Health inspection·April 14, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview, and record review the facility failed to ensure the Transportation Coordinator (TC) sat at eye level to the resident while assisting the resident with feeding for one of two sampled residents (Resident 24). This deficient practice had the potential to affect the resident's sense of self-worth and self-esteem. Findings: A review of Resident 24's Face sheet indicated the facility admitted the resident on 2/5/2021 and readmitted the resident on 11/1/2021 with diagnoses including Alzheimer's diseases (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 24's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/10/2023 indicated Resident 24 can usually make self-understood and sometimes understands other. The MDS indicated Resident 24 was totally dependent on bed mobility, transferring, dressing, eating, and toilet use. A review of Resident 24's order dated 8/11/2022 indicated mechanical soft diet. A review of Resident 24's care plan, revised on 2/17/2021, indicated a care plan for cognitive communication, falls, vision, activity of daily living (ADL), incontinence, visual, skin integrity, has history of forgetfulness confusion due to Alzheimer and dementia. The intervention included Resident 24 needing total assistance with eating. During a concurrent observation and interview on 4/11/2023 at 8:47 a.m., observed Resident 24 sitting up in bed with the bedside table in front of her with breakfast tray. Observed TC standing over Resident 24 while assisting with her meal. The TC stated she should have moved the bed up and sat at eye level with resident to provide the resident dignity and to make sure the resident has swallowed the food before taking another bite because there is a risk for the resident choking. The TC also stated standing over the resident while they are eating can make them feel like they are being looked down on. During an interview on 4/13/2023 at 2:18 p.m., the Director of Long-Term Care (DLTC) stated staff should be assisting residents with meals at eye level. The DLTC stated there is a potential for the Page 1 of 25 055034 055034 04/14/2023 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident to choke when they are not assisted with meals at eye level because the staff assisting may not see how much food the resident is getting and swallowing. The DLTC also stated it provides the resident dignity when staff sit with them at eye level during meals. A review of the facility's policies and procedures, titled, Patient/Resident Privacy and Dignity, last revised on 3/3/2023 indicated facility will contribute to each patient's/resident's positive self-image through the provision and promotion of privacy and ensuring dignity. 055034 Page 2 of 25 055034 04/14/2023 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the call light was within reach of the resident for one of two sampled residents (Resident 11). Residents Affected - Few This deficient practice had the potential to result in residents not being able to ask health care workers for assistance and increase the resident's risk for injury due to fall. Findings: A review of Resident 11's Face sheet indicated the facility admitted the resident on 6/11/2020 with diagnoses including Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy). A review of Resident 11's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/24/2023 indicated Resident 11 can usually make self-understood and can usually understand others. The MDS indicated Resident 24 was totally dependent on bed mobility, transferring, dressing, and toilet use. A review of Resident 11's care plan, revised on 6/24/2020, indicated a care plan for cognitive communication, falls, vision, activity of daily living (ADL), incontinence, visual, skin integrity, has history of forgetfulness confusion due to dementia. The interventions included Resident 11 is a high fall risk, call light in reach, red badge/armband; remote monitoring devices on bed and chair, non-skid socks/shoes, maintain bed at appropriate height for her, keep personal items within reach. During a concurrent observation and interview on 4/10/2023 at 10:50 a.m. observed Resident 11 lying in bed with call light on floor out of Resident 11's reach. The Unit Secretary (US) stated the call light was not within Resident 11's reach and the resident would not be able to get help if she needed it. During an interview on 4/10/2023 at 10:55 a.m., with Certified Nursing Assistant 4 (CNA 4), CNA 4 stated Resident 11 did not have the call light within reach and would not be able to call for help. During an interview on 4/13/2023 at 2:22 p.m. with the Director of Long-Term Care (DLTC), the DLTC stated all residents should be given a call light so they can ask for assistance and staff would be able to attend to the resident's needs. A review of the facility's policies and procedures, titled Call Light, last revised on 3/3/2023 indicated ensure call light is within reach of patient. 055034 Page 3 of 25 055034 04/14/2023 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to promote the resident rights to examine the results of the most recent survey (a survey to determine compliance with state and federal regulations) of the facility by failing to: Residents Affected - Few 1. Post the most recent survey results in a place that are prominent and accessible (a place where individuals wishing to examine survey results do not have to ask to see them) to residents and the public. 