Briarcrest Nursing Center

F-F641.

Findings:

During an interview on 3/13/2025 at 2:07 PM, with the Assistant Director of Nursing (ADON), the ADON stated the purpose of the MDS was to accurately identify and document the resident's condition. The ADON stated MDS assessments allowed staff to identify changes in a resident's condition and care areas that needed follow up and/or intervention. The ADON stated the MDS also guided the plan of care, including interventions that staff provided to the resident. The ADON stated that to conduct the MDS assessment accurately, the MDSN should be utilizing the Resident Assessment Instruction (RAI) manual. The ADON stated MDSN 1 had access to an electronic copy of the RAI manual in all residents' electronic medical records, and there were no circumstances where the RAI manual should not be followed.

During an interview on 3/13/2025 at 2:45 PM, the MDS Nurse Consultant (MDSC), the MDSC stated her role was to train and re-educate MDS staff (including MDSN 1), to ensure MDS assessments were completed accurately and in accordance with the RAI manual. The MDSC stated MDSNs were required to follow the instructions provided in the RAI manual when conducting and documenting MDS assessments. The MDSC stated she trained MDSN 1 a few years ago, but there were no routine performance evaluations of MDSN 1 since that time. MDSC stated she picked random resident MDS assessments to audit monthly, but it was not

an observation of MDSN 1 performing the assessments directly. The MDSC stated the importance of an accurate MDS was to provide an accurate assessment of the resident and ensure they received resident-centered care that addressed their needs.

During an interview on 3/13/2025 at 3:49 PM, with the Administrator (ADM), the ADM stated there was no current annual evaluation in place to evaluate MDSN 1's ability to accurately conduct or document MDS assessments.

During a review of MDSN 1's employee record titled MDS Nurse, dated 7/1/2022, the record indicated the essential duties and responsibilities of MDSN 1. The record indicated MDSN 1 was responsible for restoring and/or maintaining the resident's health and well-being by conducting resident assessments. The record indicated MDSN 1 was responsible for ensuring residents' present/potential health and wellness problems were identified, and indicated the charting was to be documented accurately.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 49 056220 Department of Health & Human Services Printed: 09/04/2025 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 056220 B. Wing 03/13/2025

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

Briarcrest Nursing Center 5648 East Gotham Street Bell Gardens, CA 90201

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 0726 During a review of the facility's policy and procedure (P&P) titled Performance Evaluations, revised 9/2020,

the P&P indicated the job performance of each employee was to be reviewed and evaluated at least Level of Harm - Minimal harm or annually. potential for actual harm

Residents Affected - Many

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 49 056220 Department of Health & Human Services Printed: 09/04/2025 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 056220 B. Wing 03/13/2025

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

Briarcrest Nursing Center 5648 East Gotham Street Bell Gardens, CA 90201

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 0740 Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47858

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure the following for one of one sampled residents (Resident 15):

1. Adequate documentation indicating Resident 15's physician (MD) 1 was made aware of Resident 15's newly prescribed antipsychotic (a class of medications used to treat mental health conditions medication)

after being readmitted from the general acute care hospital (GACH).

2. Carry out MD 1's order for a psychiatrist consult (focusing on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders, including substance use disorders) when Resident 15 displayed physically aggressive behaviors on 3/8/2025.

These failures had the potential to result in a delay of necessary behavioral health treatment and services to maintain the highest practicable physical, mental and psychosocial well-being for Resident 15.

Findings:

During a review of Resident 15's Admission Record, the Admission Record indicated Resident 15 was originally admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED]. Resident 15's diagnoses included dementia (a progressive state of decline in mental abilities), anxiety (a feeling of uneasiness), depressive disorder (a mental health condition characterized by persistent low mood, loss of interest, and other symptoms that can significantly impact daily life), and agitation (a state of restlessness, unease, and distress).

During a review of Resident 15's Minimum Data Set ([MDS], a resident assessment tool), dated 2/8/2025,

the MDS indicated Resident 15's cognitive skills (ability to think and reason) for daily decision making were severely impaired. The MDS indicated Resident 15 exhibited delusions, (misconception or beliefs that are firmly held, contrary to reality) and exhibited verbal behavioral symptoms directed towards others (threatening others, screaming at others, cursing at others). The MDS indicated Resident 15 was dependent

on staff (helper does all the effort) for toileting hygiene, bathing, and lower body dressing. The MDS indicated Resident 15 required partial or moderate assistance (helper does less than half of the effort) when performing oral hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 15 required substantial or maximal (helper does more than half of the effort) assistance for bed mobility.

