Health inspection·October 10, 2019

F 0656 6/19/15 - Assess pain level every shift. Level of Harm - Minimal harm or potential for actual harm 9/7/19- Non-pharmacological intervention (NPI) done prior to pain medication administration every shift: 1=Repositioning, 2= Dim light, 3= Cold Applications, 4=Relaxing techniques, 5=Distraction, 6=Music, 7=Quiet Environment. Residents Affected - Few During the review of Resident 42's careplans and concurrent interview with the Director of Nursing (DON) on 10/9/19 at 11:14 a.m., no careplan on pain was located reflecting the physician's order for NPI prior to pain medication administration as ordered on 9/7/19. The DON confirmed the care plan for the non-pharmacological intervention was not developed timely and should have been initiated on the day it was ordered. 2. Review of the clinical record for Resident 36's on 10/09/19 indicated diagnoses including decreased mobility, diabetic neuropathy (body pain due to diabetes) and to administer Tylenol 650 mg. every 4 hours as needed (PRN). The physician order dated 9/7/19 indicated an order for NPI prior to pain medication administration: 1= repositioning, 2= dim light, 3= cold applications, 4= relaxing techniques, 5= distraction, 6= music, 7= quiet environment every shift. Review of Resident 36 care plan initially initiated on 8/1/17 for pain did not reflect any update or revision to include the NPI as ordered on 9/7/19. The facility policy and procedures titled Comprehensive Care Plan indicated care plan shall be developed for each resident that includes measurable objectives and time tables to meet the resident medical, nursing and psychological needs. During an interview on 10/9/19 at 4:26 p.m., the DON indicated the non-pharmacological interventions was not care planned as ordered on 9/7/19 and the careplan was not updated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055022 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055022 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mary Health of the Sick Convalescent & Nursing Hos 2929 Theresa Drive Newbury Park, CA 91320 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure four of 13 sampled residents (Resident 42, 8, 36, and 151) received non-pharmacological interventions (NPI) as ordered by the physician. Residents Affected - Some This failure has the potential for the residents to receive unnecessary pain medication and mismanaged pain. Findings: Review of [NAME] and [NAME], 7th Edition, Mosby's Fundamentals of Nursing, page 419 in the section titled, Legal Implications in Nursing Practice indicates, Nurses are obligated to follow physician order unless they believe the orders are in error or would harm clients. 1. Review of the clinical record for Resident 42 on 10/9/19, indicated an admission date of 6/19/15 with the diagnoses including peripheral vascular disease (thinning with occlusion of veins in the lower extremities), osteoarthritis (pain in bones and joints), venous insufficiency (insufficient blood flow in veins) and rupture of unspecified shoulder (disintegration of shoulder bones). Resident 42 was on multiple pain medications as ordered by the physician including Norco (controlled medication) 7.5/325 mg 0.5 tablet by mouth in the morning related to unspecified osteoarthritis, Norco 7.5/325 mg 1 tablet by mouth two times a day,Hydrocodone-Acetaminophen (controlled medication)7.5/325 mg 1 tablet by mouth every 8 hours for osteoarthritis pain,Tylenol 325 mg 2 tablet PO every 8 hours as needed for mild pain, and Gabapentin 100 mg by mouth at bedtime related to osteoarthritis. On 9/7/19 another physician order was entered into the resident's clinical record to administer :Non-pharmacological intervention (NPI)done prior to pain medication administration every shift: 1=Repositioning, 2= Dim light, 3= Cold Applications, 4=Relaxing techniques, 5=Distraction, 6=Music, 7=Quiet Environment. Review of Resident 42's Medication Administration Record (MAR) dated September to October 2019 indicated the NPIs done prior to pain medication administered were not consistently marked as implemented. During an interview on 10/09/19 at 11:14 a.m., the director of nursing (DON) confirmed the non-pharmacological intervention order was not followed as indicated in the physician's order. 2. Review of the clinical record for Resident 8 indicated diagnoses including diabetes mellitus with diabetic neuropathy (nerve pain). The physician order included Tylenol 325 mg. give two tablets by mouth every 4 hours of mild pain ordered on 8/8/19 ,Tramadol 50 mg. by mouth every 4 hours as needed for moderate to severe pain ordered on 4/8/19, and NPIsprior to pain medication administration: 1= repositioning, 2= dim light, 3= cold applications, 4= relaxing techniques, 5= distraction, 6= music, 7= quiet environment, every shift ordered on 9/7/19. Review of Resident 8's MAR dated 10/1/19 to 10/31/19 indicated positioning was implemented on 10/1/19 and 10/3/19 in the day shift. No other NPIs were implemented. For the afternoon and night shift no NPIs were implemented from 10/19 to 10/9/19. Review of the clinical record for Resident 36 indicated diagnoses including generalized pain and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055022 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055022 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mary Health of the Sick Convalescent & Nursing Hos 2929 Theresa Drive Newbury Park, CA 91320 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some diabetes 2 (inability of the body to produce and absorb insulin). The physician order included Tylenol 325 mg. two tablets by mouth every four hours as needed for generalized pain ordered on 7/31/18 and NPIs prior to pain medication administration: 1= repositioning, 2= dim light, 3= cold applications, 4= relaxing techniques, 5= distraction, 6= music, 7= quiet environment, every shift ordered on 9/7/19. Review of Resident 36 MAR dated 10/1/19 to 10/31/19 indicated no NPI interventions was done from 10/4/19 to 10/9/19 for the day shift, 10/1,10/3,10/6, and 10/8/19 for the afternoon shift, and 10/1- 10/8/19 for the night shift. Review of the clinical record for Resident 151 indicated diagnoses including spinal stenosis lumbosacral region (narrowing of the spinal cord area). The physician order dated 10/4/19 had orders for Tramadol HCL 50 mg. one tablet every 4 hours as needed for moderate pain , Tylenol 325 mg two tablets by mouth every four hours as needed for mild pain, and NPI prior to pain medication administration: 1= repositioning, 2= dim light, 3= cold applications, 4= relaxing techniques, 5= distraction, 6= music, 7= quiet environment, every shift. Review of Resident 151's MAR indicated no NPI on 10/5-10/6/19 on the day shift, and 10/7/19 on the afternoon shift . Review of the MAR and concurrent interview with the DON on 10/09/19 at 4:26 p.m., the DON indicated the NPIs were not done per doctor's order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055022 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055022 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mary Health of the Sick Convalescent & Nursing Hos 2929 Theresa Drive Newbury Park, CA 91320 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident medication brought to the facility from home and not verified by the facility's servicing pharmacy and pharmacist was not left in the medication storage 1 (MS 1). This failure had the potential for medication diversion. Findings: During an observation inside MS 1 on 10/10/19 at 9:18 a.m and concurrent interview with Registered Nurse Supervisor (RNS1), a wall mounted medicine cabinet was noted to contain a bottle of the medication Preservision (eye medicine) labeled with Resident 2's name. RNS 1 indicated the medication is from home brought by the family and Resident 2 is currently discharged and the medication should have been destroyed. Review of the closed record for Resident 2 indicated an admission date of 9/18/19. Resident 2 was discharged to a hospital on 9/26/19 , readmitted back to the facility on [DATE], and discharged out to the hospital on [DATE]. No record could be located if the medication was verified by the facility's servicing pharmacy or pharmacist. The facility's policy and procedure titled, Disposal of Medications and Medication-Related Supplies dated March 2019 indicated .Medications left in the facility after a resident's discharge are destroyed . The facility was not able to present a policy regarding storage of unverified medications inside the medication storage areas upon request. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055022 If continuation sheet Page 5 of 5