Royal Care Skilled Nursing Ctr

F-F250 Social Service, dated 11/2016, the P&P indicated, Factors with a potentially negative effect on physical, mental, and psychosocial, wellbeing Residents Affected - Few includes an unmet need for: Dental if residents do not have dentures to eat, they will have to have a diet downgrade to puree. This diet change often causes residents to lose weight as they do not care for the presentation or food texture. Furthermore, a resident may suffer negative psychosocial outcome from missing dentures or partials as the resident may become isolative due to the change in his/her physical appearance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 20 055041 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 055041 B. Wing 01/10/2025

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

Royal Care Skilled Nursing Ctr 2725 Pacific Avenue Long Beach, CA 90806

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49889

Residents Affected - Some Based on observation interview and record review the facility failed to ensure a label of open date and use by dates were placed on an open bag of frozen pancakes and cinnamon rolls.

This failure had the potential to expose residents to a food-borne illnesses (any illness resulting from eating contaminated/spoiled foods).

Findings:

During an observation [DATE REDACTED] at 8:10 a.m. in the kitchen freezer an open bag of pancakes and cinnamon rolls did not have a label of open date or use by date on the bag.

During an interview on [DATE REDACTED] at 8:10 a.m., with the Dietary Supervisor (DS), the DS stated that there was not a label of open date or use by date on the open bag of pancakes or cinnamon rolls. DS stated there always needs to be label of open date and use by date on food after it has been opened to ensure the quality of the food was good and palatable for the residents.

During an interview on [DATE REDACTED] at 2:34 p.m. with the Director of Nursing (DON), the DON stated all open food needs to have a label of open date and best by date to ensure the food was fresh. The DON stated there was a possibility for gastrointestinal (GI) illness if residents were served food that was expired.

During a review of the facility's policy and procedure (P&P) titled Food Receiving dated February 2009, the P&P indicated, Upon delivery and/ or opening / using a food item's, label and date the food items at the time

they are opened, follow the used- by- dates and expiration date on the product.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 20 055041 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 055041 B. Wing 01/10/2025

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

Royal Care Skilled Nursing Ctr 2725 Pacific Avenue Long Beach, CA 90806

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** 49862 potential for actual harm Based on observation, interview and record review, the facility failed to observe infection control measures Residents Affected - Few by not ensuring Licensed Vocational Nurse (LVN) 2 and Certified Nursing Assistant (CNA) 2 perform hand hygiene for one out of five sample residents (Resident 41).

This failure had the potential to result in cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another) and place the residents at risk for the spread of infection.

Findings:

During a review of Resident 41's Admission Record, the Admission Record indicated Resident 41 was admitted to the facility on [DATE REDACTED] with diagnoses including, gastrostomy status (surgical opening that allows for nutritional support or stomach drainage), chronic obstructive pulmonary disease ( COPD-is a chronic lung disease that causes breathing difficulties.), muscle weakness ( loss of muscle strength), pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) of

the right heel.

During a review of Resident 41's Minimum Data Set (a resident assessment tool) dated 11/8/2024 indicated Resident 41 was able to make self-understood, and able to understand others. The MDS indicated Resident 41 needs extensive assistance with transfer, dressing, eating, toilet use, and personal hygiene.

During a concurrent observation and interview on 01/07/2025 at 1:13 p.m., with LVN 2, LVN 2 did not performed hand hygiene, changed her gloves, and washed her hands during and after wound care. Observed LVN 2 used the same gloves after LVN 2 performed wound care on Resident 41's right heel pressure ulcer. LVN 2 used the same gloves to check Resident 41's healing wound on Resident 41's buttocks and used the same gloves to cover the residents with linen. LVN 2 did not removed gloves to turn off the bed head light.

During an observation on 01/08/2025 at 09:51 a.m., Certified Nursing Assistance 2 (CNA 2) was observed walking in and out of resident rooms without performing hand hygiene after dropping dirty linen in the hamper outside resident's room and wheel another resident (unknown) to the dining room without washing hands.