During a review of Resident 15's situation, background, assessment, recommendation (SBAR - a communication tool used by healthcare workers when there is a change of condition among the residents), dated 9/19/2024, the SBAR indicated on 9/19/2024, Resident 15 was physically aggressive towards staff while staff tried to change her clothing.

During a review of Resident 15's SBAR, dated 2/7/2025, the SBAR indicated on 2/7/2025, Resident 15 exhibited increased confusion and was physically aggressive.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 49 056220 Department of Health & Human Services Printed: 09/04/2025 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 056220 B. Wing 03/13/2025

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

Briarcrest Nursing Center 5648 East Gotham Street Bell Gardens, CA 90201

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 0740 During a review of Resident 15's Admission Summary Note, dated 2/11/2025, the note indicated Resident 15 was admitted from the general acute care hospital (GACH). The note indicated all medications were verified Level of Harm - Minimal harm or and approved by MD 1. There was no documentation to indicate which medications were started or potential for actual harm discontinued from the GACH.

Residents Affected - Few During a review of Resident 15's SBAR, dated 3/8/2025, the SBAR indicated on 3/8/2025, Resident 15 exhibited poor safety awareness and scratched staff during activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) care.

The SBAR indicated MD 1 ordered a psychiatric consult for Resident 15 on 3/8/2025.

During an observation on 3/10/2025 at 11:00 a.m., in Resident 15's room, Resident 15 was observed lying in bed yelling, You're a demon!. Resident 15 hit Certified Nursing Assistant (CNA) 5 with her teddy bear and proceeded to yell, Get out, get out, you're one of them!.

During a concurrent observation and interview on 3/12/2025 at 8:03 a.m. with CNA 10, CNA 10's arm was observed. A two-centimeter (cm- a unit of measurement) scar was on her right arm. CNA 10 stated Resident 15 scratched her and it caused the scar. CNA 10 stated Resident 15 always hits me.

1. During a concurrent interview and record review on 3/12/2024 at 10:28 a.m. with Registered Nurse (RN) 1, Resident 15's GACH Discharge Medication List, dated 2/11/2025, and Admission Summary Note, dated 2/11/2025, was reviewed. The GACH Discharge Medication List indicated Resident 15 was to start taking Seroquel (an antipsychotic medication) 50 milligram (mg- a unit of measurement) oral tablet once a day at bedtime. RN 1 stated the normal process for admitting a resident was to verify new and old medications to continue at the facility with the physician and document. RN 1 stated if there were newly prescribed medications, the physician had to be made aware and would decide whether the medications would be continued at the facility. RN 1 stated a rational for the discontinuation of any newly prescribed medications should be documented. RN 1 stated the Admission Summary Note did not indicate MD 1 was made aware of Resident 15's new prescription of Seroquel 50 mg oral tablet once a day at bedtime.

During an interview on 3/12/2025 at 1:30 p.m. with MD 1, MD 1 stated if she was made aware Resident 15 had a newly prescribed psychotropic medication from the GACH, then she would have automatically resorted to inputting a psychiatric consult. MD 1 stated it was her practice to ensure all psychotropic medications were appropriately evaluated and prescribed for a proper psychiatric diagnosis. MD 1 stated she exercised great caution with the prescribing of psychotropic medications. MD 1 stated there was a potential for Resident 15 to not improve if there was no psychiatric consult in place. MD 1 stated she reviewed Resident 15's Physician Orders and did not see an order after Resident 15's readmission to the facility.