2. Ensure the residents know where to find the results of the most recent survey for eight out of eight (Residents 25, 65, 36, 44, 55, 35, 6, and 41). These deficient practices had the potential to impede the resident rights and negatively affect residents' psychosocial wellbeing. Findings: During the Resident Council meeting on 4/11/2023 at 10:40 a.m., Residents 25, 65, 36, 44, 55, 35, 6, and 41 were asked, Without having to ask, are the results of the State inspection available to read? Eight out of eight residents stated they do not know where to find the results of the most recent survey. During a concurrent observation and interview on 4/11/2023 at 1:30 p.m. with Receptionist 1 1 (RECP 1) at the lobby, the survey binder from the previous survey was not visible. Asked the Receptionist 1(RECP 1) if he knew where the survey binder is located. RECP 1 stated he does not knowand will call someone to come look for it. During a concurrent interview and record review on 4/11/2023 at 2:20 p.m. with the ADM, the ADM handed over the survey binder to surveyor and stated the binder was in the lobby, but it was covered by the podium. Review of the previous survey results dated 11/15/2019 were available inside the binder. During a concurrent observation and interview on 4/12/2023 at 1:20 p.m. with the Director of Long-Term Care (DLTC), the DLTC stated in the conference room. Asked DON where the survey binder is located inside the facility. stated there is a survey binder on each unit and there is also supposed to be one in the lobby. Asked DON if she can show the surveyor where the survey binder is located. The DON indicated the location of the binder was next to the podium and proceeded to place the binder in a clear acrylic holder. The DON stated they will make sure survey binder will visible from now on to the residents. 055034 Page 4 of 25 055034 04/14/2023 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on interview and record review, the facility failed to offer the resident or resident representative assistance with formulating an Advance Directive (AD - a legal document telling the doctor one's wishes about their healthcare in the event they cannot make the decision for themselves) upon admission for one (Resident 37) of two sampled residents investigated under the care area Advance Directives. This deficient practice violated the resident and/or their representatives the right to be fully informed of the option to formulate an AD and had the potential to cause conflict due to lack of communication regarding residents' wishes about their medical treatment. Findings: A review of Resident 37's Face Sheet, the facility admitted the resident on 6/15/2017 with diagnoses including cerebellar stroke syndrome (a condition that happens when blood supply to the cerebellum [part of the brain that helps with body movement, eye movement, and balance] is stopped), aphasia (a disorder that affects your ability to speak, read, write and listen) following cerebral infraction [a stroke that occurs in areas of the brain that control speech and language], hemiplegia (complete paralysis on one side of the body that can affect the arms, legs, and facial muscles) affecting left nondominant side. A review of Resident 37's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 1/10/2023, indicated the resident had severely impaired cognition ((mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicate limitation in ROM on one side of the upper and lower extremities. A review of Resident 37's Physician Orders dated 6/15/2017 indicated an order of code status (the type of emergent treatment a person would or would not receive if their - heart or breathing were to stop): do not resuscitate/do not intubate (DNR/DNI - no chest compressions, cardiac drugs, or placement of a breathing tube will be performed/chest compressions and cardiac drugs may be used, but no breathing tube will be placed) see physician's order for life sustaining order (POLST - a form consists of a set of medical orders that applies to a limited population of patients and addresses a limited number of critical medical decisions) dated 5/30/2017. A review of Resident 37's POLST indicated DNR/DNI was signed by the resident's spouse and the physician on of 2/1/2022. The POLST did not indicate if there was an AD on file. During a concurrent interview and record review on 4/12/2023 at 10:39 a.m., the electronic and physical health record were reviewed with the Medical Social Worker (MSW). The MSW stated the facility offers assistance to residents or their representatives in formulating an AD if interested. The MSW was unable to provide documented evidence that the resident and/or their representative was provided with information on how to formulate an AD. The MSW stated that it was important to offer information about AD to the resident and/or their representative to ensure that the resident has assigned someone to make the decisions for them (resident) in accordance with the resident's wishes when they are no longer able to. 055034 Page 5 of 25 055034 04/14/2023 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0578 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure titled, Advance Directives, last reviewed on 3/3/2023 indicated that AD communicates resident health preferences should they become unable to make decisions for themselves. The policy indicated social workers provide assistance to long term care residents regarding AD. The policy indicated social services offers assistance if no AD is in place upon admission, annually and if needed and documented in the medical record. Residents Affected - Few 055034 Page 6 of 25 055034 04/14/2023 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure licensed nurses provide care in accordance with professional standards by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin (a hormone that lowers the level of sugar in the blood) injection