the staff would know who was on the EBP.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 63 055742 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or 49644 potential for actual harm Based on interview, facility document review, and facility P&P review, the facility failed to implement their Residents Affected - Few Antibiotic Stewardship Program when the IP was not able to show the documentation she notified the physician of the residents who were prescribed antibiotics and did not meet the Loeb's Criteria. This failure had the potential for inaccurately identifying for true infections and potentially inhibited residents from receiving the appropriate treatment and care.

Findings:

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 hospitalization s and deaths, especially among people over age 65.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 63 055742 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Keep all essential equipment working safely.

Level of Harm - Potential for 44175 minimal harm Based on observation and interview, the facility failed to ensure the frozen storage area inside the residents' Residents Affected - Some 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 63 055742