During a concurrent interview and record review on 3/12/2025 at 3:17 p.m. with RN 3, Resident 15's GACH Discharge Medication List, dated 2/11/2025, and Admission Summary Note, dated 2/11/2025, were reviewed. RN 3 stated she authored the Admission Summary Note and stated the normal process when admitting the resident was to verify the medications with the physician and fax the medication list to the physician. RN 3 stated it was not in her practice to explicitly list each newly prescribed medication that was started or discontinued. RN 3 stated that it was important for the physician to know of any new medications that were prescribed to a resident in the hospital.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 49 056220 Department of Health & Human Services Printed: 09/04/2025 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 056220 B. Wing 03/13/2025

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

Briarcrest Nursing Center 5648 East Gotham Street Bell Gardens, CA 90201

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 0740 2. During a concurrent interview and record review on 3/12/2025 at 3:38 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 15's SBAR, dated 3/8/2025, and Resident 15's Physician Order's, dated 2/2025 to Level of Harm - Minimal harm or 3/2025, were reviewed. Resident 15's Physician Orders indicated there was no order for a psychiatric consult potential for actual harm placed on 3/8/2025. LVN 1 stated the normal process for obtaining a psychiatric consult was to place the order in the electronic medical record (EMR), call or text the psychiatrist, and notify the social services Residents Affected - Few director. LVN 1 stated she authored the SBAR and received the order on 3/8/2025, but did not place an order for a psychiatric consult in the EMR. LVN 1 stated she did not start the process of obtaining a psychiatric consult because she believed the order was already placed in the past. LVN 1 stated if the order was not placed for a psychiatric consult, then there was potential for Resident 15 to continue exhibiting behaviors, which could lead to Resident 15 being sent out the GACH for a psychiatric evaluation.

During a review of the facility's Policy and Procedure (P&P) titled, Reconciliation of Medications on Admission, revised 7/2017, the P&P indicated medication reconciliation helped to ensure that medications, routes and dosages had been accurately communicated to the Attending Physician and care team. The P&P indicated that the licensed nurse was to use an approved medication reconciliation form or other record, list all medications from the medication history, the discharge summary, the previous MAR (if applicable), and

the admitting orders (sources). The P&P indicated the licensed nurse was to review the list carefully to determine if there are discrepancies/conflicts. For example:

a. The dosage on the discharge summary does not match the dosage from the resident's previous MAR;

b. There is a potential medication interaction between a medication from the admitting orders and a supplement from the resident's medication history; or

c. There is a medication listed on the discharge summary for which there is no diagnosis or condition to support the use of the medication.

The P&P indicated to document findings and actions.

During a review of the facility's P&P titled, Telephone Orders (undated), the P&P indicated verbal telephone orders must be reduced to writing, by the person receiving the order, and recorded in the resident's medical record.

During a review of the facility's P&P titled, Behavioral Health Services (undated), the P&P indicated residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs and goals for care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 49 056220 Department of Health & Human Services Printed: 09/04/2025 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 056220 B. Wing 03/13/2025

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

Briarcrest Nursing Center 5648 East Gotham Street Bell Gardens, CA 90201

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** 47286 potential for actual harm Based on observation, interview, and record review, the facility to failed ensure infection control measures Residents Affected - Many were implemented for five of 26 sampled residents (Residents 84, 6, 40, 101, and 104) when:

1. Signage for enhanced barrier precautions (EBP, precautions utilized to prevent the spread of multi-drug-resistant organisms [MDROs, microorganisms, primarily bacteria, that have developed resistance to multiple classes of antibiotics] to residents) was not posted outside of Resident 84's room or Resident 6's room.

2. Resident 101's oxygen tubing (flexible clear tubing used to connect to an oxygen source), nebulizer (a medical device that turns liquid medicine into a mist that can be easily inhaled) and respiratory (related to breathing) setup bag (a plastic bag with drawstring closure used to store and transport respiratory equipment) were not changed according to the facility's policy and procedure (P&P).

3. Resident 104's oxygen humidifier (a medical device used to add moisture to supplemental oxygen) was not changed according to doctor's orders.

4. Resident 40's suction tubing (a flexible, clear tubing that connects to a suction device used to remove fluid from the airway) and suction filter (protects from fluid back up in the suction tubing) were on the floor.

These deficient practices placed all facility residents and staff at risk for infection from the potential spread of MDROs. These deficient practices placed Residents 101, 104, and 40 at risk for respiratory infections from contaminated respiratory equipment.

Findings:

1a. During a review of Resident 84's Admission Record, the Admission Record indicated Resident 84 was originally admitted on [DATE REDACTED] and was most recently readmitted on [DATE REDACTED]. Resident 84's admitting diagnoses included gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).