sites for one out of six sampled residents (Resident 39). Residents Affected - Few This deficient practice had the potential to cause unnecessary tissue trauma and hardening of the area where frequent subcutaneous administration occurred that could lead to impaired absorption (a condition in which the body takes in another substance) of insulin. Findings: A review of Resident 39's Face Sheet indicated the facility admitted the resident on 11/4/2020 and readmitted the resident on 1/19/2023, with diagnoses including, type 2 diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, is too high), hypoglycemia (low blood sugar), and encephalopathy (any disease of the brain that alters brain function or structure). A review of Resident 39's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/27/2023, indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was on insulin injection. A review of Resident 39's Physician Orders, dated 1/19/2023, indicated an order for: -Humalog 100 unit per milliliters (unit/ml, a standardized way to quantify the effect of a medication) vial, inject 4 units subcutaneously twice a day with lunch dinner hold for blood sugar below 150 (for diabetes type 2) -Lantus 100 unit/ml vial inject 15 units subcutaneously daily at 4: 30 p.m. hold if blood sugar below 160 (for diabetes type 2). A review of Resident 39's Care Plan, last revised on 1/19/2023, indicated a care plan for hypoglycemia, hyperglycemia (high blood sugar), and long-term use of insulin indicated a goal of the resident will be free of complications or problems with medical conditions. A review of Resident 39's eMAR (Electronic Medication Administration Record) on 1/1/2023-4/14/2023 indicated: -Humalog 100 unit/ml vial, inject 4 units subcutaneously twice a day with lunch dinner hold for blood sugar below 150 (for diabetes type 2) 1/4/2023 at 11:30 a.m. Right Lower Quadrant (RLQ) 1/4/2023 at 4:30 p.m. RLQ 055034 Page 7 of 25 055034 04/14/2023 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0658 1/20/2023 at 4:30 p.m. Level of Harm - Minimal harm or potential for actual harm Right Deltoid (RDelt) 1/21/2023 at 11:30 a.m. Residents Affected - Few RDelt 1/21/2023 at 4:30 p.m. Left Deltoid (LDelt) 1/22/2023 at 11:30 a.m. LDelt 1/7/2023 at 4:30 p.m. RLQ 1/8/2023 at 4:30 p.m. RLQ 1/28/2023 at 11:30 a.m. Left Lower Quadrant (LLQ) 1/28/2023 at 4:30 p.m. LLQ 2/5/2023 at 11:30 a.m. Right Upper Quadrant (RUQ) 2/6/2023 at 4:30 p.m. RUQ 3/7/2023 at 11:30 a.m. RLQ 3/7/2023 at 4:30 p.m. RLQ 3/8/2023 at 11:30 a.m. 055034 Page 8 of 25 055034 04/14/2023 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0658 RLQ Level of Harm - Minimal harm or potential for actual harm 3/9/2023 at 11:30 a.m. RLQ Residents Affected - Few 3/10/2023 at 11:30 a.m. RLQ 3/13/2023 at 11:30 a.m. RLQ 3/13/2023 at 4:30 p.m. RLQ 3/16/2023 at 4:30 p.m. RUQ 3/17/2023 at 11:30 a.m. RUQ 3/25/2023 at 11:30 p.m. LLQ 3/25/2023 at 4:30 p.m. LLQ 3/27/2023 at 11:30 a.m. RLQ 3/27/2023 at 4:30 p.m. RLQ 3/30/2023 at 11:30 a.m. RUQ 3/31/2023 at 11:30 a.m. RUQ 055034 Page 9 of 25 055034 04/14/2023 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0658 4/2/2023 at 11:30 a.m. Level of Harm - Minimal harm or potential for actual harm LUQ 4/2/2023 at 4:30 p.m. Residents Affected - Few LUQ 4/7/2023 at 4:30 p.m. RUQ 4/8/2023 at 11:30 a.m. RUQ -Lantus 100 unit/ml vial inject 15 units subcutaneously daily at 4: 30 p.m. hold if blood sugar below 160 (for diabetes 2). 2/10/2023 at 4:30 p.m. Right Lower Quadrant (RLQ) 2/11/2023 at 11:30 p.m. RLQ 3/25/2023 at 4:30 p.m. RLQ 3/26/2023 at 4:30 p.m. RLQ 4/1/2023 at 4:30 p.m. RLQ 4/2/2023 at 4:30 p.m. RLQ 4/8/2023 at 4:30 p.m. LLQ 4/9/2023 at 4:30 p.m. 055034 Page 10 of 25 055034 04/14/2023 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0658 LLQ Level of Harm - Minimal harm or potential for actual harm 4/11/2023 at 4:30 p.m. RUQ Residents Affected - Few 4/12/2023 at 4:30 p.m. RUQ During a concurrent interview and record review on 4/13/2023, at 8:09 a.m., reviewed eMAR with Licensed Vocational Nurse 1 (LVN 1). LVN 1 stated there were multiple incidence that the insulin administration sites were not rotated. LVN 1 stated the sites of administration should be rotated to prevent bruising and other complications. During an interview on 4/13/2023, at 2:05 p.m., the Director of Long-Term Care (DLTC) stated the site of administration should be rotated to prevent possible swelling and redness. The DLTC also added the deficient practice can result to potential infection at the injection site. A review of the facility's recent policy and procedure titled Medication Administration, last reviewed 3/3/2023, indicated when administering insulin, rotate injection sites. A review of the manufacturer's guideline on the use of Lantus (insulin glargine injection) for subcutaneous injection, with initial U.S. approval: 2000, indicated rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. A review of the manufacturer's guideline on the use of Humalog (insulin lispro injection), for subcutaneous or intravenous use with initial U.S. approval: 1996, indicated change (rotate) your injection sites within the area you choose with each dose to reduce your risk of getting lipodystrophy (pits in skin or thickened skin) and localized cutaneous amyloidosis (skin with lumps) at the injection sites. 