Rosemead Healthcare Center

During a review of Resident 26's Fall Risk Assessment (FRA- method of assessing a patient's likelihood of falling) dated 2/23/2026, the FRA indicated Resident 26 was assessed as higher moderately at risk for falls due to weak gait (a person's manner of walking) and use of the wheelchair for mobility assistive device.

During a review of Resident 26's MDS dated [DATE], the MDS indicated Resident 26 had moderately impaired cognition.

The MDS indicated Resident 26 needed moderate assistance (helper does less than half the effort) from staff for shower.

The MDS indicated Resident 26 needed supervision (helper provides verbal cues) from staff for toileting, upper/lower body dressing, putting on/taking off footwear, and personal hygiene.

During a concurrent observation and interview on 3/24/2026 at 9:40 am with Registered Nurse 1 (RN 1) in Resident 26's room, Resident 26 was awake, sitting in a wheelchair at the bottom right side of the bed with the call light on the left upper side of the bed. RN 1 stated, Resident 26 was unable to reach the call light because it was placed on the upper left side of the bed and was hanging on the left side rails. RN 1 stated, the call light needed to be within resident's reach at all times for safety. RN 1 stated, residents could be in danger if help was not provided.

During an interview on 3/26/2026 at 12:35 pm with the DON, the DON stated Resident 26's call light should always be within reach to prevent any falls and if Resident 26 needed help or assistance.

During a review of the facility's policy and procedure (P&P) titled, Communication-Call System, dated 2/20/2026, the P&P indicated the purpose of the call system was providing a mechanism for residents to promptly communicate with nursing staff.

The P&P indicated, call cords would be placed within the resident's reach in the resident's room.

055202 03/27/2026

Rosemead Healthcare Center 4096 Easy Street El Monte, CA 91731

During a review of Resident 93's History & Physical Note (H&P), dated 8/15/2025, the H&P indicated the resident had the capacity to understand and make decisions and no Physician Orders for Life-Sustaining Treatment (POLST, a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) or AD record was in the medical record.

During a review of Resident 93's Minimum Data Set (MDS, a resident assessment tool), dated 2/18/2026, the MDS indicated Resident 93 had moderately impaired cognition (ability to think).

During a concurrent interview and record review on 3/25/2026 at 10:13 am with Licensed Vocational Nurse 1 (LVN 1), Resident 93's medical record (paper chart and electronic medical record) was reviewed. Resident 93's medical record indicated no AD or POLST documentation was present. LVN 1 stated that the AD and POLST should be in Resident 93's medical record. LVN 1 further stated that the information should be available to nurses for emergency situations to allow acknowledgment and respect of the resident's code status (refers to a patient's documented wishes about what medical actions should be taken if their heart or breathing stops [a life-threatening emergency]) choices and decisions.

During an interview on 3/25/2026 at 10:20 am with Social Services Director (SSD), SSD stated that SSD kept a folder with copies of residents' POLST and Advance Directives in the SSD office. SSD stated that the original copies should be kept in the resident's paper chart or in the electronic medical record. SSD stated she did not know why Resident 93's chart lacked copies of the POLST or AD, but stated SSD would make copies and add them in the medical records.

During an interview on 3/26/2026 at 12:58 pm with the Director of Nursing (DON), DON stated that the AD and POLST should be kept in the resident's chart and the Medical Records Director should maintain a copy. DON stated, during an emergency, nursing staff needed access to the resident's AD information quickly and the DON preferred a hard copy present in the physical chart for convenience. DON stated that it was important to have this information to allow the licensed nurses to respect the resident's wishes and decide what was the resident's next step of care based on their condition.

During a review of the facility's policy and procedure (P&P) titled, Advance Directives, dated 10/1/2023, the P&P indicated during emergency situations the Charge Nurse would be required to inform emergency medical personnel of the resident's AD regarding treatment options.

The P&P indicated, nursing staff would provide emergency staff with a copy of the directive if the resident was transferred to the hospital in an ambulance.

The P&P indicated, copies of a resident's AD will be included in the resident's medical record.

055202 03/27/2026

Rosemead Healthcare Center 4096 Easy Street El Monte, CA 91731

During a review of the Centers for Medicare and Medicaid

requirements.

The manual indicated, federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h)

055202 03/27/2026

Rosemead Healthcare Center 4096 Easy Street El Monte, CA 91731

and resident with hypertrophic (abnormal enlargement or thickening), mycotic (having fungus or

055202 03/27/2026

Rosemead Healthcare Center 4096 Easy Street El Monte, CA 91731

During a review of Resident 66's MDS dated [DATE], the MDS indicated Resident 66 had severely impaired cognition.