During a review of Resident 84's Minimum Data Set (MDS, a resident assessment tool), dated 2/17/2025,

the MDS indicated Resident 84 had severely impaired cognition (ability to think and reason). The MDS indicated Resident 84 required substantial to maximal assistance from staff for mobility while in bed. The MDS indicated Resident 84 had a gastrostomy and received more than 51 percent (%) of her calories from feeding administered through the feeding tube.

During a review of Resident 84's active physician order, dated 7/10/2024, the order indicated Resident 84 required enhanced barrier precautions (EBP, precautions utilized to prevent the spread of multi-drug-resistant organisms [MDROs] to residents) due to dependency of [gastrostomy] tube.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 49 056220 Department of Health & Human Services Printed: 09/04/2025 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 056220 B. Wing 03/13/2025

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

Briarcrest Nursing Center 5648 East Gotham Street Bell Gardens, CA 90201

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 During a review of Resident 84's care plan titled Enhanced Barrier Precautions due to dependency of [gastrostomy] tube, dated 7/10/2024, the care plan indicated the goal of care was to prevent spread of Level of Harm - Minimal harm or infection and other MDROs. Staff interventions indicated a blue dot was to be placed next to the resident's potential for actual harm name outside of the room to indicate the requirement for exercising EBP.

Residents Affected - Many During an observation on 3/10/2025 at 9:36 AM, at Resident 84's bedside, observed Resident 84 lying in bed receiving feeding through her gastrostomy.

During an observation on 3/10/2025 at 9:41 AM, outside of Resident 84's room, no EBP signage, or indicators of the need for staff to exercise EBP, were observed. There was no personal protective equipment (PPE, clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) observed outside of Resident 84's room.

b. During a review of Resident 6's Admission Record, the Admission Record indicated Resident 6 was originally admitted on [DATE REDACTED] and was most recently readmitted on [DATE REDACTED]. Resident 6's admitting diagnoses included transient ischemic attack (TIA, a temporary interruption of blood flow to the brain that causes sudden neurological symptoms that typically resolve within 24 hours) and cerebral infarction (stroke, loss of blood flow to a part of the brain).

During a review of Resident 6's MDS, dated [DATE REDACTED], the MDS indicated Resident 6 was cognitively intact.

The MDS indicated Resident 6 required substantial to maximal assistance from staff for toileting hygiene.

During a review of Resident 6's active physician order, dated 3/10/2025, the order indicated Resident 6 required EBP due to the use of an indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine).

During an observation on 3/10/2025 at 2:53 PM, at Resident 6's bedside, observed Resident 6 lying in bed, with an indwelling urinary catheter drainage bag hanging from the side of the bed.

During an observation on 3/10/2025 at 3:03 PM, outside of Resident 6's room, observed no EBP signage, or indicators of the need for staff to exercise EBP. There was no PPE observed.

During an interview on 3/12/2025 at 10:48 AM, with the Infection Preventionist Nurse (IPN), the IPN stated

the purpose of EBP was to prevent spread of MDROs and infection. The IPN stated that absence of signage or indicators alerting staff of the need to exercise EBP created the potential for the spread of infection because staff would not know they needed to don (wear) PPE during high-risk patient care activities.

During a concurrent interview and record review on 3/12/2025 at 10:52 AM, with the Infection Preventionist Nurse (IPN), the facility's policy and procedure (P&P) titled Enhanced Barrier Precautions, dated 4/2024, was reviewed. The IPN stated the P&P indicated EBP were indicated for residents with indwelling medical devices, including gastrostomy tubes and urinary catheters. The IPN stated the P&P indicated signs were supposed to be posted in the door or on the wall outside of the resident rooms indicating EBP and use of PPE was required.

48131

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 49 056220 Department of Health & Human Services Printed: 09/04/2025 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 056220 B. Wing 03/13/2025

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

Briarcrest Nursing Center 5648 East Gotham Street Bell Gardens, CA 90201

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 2. During a review of Resident 101's Admission Record, dated 3/14/2025, the admission record indicated Resident 101 was admitted on [DATE REDACTED]. The admission record indicated the following diagnoses which Level of Harm - Minimal harm or included, chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in potential for actual harm breathing) and asthma (a condition in which the airways narrow and swell and may produce extra mucus).