055034 Page 11 of 25 055034 04/14/2023 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. A review of Resident 29's face sheet indicated the facility admitted the resident on 4/8/2021 with diagnoses including multiple sclerosis (MS-a potentially disabling disease of the brain and spinal cord (central nervous system), major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), and neuromuscular dysfunction of bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems). A review of Resident 29's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/13/2023 indicated Resident 29 understood others and was understood by others. The MDS indicated Resident 29 required total assistance with bed mobility, transferring, and dressing, eating and toilet use. A review of Resident 29's Physician Orders dated 7/19/2022 indicated Restorative Nursing Assistant (RNAwork with individuals who need physical therapy or other restorative treatment) to provide passive range of motion exercises to all extremities including hands, wrist, and fingers daily 5 days a week. A review of facility document titled RNA Daily Notes for Resident 29 indicated: -Week of 3/17/2023-3/2023 was seen on 3/17/2023, 3/21/2023, 3/22/2023 total of 3 out of 5 ordered visits - Week of 3/3/2023-3/9/2023 was seen on 3/6/2023, 3/7/2023, 3/8/2023, 3/9/2023 4 out of 5 ordered visits -Week of 2/27/2023-3/2/2023 was seen on 2/28/2023, 3/1/2023, 3/2/2023 3 out of 5 ordered visits -Week of 2/20/2023-2/26/2023 was seen on 2/20/2023, 2/21/2023. 2/22/2023 3 out of 5 ordered visits -Week of 2/6/2023-2/1/20232 was seen on 2/6/2023, 2/7/2023, 2/8/2023, 3 out of 5 -Week of 1/23/2023-1/29/2023 was seen on 1/23/2023, 1/24/2023, 1/25/2023, 1/27/2023, 4 out of 5 ordered visits -Week of 1/9-1/15 was seen on 1/9, 1/10, 1/12, 1/13 4 out of 5 ordered visits -Week of 1/2-1/8 was seen on 1/4, and 1/6 2 out of 5 ordered visits During an interview on 4/10/2023 at 10:11 a.m. with Resident 29 stated that he has MS and his hands have become constricted and has not been getting any therapy for it. During an interview on 4/11/2023 at 2:22 p.m. with Restorative Nursing Assistant (RNA 1) stated she provides therapy to the residents on the RNA program based on the orders and schedule indicated in the RNA book. RNA 1 stated that when therapy is provided to the resident, the RNAs will make a note on the resident's chart, and if there is no note than the therapy was not done. RNA1 stated that the facility is short staffed sometimes and the RNAs are instructed to work as Certified Nursing 055034 Page 12 of 25 055034 04/14/2023 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Assistants (CNAs). RNA 1 stated that on the days that she was working as a CNA, she was not able to provide therapy to the residents. RNA1 stated the resident can possibly have a decline in range of motion (ROM) and ambulation if the facility does not have the staff to provide RNA therapy. During a follow-up interview on 4/11/2023 at 2:36 p.m. with Resident 29, the resident stated RNA1 came in and offered therapy but stated he refused because he was too tired. Resident 29 stated that staff did use to come in and ask if they could do therapy with him but today was the first time it was offered in a month. During an interview on 4/13/2023 at 2:10 p.m. with the Director of Long-Term Care (DLTC), the DLTC stated the RNAs are scheduled Monday through Friday from 7:30-3p.m. The DLTC stated that during the pandemic had staffing issues had to pull RNAs out of RNA work to do CNA work to meet resident care needs and some RNAs are currently on medical leave. The DLTC stated RNA therapy must offered to resident and documented when it is done. The DLTC stated not providing RNA therapy as ordered can potentially cause residents to develop more contractures. A review of the facility's policies and procedures titled, LTC Standard of Care Nursing Protocol, last revised on 2/2023 indicated provide measures to increase mobility per medical provider order: -ROM exercise, ambulation, transfers. -Overhead frames/trapeze -Physical therapy consults as ordered. -Occupational therapy consults as ordered. -If a resident refuses, document and inform medical provider. d. A review of Resident 37's Face Sheet, indicated the facility admitted the resident on 6/15/2017 with diagnoses including cerebellar stroke syndrome (a condition that happens when blood supply to the cerebellum [part of the brain that helps with body movement, eye movement, and balance] is stopped), aphasia (a disorder that affects your ability to speak, read, write and listen) following cerebral infraction [a stroke that occurs in areas of the brain that control speech and language], hemiplegia (complete paralysis on one side of the body that can affect the arms, legs, and facial muscles) affecting left nondominant side. A review of Resident 37's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 1/10/2023, indicated the resident had severely impaired cognition ((mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicate limitation in ROM on one side of the upper and lower extremities. A review of Resident 37's Physician Orders indicated the following orders: 1. RNA to continue for passive range of motion (PROM - a type of ROM in which a part of the body can move when someone or something is creating the movement) to all extremities as tolerated five days per week (5 days/week) 10/10/2019. 055034 Page 13 of 25 055034 04/14/2023 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. RNA to continue placing bilateral elbow extension splints, right hand carrot, and left-hand palm protector in order to prevent worsening contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues causing the joints to shorten and become very stiff) for five times per week (5x/week) for six to eight hours as tolerated. A review of Resident 37's daily RNA Progress Notes from 2/1/2023 to 4/11/2023 indicated there were no RNA therapy notes for PROM to all extremities and bilateral elbow extension splints, right hand carrot, and left-hand palm protector on the following dates: missing documentation on the following days: 1. 