The MDS indicated Resident 66 was dependent on staff for oral hygiene, toileting, lower body dressing, putting on/taking off footwear, and personal hygiene.

During a review of Resident 66's untitled CP dated 2/17/2026, the CP indicated Resident 66 required tube feeding related to dysphagia.

The CP interventions indicated for licensed nursing staff to administer enteral feeding as prescribed and to keep Resident 66's HOB elevated at 30 to 45 degrees at all times during feeding and at least one hour after feeding.

During a review of Resident 66's OSR dated 3/21/2026, the OSR indicated Resident 66 was on continuous GT feeding of Glucerna 1.2 (formula) via enteral feeding pump to run at 50 milliliters (ml, unit of measurement) per hour (hr.) for 20 hours to provide 1,000 m/1,200 kilocalories (kcal, unit of measurement) of formula in 24 hours; start the infusion at 6 pm and stop the infusion at 2 pm.

During a concurrent observation and interview on 3/24/2026 at 2:08 pm, together with Licensed Vocational Nurse 1 (LVN 1), Resident 66 was awake, lying in bed, in supine position with the HOB not elevated to 30 to 45 degrees and was connected to an ongoing GT feeding. LVN 1 stated Resident 66 was lying flat in bed and the HOB was not elevated to 30 to 45. LVN 1 stated Resident 66's HOB should have been elevated to 30 to 45 degrees while the feeding is ongoing to prevent aspiration pneumonia (a lung infection that occurs when food, liquid, saliva, or vomit was breathed into the airways instead of being swallowed into the stomach).

During an interview on 3/26/2026, at 12:36 pm, with the Director of Nursing (DON), the DON stated Resident 66's HOB needed to be elevated from 30 to 45 degrees while receiving GT feeding to prevent aspiration.

055202 03/27/2026

Rosemead Healthcare Center 4096 Easy Street El Monte, CA 91731

During a review of Resident 99's admission Record (AR), the AR indicated the facility admitted Resident 99 on 3/23/2026 with diagnoses including urinary tract infection (UTI, an infection in the bladder/urinary tract), dementia (characterized by progressive decline in cognitive function), and muscle weakness (loss of muscle strength).

During a review of Resident 99's Minimum Data Set (MDS, a resident assessment tool), dated 3/29/2026, the MDS indicated Resident 99 had moderately impaired cognition (ability to understand and process information).

The MDS indicated Resident 99 required partial/moderate assistance (helper did less than half of the effort) with eating and oral hygiene.

The MDS indicated Resident 99 required substantial/maximal assistance (helper did more than half the effort) with toileting, shower, upper/lower body dressing, and personal hygiene.

The MDS indicated Resident 99 had an IV peripheral line.

During a review of Resident 99's Order Summary Report (OSR) for the active orders as of 3/26/2026, the OSR indicated Resident 99 had an order to monitor IV site for signs of inflammation (the vein becomes irritated and inflamed)/infiltration (IV fluid leaks out of the vein into the surrounding tissue) every shift with an order date of 3/23/2026.

During a review of Resident 99's Care Plan Report (CP), initiated on 3/24/2026, the CP indicated Resident 99 had IV peripheral line for antibiotic (a type of medication used to treat bacterial infection) medication administration.

The CP's Interventions section included an intervention to change and label IV dressing and to monitor IV site for signs of inflammation and infiltration.

During a concurrent observation inside Resident 99's room and interview on 3/24/2026 at 9:59 am with the Director of Nursing (DON), Resident 99 was lying in bed with peripheral IV line on Resident 99's right hand.

The DON stated the IV site dressing was loose and tapes were coming out.

Observed the IV site dressing was not labeled with the insertion date.

The DON stated peripheral IV line should be labeled with date the IV line was inserted to keep track of when to change or rotate the IV site.

The DON stated IV site should be changed or rotated every seventy-two (72) hours to prevent infection and skin irritation.

During a review of the facility's policy and procedure (P&P) titled, Intravenous Site Care, implemented on October 1, 2023, the Purpose section of the P&P indicated, Reduce the risk of local and bloodstream infections (such as phlebitis or catheter-related bloodstream infections) through proper routine site maintenance.

055202 03/27/2026

Rosemead Healthcare Center 4096 Easy Street El Monte, CA 91731

During a review of Resident 41's AR, the AR indicated the facility admitted Resident 41 on 8/23/2002 and re admitted on [DATE] with diagnoses including COPD and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities).

During a review of Resident 41's OSR dated 12/7/2025, the OSR indicated Resident 41 had an active order for oxygen at two liters per min (L/min) via nasal cannula (NC, a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) continuously for chronic hypoxic respiratory failure (the lungs cannot effectively exchange oxygen and carbon dioxide, leading to chronically low oxygen levels or high carbon dioxide levels in the blood).