Residents Affected - Many During a review of Resident 101's Progress Note, dated 2/14/2025, the progress note indicated Resident 101 was alert and oriented to person, place and time and forgetful of the date.

During a review of Resident 101's MDS, dated [DATE REDACTED], the MDS indicated Resident 101's cognition (ability to think, remember, and reason) was moderately impaired. The MDS indicated Resident 101 required supervision (helper provides verbal cues and/or touching/steadying to complete activity) with eating, oral hygiene and toileting and moderate assistance (helper does less than half the effort) for bathing.

During an observation on 3/10/2025 at 10:25 AM, in Resident 101's room, observed Resident 101's oxygen tubing, nebulizer and respiratory set up bag was dated 2/14/2024.

3. During a review of Resident 104's Admission Record, dated 3/17/2025, the Admission Record indicated Resident 40 was admitted on [DATE REDACTED]. The admission record indicated the following diagnoses which included tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck), respiratory failure with hypoxia (lack of sufficient oxygen in the blood, tissues and cells).

During a review of Resident 104's Progress Note, dated 2/14/2025, the progress note indicated Resident 104 was alert and oriented to person, place, time and event and could make needs known.

During a review of Resident 104's MDS, dated [DATE REDACTED], the MDS indicated Resident 104's cognition was intact. The MDS indicated Resident 104 required supervision for eating and was dependent (helper does all

the effort) for toileting and bathing.

During a review of Resident 104's Order Summary Report dated 3/17/2025, the order summary report indicated Resident 104 had an active order on 5/4/2024 to change the humidifier every Monday on night shift and as needed.

During an observation on 3/10/2025 at 11:15 AM, in Resident 104's room, observed Resident 104's oxygen humidifier dated 2/28/2024.

4. During a review of Resident 40's Admission Record, dated 3/14/2025, the admission record indicated Resident 40 was initially admitted on [DATE REDACTED] and readmitted on [DATE REDACTED]. The admission record indicated the following diagnoses which included tracheostomy status, acute respiratory failure (a serious condition that makes it difficult to breathe on your own), dependence on respirator (ventilator, a machine that helps you breathe), and cerebral infarction.

During a review of Resident 40's History and Physical (H&P), dated 12/22/2024, the H&P indicated Resident 40 could make needs known but could not make medical decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 49 056220 Department of Health & Human Services Printed: 09/04/2025 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 056220 B. Wing 03/13/2025

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

Briarcrest Nursing Center 5648 East Gotham Street Bell Gardens, CA 90201

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 During a review of Resident 40's MDS, dated [DATE REDACTED], the MDS indicated Resident 40's was intact. The MDS indicated Resident 40 was dependent on staff for oral hygiene, toileting, bathing, and personal hygiene. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 40's Order Summary Report dated 3/13/2025, the order summary report indicated Resident 40 had an active order on 2/26/2025 to change the resident's suction filters as needed. Residents Affected - Many

During an observation on 3/10/2025 at 12:12 PM, in Resident 40's room, observed Resident 40's suction tubing and suction filter lying on the floor.

During an interview on 3/12/2025 at 4:27 PM, with Licensed Vocational Nurse (LVN) 2, LVN 2 stated the respiratory therapy department, and the nursing staff were responsible for changing out respiratory equipment and making sure the equipment was up to date. LVN 2 stated Resident 40's suction tubing and filter should not be on the floor. LVN 2 stated respiratory equipment should be changed if found on the floor because the floor is dirty and can cause contamination and infection in the mouth and lungs.

During an interview on 3/13/2025 at 12:25 PM, with the Treatment Nurse (TN) 1, TN 1 stated the humidifier should have been changed for Resident 104. TN 1 stated if the water in the humidifier was not fresh, it could grow bacteria and lead to infection.

During a concurrent observation and interview on 3/13/2025 at 2:49 PM, with Respiratory Therapist (RT) 1, Resident 104's nebulizer, oxygen tubing and setup bag were observed with a date of 2/14/2025. RT 1 stated Resident 104's equipment should be changed every week. RT 1 stated 2/14/2025 was too long to keep respiratory equipment. RT 1 stated the respiratory equipment should have been changed to prevent Resident 104 from an infection.