2/8/2023 2. 2/13/2023 3. 2/14/2023 4. 2/24/2023 5. 3/7/2023 6. 3/9/2023 7. 3/24/2023 8. 4/5/2023 9. 4/6/2023 10. 055034 Page 14 of 25 055034 04/14/2023 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0688 4/7/2023 Level of Harm - Minimal harm or potential for actual harm 11. 4/10/2023 Residents Affected - Some 12. 4/11/2023 A review of Resident 37's care plan indicated care plans for the following: 1. Medical Condition: History of cerebrovascular accident (CVA - also known as stroke, an interruption in the flow of blood to cells in the brain), hemiplegia and hemiparesis (weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) affecting left nondominant side initiated on 6/26/2017 with a target date of 6/20/2023 indicated RNA to continue for PROM to all extremities as tolerated 5x/week and RNA to continue placing bilateral elbow extension splints, right hand carrot and left hand palm to prevent worsening contractures for 5x/week for 6-8 hours or as tolerated. 2. ADL/Self-care: Resident had a stroke which left her unable to move her left side and has contractures on the left upper extremity (LUE) initiated on 6/23/2017 with a target date of 6/30/2023 indicated RNA to continue for PROM to all extremities as tolerated 5x/week and RNA to continue placing bilateral elbow extension splints, right hand carrot and left-hand palm to prevent worsening contractures for 5x/week for 6-8 hours or as tolerated. During observations on 4/10/2023 at 10:04 a.m. and 4/11/2023 at 11:24 a.m., observed Resident 37's LUE with contracture. During an interview on 4/11/2023 at 2:15 p.m., Certified Nursing Assistant 2 (CNA 2) confirmed that Resident 37 did not have her splints on 4/10/2023 and 4/11/2023 as the unit did not have an RNA scheduled. CNA 2 stated the splints should have been applied on the resident because the resident's contractures could potentially worsen. During a concurrent observation and interview on 4/12/2023 at 9:17 a.m., observed Resident 37 with the right carrot shaped cushion on the right hand, bilateral elbow splints and left-hand palm protector. Restorative Nursing Assistant 1 (RNA 1) stated that she was off on 4/10/2023 and 4/11/2023. RNA 1 stated RNA services are provided to resident 5 times a week on Mondays thru Fridays. RNA 1 stated all RNA services provided to residents are documented under the RNA Progress Notes daily and if it was not documented, then it was not done. RNA 1 stated that it is important to apply the splints to Resident 37 as ordered by the physician to prevent worsening of contractures. During a concurrent interview and record review on 4/12/2023 at 11:59 a.m., the daily RNA Progress Notes for Resident 37 were reviewed with Registered Nurse 1 (RN 1). RN 1 was unable to provide documented evidence that RNA services were provided to the resident on 2/8/2023, 2/13/2023, 2/14/2023, 2/24/2023, 3/7/2023, 3/9/2023, 3/24/2023, 4/5/2023, 4/6/2023, 4/7/2023, 4/10/2023, 4/11/2023 for Resident 37. RN 1 stated if it was not documented then it was not done. RN 1 stated the RNA services should have been provided as ordered by the physician to prevent worsening of contractures. 055034 Page 15 of 25 055034 04/14/2023 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent interview and record revied on 4/13/2023 at 2:08 p.m., the daily RNA Progress Notes for Resident 37 were reviewed with the Director of Long-Term Care (DLTC). The DLTC verified that the RNA services were provided to the resident on 2/8/2023, 2/13/2023, 2/14/2023, 2/24/2023, 3/7/2023, 3/9/2023, 3/24/2023, 4/5/2023, 4/6/2023, 4/7/2023, 4/10/2023, 4/11/2023 for Resident 37. The DLTC stated that the facility had staffing issues and had the RNAs work as CNAs to provide direct patient care to meet the resident ADL needs. The DLTC stated that the RNA services should have been provided to Resident 37 as ordered by the physician because the resident could potentially develop more contractures. A review of the facility's policy ad procedure titled, LTC Standard of Care Nursing Protocol, last reviewed and approved on 3/3/2023 indicated the following: 1. Document that activities are performed as ordered such as performing/assisting with ROM exercises as ordered. 2. Provide measures to increase mobility per medical provider order such as ROM exercises, ambulation, and transfers. Based on interview, and record review, the facility failed to provide Restorative Nursing Assistance (RNA, a program designed to ensure each resident maintains their physical and functional abilities) services as ordered by the physician to four of thirteen sampled residents (Residents 2 and 43, 29, and 37). This deficient practice had the potential to result in a decline in mobility and range of motion (the extent or limit to which part of the body can be moved around a joint or a fixed point) for residents. Findings: a. A review of Resident 2's Face Sheet indicated the facility admitted the resident on 1/23/2020 and readmitted the resident on 9/12/2020, with diagnoses including, abnormalities of gait (a manner of walking or moving on foot) and mobility, polyosteoarthritis (a joint disease that involves at least five joints), and venous insufficiency (a condition in which the veins have problems sending blood from the legs back to the heart). A review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/27/2023, indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident required extensive assistance on bed mobility, transfer, locomotion on and off unit, dressing, toilet use, and personal hygiene. The MDS also indicated the resident was using a walker (a light portable framework used for support and assistance in walking by a person with a gait impairment) and a wheelchair. A