During a review of Resident 41's History & Physical (H&P) dated 12/8/2025, the H&P indicated the resident had the capacity to understand and make decisions.

During a review of Resident 41's CP revised 12/9/2025, the CP indicated Resident 41 was at risk for respiratory distress related to diagnoses of chronic heart failure (heart does not pump blood effectively causing fluid buildup in the lungs or body), COPD, pneumonia (an infection/inflammation in the lungs), acute respiratory failure (a condition caused by inadequate supply of oxygen and/or the inability to remove carbon dioxide from the lungs), interstitial pulmonary disease (progressive lung disease that occurs when lung tissue is damaged and scarred), and pleural effusion (a collection of fluid around the lungs).

The CP interventions included for licensed staff to administer medication as ordered and oxygen at 2L/min via NC continuously.

During a concurrent observation and interview on 3/24/2026 at 9:45 am with Licensed Vocational Nurse 1 (LVN 1) in Resident 41's room, Resident 41 was lying in bed with ongoing oxygen via NC.

The NC tubing touched the bedroom floor. LVN 1 stated Resident 41 had COPD and used oxygen. LVN 1 stated Resident 41's ongoing oxygen level was set at 3.5 L/min and the tubing should not be touching the floor to prevent the resident from developing an infection.

During an interview on 3/26/2026 at 1:00 pm with the DON, the DON stated the NC tubing on a resident receiving oxygen should not touch the floor and should be replaced for infection control.

The DON stated registered nurses titrate oxygen levels and for a resident with an order of 2L of oxygen via NC and COPD diagnosis, the physician's order should be followed to prevent the resident from receiving excessive oxygen.

The DON stated, the incorrect oxygen administration could lead to complications, putting the resident at risk for respiratory acidosis (body builds up carbon dioxide and becomes too acidic causing fatigue and other symptoms).

During a review of the facility's Policy and Procedure (P&P) titled, Oxygen Administration, dated 10/1/2023, the P&P indicated, the P&P purpose was to prevent or reverse hypoxemia (low level of oxygen in the blood) and provide oxygen to the tissues.

The P&P indicated, a physician's order was required to initiate oxygen therapy, except in an emergency situation and the order would include the oxygen flow rate.

The P&P indicated, oxygen is stored in a clean, dry location for safe handling of oxygen/equipment.

055202 03/27/2026

Rosemead Healthcare Center 4096 Easy Street El Monte, CA 91731

During an interview on 3/26/2026 at 9:00 am with Registered Nurse Supervisor 1 (RN 1), RN 1 stated Resident 15 did not have a physician's order for glucose tablets nor to keep medications at the bedside and or to self-administer medications. RN 1 stated, it was dangerous for Resident 15 to have the glucose tablets because Resident 15 was diabetic and received insulin. RN 1 stated Resident 15 could have been double-dosing and there could have been contraindications between the medications (drugs that should not be used together due to the risk of adverse reactions).

During an interview on 3/26/2026 at 9:07 am with the Director of Nursing (DON), DON stated there were no residents within the facility permitted to have medications at their bedside or self-administer medications.

The DON stated all medications must be verified by the pharmacy or the physician to ensure it was appropriate for the resident.

The DON stated medications kept by Resident 15 were a hazard because Resident 15 could have overdosed or had an adverse reaction.

The DON further stated the resident may not know what they're taking, other residents could obtain and use the medications, and the licensed nurses would not know what medications the residents were taking.

During a review of the facility's Policy and Procedure (P&P) titled, Storage of Medications, revised December 2023, the P&P indicated, its purpose was to ensure that medications were stored in an environment that guaranteed integrity and security in the facility.

The P&P indicated, medications were stored in locked medication carts and/or locked medication rooms.

055202 03/27/2026

Rosemead Healthcare Center 4096 Easy Street El Monte, CA 91731

During an interview with the kitchen staff dishwasher (DW) on 3/24/26 at 9:24 AM, the DW stated it was the responsibility of the DW to test the red bucket solution to ensure it had the required concentration of chemicals to kill bacteria.

The DW stated this was important to prevent cross-contamination when the kitchen staff prepared food that would be served to the residents.

The DW stated the test strips that were being used for the red bucket did not have an expiration date.

The DW stated, I don't know if the testing results were correct if the strips were without an expiration date.

The DW stated the kitchen staff use the red bucket solution to sanitize the surfaces where staff prepare food for the residents.

The DW stated bacteria could be spread if the red bucket solution does not have the proper concentration to sanitize the areas.