During an interview on 3/13/2025 at 3:01 PM, with RT 1, RT 1 stated Resident 104's humidifier should have been changed once a week. RT 1 stated Resident 104's humidifier needed to be changed to prevent the water from becoming contaminated which could have led to a lung infection.

During an interview on 3/13/2025 at 3:38 PM, with the Director of Nursing (DON), the DON stated respiratory equipment should be changed every week and as needed due to infection control. The DON stated it was important to make sure the respiratory equipment was changed weekly because the residents are prone to infection.

During a review of the facility's policy and procedure (P&P) titled Administering Medications through a Small Volume (Handheld Nebulizer), revised 10/2010, the P&P indicated the purpose of the policy was to safely and aseptically administer aerosolized particles of mediation into the resident's airway. The P&P indicated staff were to change the equipment and tubing every seven days.

During a review of the facility's P&P titled Departmental (Respiratory Therapy) - Prevention of Infection, revised 11/2011, the P&P indicated the purpose of the policy was to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. The P&P indicated staff were to change the oxygen cannula and oxygen tubing every seven days or as needed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 49 056220 Department of Health & Human Services Printed: 09/04/2025 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 056220 B. Wing 03/13/2025

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

Briarcrest Nursing Center 5648 East Gotham Street Bell Gardens, CA 90201

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 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48343

Residents Affected - Few Based on observation and interview, the facility failed to ensure a resident window screen was the correct size and without gaping, and the toilet seat was not broken for one of six sampled residents (Resident 133).

These deficient practices had the potential to place Resident 133 at risk for injury, entry of insects into the room, and negatively impact Resident 133's well-being.

Findings:

During a concurrent observation and interview on 3/10/2025 at 1:19 PM, with Resident 133, in Resident 133's room, observed two gaps around the window screen. Resident 133 stated flies and mosquitos were entering his room through the gaps of the screen. Resident 133's bathroom seat was not anchored in place and was broken. Resident 133 stated he felt scared while using the bathroom because the seat was moving around and he could fall.

During a review of Resident 133 Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 133 was admitted to the facility on [DATE REDACTED] with diagnoses which included diabetes mellitus ([DM]- a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension ([HTN]- high blood pressure), and muscle weakness (loss of muscle strength).

During a review of Resident 133's Minimum Data Set ([MDS] - a resident assessment tool), dated 2/27/2025,

the MDS indicated Resident 133's cognitive (the ability to think and process information) skills for daily living was intact. The MDS indicated Resident 133 required supervision or touching (helper seat and clean up; resident completes activity) assistance from staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).

During a concurrent observation and interview on 3/10/2025 at 1:36 PM, with Maintenance Manager (MM 1),

in Resident 133's room, the window was observed with a gap to the left and right side of the screen. MM 1 stated the window screen was not the correct size. MM 1 stated there was a seven inch gap to the left and right side of the window screen. MM 1 stated the ill-fitting window screen was dangerous and had the potential for a pest infestation. MM 1 stated he was not aware of this issue. MM 1 stated the window screen needed to be changed.

During a concurrent observation and interview on 3/10/2025 at 1:45 PM, with MM 1, in Resident 133's bathroom, the toilet seat was observed. MM 1 stated the toilet seat was not locked into place and was broken. MM 1 stated the broken seat was a safety issue and had the potential to place Resident 133 at risk for fall and injury. MM 1 stated it was his responsibility to keep the resident's rooms and equipment in a safe manner.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 49 056220 Department of Health & Human Services Printed: 09/04/2025 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 056220 B. Wing 03/13/2025

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

Briarcrest Nursing Center 5648 East Gotham Street Bell Gardens, CA 90201

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 0921 During a review of the facility's policy and procedure (P&P) titled Maintenance Services, revised 12/2009, the P&P indicated the facility would always maintain the buildings and equipment in a safe and operable manner. Level of Harm - Minimal harm or The P&P indicated maintenance department would maintain the building in good repair and free from potential for actual harm hazards.

Residents Affected - Few During a review of the facility P&P titled Maintenance Manager Job Description, undated, the P&P indicated maintenance manager would perform regular inspections of resident rooms for safety.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 49 056220