During an interview 01/09/2025 at 1:24 p.m., LVN 2 stated she should perform hand hygiene before and after resident care.

During an interview with Infection Preventionist (IP) nurse on 01/09/25 at 1:43 p.m., IP nurse stated if facility staff were not performing hand hygiene it will put the residents at risk including the staff for the spread of infection and disease.

During a phone interview with CNA 2 on 01/10/2025 at 1:43 p.m., CNA 2 stated she should perform hand hygiene by using the hand sanitizer and wash her hands, but she forgets because she was rushing out. CNA 2 stated it was not a safe practice to not perform hand hygiene.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 20 055041 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 055041 B. Wing 01/10/2025

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

Royal Care Skilled Nursing Ctr 2725 Pacific Avenue Long Beach, CA 90806

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 an interview with Director of Nursing (DON) on 1/09/25 at 1:45 p.m., the DON stated all facility staff should always perform hand hygiene. The DON stated this will prevent the spread of infectious disease on all Level of Harm - Minimal harm or resident and staff. The DON stated all staff needs to wash hands, gel in and gel out before and after each potential for actual harm resident care.

Residents Affected - Few During a review of the facility's policy and procedure (P&P) revised 10/22, titled Infection Prevention and Control Program, the P&P indicated, Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedure. The objectives of the infection control policies and practices are to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections as per accepted national standards and guidelines.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 20 055041 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 055041 B. Wing 01/10/2025

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

Royal Care Skilled Nursing Ctr 2725 Pacific Avenue Long Beach, CA 90806

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44898 potential for actual harm Based on interview and record review, the facility failed to implement Antibiotic Stewardship Program Residents Affected - Few (measures used by the facility to ensure antibiotics [drug to treat infection] are used only when necessary and appropriate) for one of 21 sampled residents (Resident 42).

This failure had the potential to put Resident 42 at risk for antibiotic resistance (when bacteria change to resist antibiotics used to effectively treat them) and inappropriate use of antibiotic.

Findings:

During a review of Resident 42's Admission Record, the Admission Record indicated, Resident 42 was admitted to the facility on [DATE REDACTED] with diagnoses including left temporomandibular joint disorder (a condition that affects the joint that connects the jaw to the [NAME] and causes pain and discomfort in the jaw, face, neck and shoulders.), muscle weakness and chronic viral hepatitis C (a lifelong liver infection caused by the hepatitis C virus).

During a review of Resident 42's Physician Progress Notes History and Physical, dated 12/23/2024, the Physician Progress Notes History and Physical indicated, Resident 42 did not appear to have decision making capacity.

During a review of Resident 42's Minimum Data Set (MDS -a resident assessment tool), dated 10/3/2024,

the MDS indicated Resident 42 needed partial to moderate assistance from nursing staff with toileting, showering, dressing, and transferring. The MDS indicated Resident 42 needed nursing staff supervision or touching assistance with rolling from left to right, eating, oral hygiene, and personal hygiene. The MDS indicated Resident 42 did not attempt to walk due to medical condition or safety concerns.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 20 055041 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 055041 B. Wing 01/10/2025

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

Royal Care Skilled Nursing Ctr 2725 Pacific Avenue Long Beach, CA 90806

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 During a concurrent interview and record review on 1/10/2025 at 11:12 a.m., with the Infection Preventionist (IP), Resident 42's Progress Notes, dated 12/30/2024 was reviewed. The Progress Note indicated, on Level of Harm - Minimal harm or 12/20/2024 Resident 42 had left facial pain of unclear etiology. The Progress Notes indicated, Resident 42 potential for actual harm was being treated with Augmentin (amoxicillin/clavulanate- an antibiotic used to treat bacterial infections) 875-125 milligrams (mg-unit of measurement) one tablet by mouth every 12 hours for seven days just in Residents Affected - Few case the cause of the pain was from dental or soft tissue. The Progress Notes indicated after being seen by