The DW stated if the residents ate contaminated food, it would make them sick.

During a concurrent interview with the DS on 3/24/2026 at 9:38 AM, the DS stated if the facility was using the solution in the red bucket to clean and did not know if the test strips have expired, it would not give accurate reading, and the solution would not effectively sanitize.

The DS stated this would cause cross contamination of the food and would make the residents sick.

During an interview with the facility's Infection Control Nurse (IPN1) on 3/25/2026 at 11:40 AM, the IPN1 stated there could be cross contamination if the kitchen staff were testing the red bucket solution with strips that did not have an expiration date.

The IPN1 stated, without an expiration date, staff would not know if the solution had the proper concentration to disinfect the food preparation areas.

During a review of the facility's P&Ps titled, Infection Prevention and Control Program, reviewed 10/1/23, the P&P indicated, The ensure the Facility establishes and maintains an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State requirements.

055202 03/27/2026

Rosemead Healthcare Center 4096 Easy Street El Monte, CA 91731

During a facility tour on 3/25/2026 at 7:39 AM, one large recycling trash bin had open lid and there was trash on the floor surrounding the trash bin area.

During an observation and interview with Central Supply Staff (CS) on 3/25/2026 at 8:00 AM, CS was outside the facility in the parking lot with over twenty boxes of supplies that were delivered earlier in the morning. CS stated there was no more room for additional cardboard boxes in the recycling bin. CS stated CS would remove the new supplies from the cardboard boxes. CS stated CS would break down the empty boxes and leave them on the side of the trash bins or throw them inside the regular trash bins. CS stated the trash would be picked up the next day (3/26/26).

During an interview with the Infection Prevention Nurse (IPN1) on 3/25/2026 at 11:39 AM, IPN1 stated the trash bin lids should be closed even if it was the recycling bin.

The IPN1 stated the floor surrounding the trash bin area should be cleaned by housekeeping staff (HKP) because it was not sanitary and even if it was outside the facility, it could attract vermin or cockroaches.

During an interview with the Dietary Supervisor (DS) on 3/25/2026 at 12:11 PM, the DS stated it was not acceptable to have trash on the floor surrounding the trash bin area and the trash bin lid left open.

The DS stated the trash bin lid should be kept closed at all times because it was unsanitary and to prevent cross contamination (transfer from one substance or object to another, with harmful effect) and rodent infestation.

During an interview with the Maintenance Supervisor (MS) on 3/26/2026 at 12:22 PM, MS stated the area where the big trash bins were located should be kept clean.

The MS stated one of the kitchen staff went to throw out the trash and left the bag on the floor next to the trash bin overnight.

The MS stated it was not acceptable for staff to leave trash bags or any type of trash outside the trash bins because it would attract rodents.

The MS stated the trash bin lids should be closed to prevent any type of rodent activity and infestations causing harm to the residents.

During an interview with the Director of Nursing (DON) on 3/26/2026 at 12:41 PM, the DON stated the trash bins should be always covered with lids for infection control.

During a review of the facility's P&P titled, Garbage and Trash Can Use and Cleaning, revised 10/1/2023, the P&P indicated, Food waste will be placed in covered garbage and trash cans.

During a review of the facility's P&P titled, Pest Control, revised 10/1/2023, the P&P indicated, To ensure the facility is free of insects, rodents, and other pests that could compromise the health, safety, and comfort of residents, facility staff, and visitors.

Garbage and trash are not permitted to accumulate in any part of the facility.

055202 03/27/2026

Rosemead Healthcare Center 4096 Easy Street El Monte, CA 91731

During a review of Resident 91's History and Physical (H&P) dated 3/4/26, the H&P indicated Resident 91 had the capacity to understand and make decisions.

During a review of Resident 91's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 3/10/26, the MDS indicated Resident 91 was dependent (helper does all of the effort) for eating, oral and toileting hygiene, shower, upper and lower body dressing, putting on and taking off footwear and personal hygiene.

During a review of Resident 91's CP initiated on 3/16/26, the CP indicated the resident had impaired immunity related to immunodeficiencies.

The CP interventions indicated Resident 91 was at risk for contracting infections due to impaired immune status and to keep the environment clean and people with infection away.

During an observation and interview inside Resident 91's room on 3/24/26 at 9:56 AM, Resident 91 was resting in bed holding a urinal with yellow liquid inside. Resident 91 placed the urinal on top of Resident 91's side table next to a water pitcher and a cup of water.

During a concurrent observation and interview inside Resident 91's room on 3/26/26 at 7:48 AM, Resident 91's side table had a urinal containing yellow liquid inside.