review of Resident 2's Physician Orders, dated 6/17/2021, indicated an order for Restorative Nurse Assistant (RNA) to ambulate resident with two-wheel-walker (2WW, a walking aid with two front wheels and no rear wheels) as tolerated with distance (per Physical Therapist [PT]) 5 days per week. 055034 Page 16 of 25 055034 04/14/2023 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 2's Care Plan, initiated on 6/17/2021, indicated a care plan for cognitive/falls/activities of daily living (ADL) and incontinence. The care plan indicated RNA to ambulate resident with 2WW as tolerated with distance (per PT) 5 days/week. A review of Resident 2's RNA Daily Notes for 1/1/2023 thru 4/10/2023 indicated there were no RNA notes on the following dates: 1/2/2023, 1/5/2023, 1/6/2023, 1/9/2023, 1/12/2023, 1/13/2023, 2/1/2023, 2/2/2023, 2/8/2023, 2/9/2023, 2/10/2023, 2/13/2023, 2/15/2023, 2/16/2023, 2/17/2023, 2/22/2023, 2/27/2023, 3/3/2023, 3/6/2023 to 3/10/2023, 3/13/2023 to 3/17/2023, 3/20/2023 to 3/24/2023, 3/27/2023 to 3/31/2023, 4/3/2023 to 4/7/2023, 4/10/2023, and 4/11/2023. During an interview on 4/11/2023 at 2:22 p.m., Restorative Nursing Assistant 1 (RNA 1) stated that her job title is RN, however, if they are short staffed, they have her work as a Certified Nursing Assistant (CNA). RNA 1 stated that on the days that she was working as a CNA, she was not able to provide therapy to the residents. During an interview on 4/12/2023, at 9:24 a.m., Restorative Nursing Assistant 2 (RNA 2) stated that there were two RNAs out on medical leave. During a concurrent interview and record review on 4/12/2023, at 11:59 a.m., reviewed RNA daily notes with Registered Nurse 1 (RN 1). RN 1 stated there were a lot of missing RNA therapy notes. RN 1 stated the failure to provide RNA therapy as ordered can result in resident losing or declining in function. RN 1 stated that in nursing if it was not documented, it was not done. b. A review of Resident 43's Face Sheet indicated the facility admitted the resident on 9/23/2021 and the readmitted the resident on 9/19/2022, with diagnoses including myasthenia gravis (a rare long-term condition that causes muscle weakness), osteoporosis (a condition in which there is a decrease in the amount and thickness of bone tissue), and polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body). A review of Resident 43's MDS, dated [DATE], indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident requires extensive assistance on bed mobility and transfer. The MDS further indicated the resident required total dependence on ambulating in the unit, toilet use, and personal hygiene. The MDS added that the resident was using a wheelchair. A review of Resident 43's Physician Orders, dated 1/20/2023, indicated an order of RNA for range of motion (ROM, the extent or limit to which a part of the body can be moved around a joint or a fixed point) of upper and lower extremities passive versus active/assisted exercises 5 days per week as tolerated. A review of Resident 43's Care Plan, initiated on 1/20/2023, indicated a care plan for cognitive/falls/ADL and incontinence. The care plan indicated RNA for ROM of upper and lower extremities passive vs active/assisted exercises 5 days per week as tolerated. A review of Resident 43's RNA Daily Notes for 1/1/2023-4/10/2023 indicated there were no RNA therapy notes on the following dates: 055034 Page 17 of 25 055034 04/14/2023 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1/2/2023, 1/5/2023, 1/6/2023, 1/9/2023, 1/12/2023, 1/13/2023, 2/1/2023, 2/2/2023, 2/8/2023, 2/9/2023, 2/10/2023, 2/13/2023, 2/15/2023, 2/16/2023, 2/17/2023, 2/27/2023, 3/3/2023, 4/3/2023, 4/4/2023, 4/5/2023, 4/6/2023, 4/7/2023, 4/10/2023, and 4/11/2023. During a concurrent interview and record review on 4/12/2023, at 11:59 a.m., reviewed RNA daily notes with RN 1. RN 1 stated there were a lot of missing RNA therapy notes. RN 1 stated the failure to provide RNA therapy as ordered can result in resident losing or declining in function. RN 1 stated that in nursing if it was not documented, it was not done. During an interview on 4/13/2023, at 2:08 p.m., the Director of Long-Term Care (DLTC) stated they have RNAs from M-F 7:30 -3pm. The DLTC stated they were not able to provide RNA therapy on some days because some of the RNAs are out on medical leave. The DLTC stated not providing RNA therapy can potentially cause residents to develop more contractures. A review of the facility's recent policy and procedure titled LTC Standards of Care Nursing Protocol, last revised on 2/2023, indicated document that activities are performed as ordered. Perform/assist with range of motion exercises as ordered. Provide measures to increase mobility per medical provider order: (1) ROM exercises, ambulation, transfers. Overhead frames/trapeze. Physical therapy consults as ordered. Occupational therapy results as ordered. If resident refuses, document and inform medical provider. 055034 Page 18 of 25 055034 04/14/2023 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review the facility failed to ensure resident safety for one (Resident 41) out of two sampled residents investigated under the Accidents care area by failing to: Residents Affected - Few 1. Implement its policy and procedure to provide supervision and smoking apron to the resident while smoking in the patio during scheduled smoking times. 