the physician he was unable to differentiate if the pain was from a tooth, the jaw, or the cheek. IP stated Resident 42 had a bacterial infection and was prescribed amoxicillin to treat a bacterial infection. IP stated

the McGeer criteria was not used, and the physician ordered Augmentin for seven days for symptoms of left facial pain. IP stated the McGeer determines if there was an actual infection for skin or soft tissue and is used to establish if infection was present. IP stated on 12/27/2024 Resident 42 was referred to the dentist but was not seen by the dentist due to being discharged from the facility. IP stated before antibiotics were given to residents an assessment should be done by the licensed nurse, the physician orders labs, and the results of the labs are reviewed by the doctor. IP stated she reviews the Loeb Minimum Criteria (a set of signs and symptoms that indicate a resident in long-term care may have an infection and could benefit from antibiotics) to see if the resident meets the criteria for antibiotics. IP stated Resident 42 did not have an assessment documented, and labs were not ordered. IP stated she did not check to see if Resident 42 met

the Loeb Minimum Criteria. IP stated she was not aware Resident 42 was prescribed antibiotics. IP stated

the licensed nurse who transcribed the order was supposed to notify the IP or put the order in the facility's communication board. IP stated when the McGeer criteria (set of guidelines used by healthcare providers in for long term care facilities to determine when a resident likely has a significant infection and needs antibiotics based on symptoms) or Loeb criteria was not used prior to antibiotic used, residents can become resistant to antibiotics, the resident could be taken antibiotics unnecessarily, or the resident could be taking

the wrong antibiotic.

During an interview on 1/10/2025 at 2:08 p.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated the McGeer criteria was a screening tool used before starting antibiotics. RNS 1 stated when an antibiotic order was received the licensed nurses always notify the IP of any antibiotics ordered. RNS 1 stated the IP needs to be notified for Antibiotic Stewardship to make sure the resident gets the right antibiotics. RNS 1 stated if Antibiotic Stewardship was not done the resident could develop resistance to the antibiotic and the resident will be hard to treat with antibiotic if the resident gets an infection.

During a review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship Program, date revised 6/2023, the P&P indicated, Nursing staff shall assess residents who are suspected to have an infection prior to notifying the physician. Laboratory testing shall be in accordance with current standards of practice. The facility uses the McGeer criteria to define infections. The Loeb Minimum Criteria may be used to determine whether to treat an infection with antibiotics. Prescriptions for antibiotics shall specify the dose. Duration, and indication for use. Whenever possible, narrow-spectrum antibiotics that are appropriate for the condition being treated shall be utilized.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 20 055041 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 055041 B. Wing 01/10/2025

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

Royal Care Skilled Nursing Ctr 2725 Pacific Avenue Long Beach, CA 90806

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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49889 potential for actual harm Based on interview and record review the facility failed to ensure two out of five sampled residents, Residents Affected - Few Residents 42 and 71 were provided with education regarding the risk and benefits of refusing an influenza (Flu-a contagious respiratory illness), pneumonia (PNA-an infection of the lungs), Corona virus-19 (COVID 19 virus that causes fever and cough) vaccine (medication to prevent a particular disease).

This failure violated the resident or responsible party's rights to make an informed decision and placed two residents at a higher risk of acquiring and transmitting the influenza, pneumonia and COVID19 to other vulnerable and immunocompromised (a weak immune system) residents in the facility.

Findings:

During a review of Resident 42's Admission Record, dated 1/10/2025, the Admission Record indicated, Resident 42 was admitted to the facility on [DATE REDACTED] with diagnoses including hepatitis c (a viral infection of the liver that leads to illness and can be spread by contact with the contaminated blood), asthma (airways become inflamed), schizophrenia (a mental illness that is characterized by disturbances in thought).

During a review of Resident 42's Minimum Data Set (MDS- a resident assessment tool) dated 12/27/2024,

the MDS indicated Resident 42's cognition (ability to think, understand, learn, and remember) was intact. The MDS indicated, Resident 42 needs partial/moderate assistance (helper does less than half the work) with her activities of daily living (ADL's- activities such as bathing, dressing, and toileting a person performs daily).