Some of the yellow liquid was dripping on the outside of the urinal landing on Resident 91's side table. A urinal holder was attached to the bottom of Resident 91's bed. Resident 91 stated Resident 91 could not reach the urinal holder so Resident 91 placed the urinal on top of the side table.

During an observation and interview with the Treatment Nurse (TN) on 3/26/26 at 7:58 AM, the TN stated Resident 91's urinal had urine inside and should not be placed on top of Resident 91's side table.

The TN stated Resident 91 would put Resident 91's food and drink on the side table.

The TN stated having a urinal filled with urine on top of the side table was an infection control issue.

The TN stated having a urinal filled with urine on top of the resident's side table could cause bacteria to spread to Resident 91's foods or drink.

During an interview with the Infection Prevention Nurse (IPN) on 3/26/26 at 9:27 AM, the IPN stated a urinal placed on top of a resident's side table was an infection control issue because it was not sanitary and could potentially contaminate the resident's food.

The IPN stated the resident's side table should be a clean surface used for meals and personal care.

The IPN stated when a urinal filled with urine was kept on the side table, it created a risk for contamination of other items.

The IPN stated having a urinal with urine on Resident 91's side table posed a risk of spillage and contaminating areas on Resident 91's table.

During a review of the facility's Policy and Procedure titled, Infection Prevention and Control Program, revised 10/1/23, the P&P indicated, The facility establishes and maintains an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State requirements.

During a review of the facility's P&P titled, Urinal and Bedpan-Offering and Removing, revised 10/1/23, the P&P indicated, to remove urinal or bedpan from the resident's bedside stand.

055202 03/27/2026

Rosemead Healthcare Center 4096 Easy Street El Monte, CA 91731

During a review of Resident 96's Order Summary Report (OSR) dated 3/23/2026, the OSR indicated a physician's order for licensed staff to administer Meropenem (antibiotics, a substance used to kill bacteria and to treat infections) Intravenous (IV) Solution Reconstituted, one (1) gram (gr.- unit of measurement) IV two times a day for UTI/ESBL urine until 3/30/2026; administer at 6 am and 6 pm.

During an interview on 3/26/2026 at 9:56 am with the facility's Infection Preventionist Nurse (IPN- a healthcare professional who specializes in preventing the spread of infections in healthcare settings), the IPN stated when Resident 96 was admitted to the facility from the hospital, Resident 96 continued the antibiotics and the facility did not confirm with Resident 96's physician.

The IPN stated the IPN did not fill out the SDCF dated 3/24/2026 completely.

The IPN stated the SDCF needed to be filled out to ensure Resident 96 was screened before initiating antibiotic therapy to ensure antibiotic use was appropriate, met the criteria for the provision of antibiotics and prevented antibiotic resistance on Resident 96.

During an interview on 3/26/2026 at 12:26 am with the facility's Director of Nursing (DON), the DON stated the SDCF needed to be completely filled out to determine if the resident met the criteria before receiving antibiotic therapy.

During a review of the facility's Policy and Procedure (P&P) titled, Antibiotic Stewardship Program, dated 7/31/2025, the P&P indicated the antibiotic stewardship Program (ASP) was designed to promote the appropriate use of antibiotics while optimizing the treatment of infections, and simultaneously reducing the possible adverse events associated with antibiotic use.

The P&P indicated, the IP will collect and analyze infection surveillance data and monitor the adherence to the ASP.

During a concurrent observation inside Resident 90's room and interview on 3/24/2026 at 10:41 am with LVN 2, Resident 90 was sitting in a wheelchair with a standing black electric fan in front of Resident 90. LVN 2 stated the electric fan's cover and blades were dusty. LVN 2 stated the facility provided electric fans inside the residents' room. LVN 2 stated the electric fans should be maintained clean to prevent the residents from inhaling the dust and causing respiratory complications.

During an interview on 3/25/2026 at 11:22 am with the Infection Prevention Nurse (IPN), the IPN stated housekeeping staff should clean the electric fan inside the resident's room to prevent the resident from breathing in dust leading to exacerbation of respiratory infections.

During an interview on 3/26/2026 at 1:44 pm with the Director of Nursing (DON), the DON stated all equipment inside the resident's room should be maintained clean, free from dust and in good working condition for the safety of the resident.

During a review of the facility's P&P titled, Maintenance Services, implemented on October 1, 2023, the P&P indicated the facility will protect the health and safety of residents, visitors, and facility staff.

The P&P indicated the facility will maintain all mechanical, electrical, and patient care equipment in safe operating condition.

055202 03/27/2026

Rosemead Healthcare Center 4096 Easy Street El Monte, CA 91731