2. Conduct a smoking risk assessment to determine if the resident required supervision during scheduled smoking times. These deficient practices placed Resident 41 at risk for smoking-related injuries Findings: A review of Resident 41's Face Sheet indicated the facility admitted the resident on 10/22/2020 with diagnoses including human immunodeficiency virus (HIV - a condition that weakens a person's immune system by destroying important cells that fight disease and infection), ataxia (lack of muscle coordination that may affect a person's speech, eye movements, and ability to swallow, walk, and pick up objects), spinal stenosis lumbar region (a condition that happens when the space inside the backbone is too small that may lead to walk, pain or numbness on the legs, and bowel and bladder difficulty). A review of Resident 41's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 1/27/2023, indicated the resident had moderately impaired cognition ((mental action or process of acquiring knowledge and understanding) and required supervision with eating and locomotion in the unit, extensive assistance from staff with bed mobility, personal hygiene, and dressing, and totally dependent to staff with other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 41's Physician Orders dated 1/13/2022 indicated resident may smoke on designated areas, assist with lighter use, supervise as needed, and resident to use protective apron while smoking. A review of Resident 41's care plan on smoking initiated on 1/13/2022, indicated the resident did not require supervision, will notify nurses when going out for a smoke, and provide the resident with an apron while smoking. A review of Resident 41's electronic health record (HER) and physical medical record indicated there was no documented evidence that a smoking risk assessment was done when the physician ordered to allow the resident to smoke. During an interview on 4/11/2023 at 11:48 a.m., Registered Nurse 1 (RN 1) stated she was not sure if there was a smoking risk assessment done on Resident 41. During a concurrent observation and interview on 4/11/2023 at 3:00 p.m., observed Resident 41 on his motorized wheelchair smoking in the water patio area by the hospital main entrance without any 055034 Page 19 of 25 055034 04/14/2023 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few staff supervision and a protective apron. Resident 41 stated the nurse was aware he was going out to smoke and was not provided an apron. Resident 41 stated he is aware that he must be accompanied by staff and wear the apron while smoking for his safety. During a follow up interview on 4/12/2023 at 9:11 a.m., RN 1 stated that there was no smoking risk assessment done on Resident 41. as confirmed by the Director of Long-Term Care (DLTC). During an interview on 4/12/2023 at 2:48 p.m., Licensed Vocational Nurse 2 (LVN 2) stated Resident 41 should have been supervised by staff and provided a protective apron while smoking for his safety. and usually asks one of the social workers or activity staff to accompany him. LVN 2 stated Resident 41's cigarette, lighter, and apron were locked at the nurse's station. LVN 2 stated that she was not working on 4/11/2023 and in her opinion, the resident should have been accompanied by staff and should be wearing a protective apron for his safety. During a concurrent interview and record review on 4/13/2023 at 9:04 a.m., Resident 41's assessments, smoking care plan, and care conference meetings in the EHR were reviewed with the Medical Social Worker (MSW). The MSW stated that Resident 41 usually asks her to accompany him outside to smoke. The MSW stated that according to the resident's care plan, Resident 41 did not require supervision when smoking and but should have been provided with an apron. The MSW was unable to find documented evidence that an assessment was done when the physician allowed the resident to smoke. The MSW stated it is important to conduct a smoking risk assessment to determine if Resident 41 is able to smoke safely without supervision. During an interview on 4/13/2023 at 10:04 a.m., the DLTC stated that the facility does not do a smoking risk assessment. The DLTC stated that during the pre-admission care plan meeting with the resident and/or representative the facility will just initiate a care plan and obtain an order from the physician allowing a resident to smoke without supervision. The DLTC stated there was no documented evidence that a smoking risk assessment was done for Resident 41. The DLTC stated that the physician's order indicated to assist resident with lighter use, supervise as needed, and use of protective apron while smoking. The DLTC stated conducting a smoking risk assessment for Resident 41 ensures the safety of the resident. The DLTC stated Resident 41 should have been wearing the protective apron while smoking because it placed the resident at risk for accidents and injuries such as burns. A review of the facility's policy and procedure titled, Smoking, last reviewed on 3/3/2023 indicated smoking is permitted in designated areas and residents will be transported to these areas and observed by nursing staff according to a physician's orders. 055034 Page 20 of 25 055034 04/14/2023 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