During a review of Resident 42's History and Physical (H&P), dated 5/30/2024, the H&P indicated, Resident 42 does not appear to have decision making capacity.

During a review of Resident 42's Immunization Informed Consent Record dated 12/20/2024, the immunization informed consent record indicated, Resident 42 refused PNA, COVID 19 and influenza vaccines.

During a review of Resident 71s Admission Record dated 1/10/25 the Admission Record indicated Resident 71 was admitted to the facility on [DATE REDACTED] with diagnoses including, osteomyelitis (inflammation of bone or bone marrow, usually due to infection), type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), morbid obesity (excessive body fat that increases the risk of health problems).

During a review of Resident 71's MDS dated [DATE REDACTED], the MDS indicated Resident 71 has moderate cognitive impairment. The MDS also indicated Resident 71 needs substantial/maximal assistance (helper does more than half the work) with her ADL's

During a review of Resident 71's Immunization Informed Consent Record dated 12/29/2024, the Immunization Informed Consent Record indicated, Resident 71 refused the PNA, COVID 19 and influenza vaccines.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 20 055041 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 055041 B. Wing 01/10/2025

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

Royal Care Skilled Nursing Ctr 2725 Pacific Avenue Long Beach, CA 90806

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 0883 During an interview on 1/10/2025 at 10:23 a.m., with the Infection Preventionist (IP), the IP stated that all residents are offered the influenza, PNA, and COVID 19 vaccines upon admission. The IP stated that after Level of Harm - Minimal harm or the vaccines were offered the nurses should document in the clinical record if the resident accepted or potential for actual harm refused and that education was provided. The IP stated that it was important with these resident population that we make sure they were informed and educated on the risks and benefits of refusing vaccines. The IP Residents Affected - Few stated that she could not find in the clinical record that Residents 42 or Resident 71 were educated on the risk and benefits of refusing the vaccines.

During an interview on 1/10/2025 at 2:34 p.m. with the Director of Nursing (DON), the DON stated that when

the resident refuses to get a vaccine the nurses should educate the resident on the risk and benefits of refusing and document in the clinical record, that the resident knows the importance of getting vaccinated.

The DON stated she was aware that Resident's 42 and 71 did not have documentation of being educated of

the risk and benefits of refusing the vaccine in the clinical record.

During a review of the facility's policy and procedure (P&P) titled Infection Prevention and Control Program dated 10/22 the P&P indicated this facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.

1.Influenza and Pneumococcal Immunization:

Residents will be offered the influenza vaccine each year between October 1 and March 31 unless contraindicated or received the vaccine elsewhere during that time. '

Residents will be offered the pneumococcal vaccines recommended by the CDC upon admission, unless contraindicated or received the vaccines elsewhere.

Education will be provided to the residents and/or representatives regarding the benefits and potential side effects of the immunizations prior to offering the vaccines.

Residents will have the opportunity to refuse the immunizations.

Documentation will reflect the education provided and details regarding whether or not the resident received

the immunizations.

2.COVID-19 Immunization:

Residents and staff will be offered the COVID-19 vaccine when vaccine supplies are available to the facility.

Residents and staff will be screened prior to offering the vaccination for prior immunization medical precautions and contraindications to determine candidacy for the vaccination. '

Education about the vaccine, risks, benefits, and potential side effects will be given to residents or resident representatives and staff prior to offering the vaccine.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 20 055041 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 055041 B. Wing 01/10/2025

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

Royal Care Skilled Nursing Ctr 2725 Pacific Avenue Long Beach, CA 90806

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 0883 Residents or resident representatives will have the opportunity to accept or refuse a COVID-19 vaccination, and change their decision based on current guidance. Level of Harm - Minimal harm or potential for actual harm Documentation will reflect the education provided and details regarding whether or not the resident or staff received the vaccine. Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 20 055041