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 discard expired needles and syringes (small hollow tube used for injecting or withdrawing liquids) stored in the medication storage room. The deficient practice had the potential for nursing staff using needles and syringes on residents that may no longer be sterile. Findings: During an observation and interview on [DATE], at 9:06 a.m., with the Director of Pharmacy (DP), observed an expired, unopened 24 gauge needles with expiration date of 11/2020 and 20 milliliter (ml, a unit of volume) syringes with expiration date of 11/2017, in a bin in the medication storage room. The DP stated she will dispose of the expired supplies to prevent accidental usage that may cause infection. During an interview on [DATE], at 2:07 p.m., with the Director of Long-Term Care (DLTC), the DLTC stated the expired supplies should not be used because it can cause infection. A review of the facility's policy and procedure titled Shelf Life of Sterile Supplies, last reviewed on [DATE], indicated the purpose of the facility policy was to establish the period of time or circumstances when sterile items stocked on shelves, cabinets or in drawers are to be considered sterile and safe for use on a sterile procedure. Sterility is considered event related. Items packaged by the manufacturer are considered sterile as indicated, with the expiration date established by the manufacturer. NOTE: If there is no expiration date, the package is sterile indefinitely as long as the integrity is maintained in accordance with the event related sterility. 055034 Page 21 of 25 055034 04/14/2023 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store food in a sanitary manner by failing to ensure food items were not expired. Residents Affected - Some These deficient practices had the potential to result in foodborne illnesses (also called food poisoning, illness caused by eating contaminated food) for residents living in the facility. Findings: During a concurrent initial kitchen tour observation and interview on 4/10/2023 at 8:38 a.m. with the Director Hospitality (DH) and the Facility Chef (FC), observed the following: 1. A package of strawberries with grayish white fluff. 2. Two (2) cases of graham cracker crumb a total of four (4) bags that had an expiration date of November 28, 2022. 3. Frozen food with use by of 3/23/2023 stored in the freezer. 4. Prepared food with use by date of 3/11/2023 stored in the freezer. The DH and the FC verbally acknowledged the items were expired and stated it should have been discarded. The DH stated expired items have the potential to cause residents to get sick when ingested. During an interview on 4/11/2023 at 12:53 p.m. with the Dietary Supervisor (DS), the DS stated expired food should be thrown away; produce strawberries that were visibly moldy can spread mold and contaminate other food items. The DS stated contaminated food poses a risk for major respiratory issues and stomach issues for residents when ingested. A review of the facility's policy and procedures titled, Food and Supply Storage, last revised on 1/2023 indicated all food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Policy further indicated the word sell by date is the last date that food can be sold or consumed; do not sell products in retail areas or place on patient tray/resident plates past the date on the product, foods past the use by, sell by, best-by, or enjoy by date should be discarded. 055034 Page 22 of 25 055034 04/14/2023 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program by: Residents Affected - Some 1. Failing to ensure Food Service Worker (FSW 1) and FSW 2 washed their hands before donning and after removal of gloves 2. Failing to ensure the Transportation Coordinator (TC) observe hand hygiene and change gloves between residents during meal tray pass. 3. Failing to ensure CNA 1 provide hand hygiene to one out of six sampled residents (Resident 75) prior to meals. These deficient practices had the potential to result in contamination of residents' food through cross contamination (bacteria or other microorganisms are unintentionally transferred from one substance or object to another with harmful effect). Findings: 1.a. During an observation of the tray line service on 4/10/2023 at 11:17 a.m. observed Food Service Worker (FSW 1) wearing gloves while serving the trays. FSW 1 was observed removing gloves and applying new gloves, without washing his hands. observation of hand hygiene; washing hands and or using antibacterial hand rub (ABHR) in between glove change. During an interview on 4/10/2023 at 11:58 a.m. with FSW 1, FSW stated he should have washed his hands in between glove changes for infection control. During an interview on 4/10/2023 at 12:19 p.m. with the Dietary Supervisor, the (DS) stated staff should be washing hands in between glove changes because of a risk of spreading infection. During an interview on 4/13/2023 at 11:16 a.m. with the Infection Control Coordinator (ICC), the ICC stated kitchen staff should be washing their hands in between glove changes to prevent cross contamination. During an interview on 4/13/2023 at 2:33 p.m. with the Director of Long-Term Care (DLTC), the DLTC stated kitchen staff should be removing gloves before leaving the kitchen and wash their hands before and after glove changes. The DLTC also stated when staff are passing out trays, they do not need to be wearing gloves but if do, they need to change gloves and observe hand hygiene after exiting the resident room. The DLTC stated hand hygiene and changing gloves should be observed in order to prevent cross contamination. A review of the facilities policy and procedures titled Infection Control Manual, last reviewed on 3/3/2023 indicated gloves must be changed between task and procedures on the same patient/resident, and after contact with contaminated material. The policy further indicated gloves must be removed promptly after use and hand hygiene completed before touching ono-contaminated surfaces/items and before contact with another patient/resident. 055034 Page 23 of 25 055034 04/14/2023 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1.b During an observation of the tray line service on 4/10/2023 at 12:15 p.m. observed Food Service Worker (FSW 2) wearing gloves. FSW 2 observed leaving tray line wearing gloves and exited kitchen, FSW 2 reentered kitchen shortly wearing gloves and went back on tray line. FSW 2 was not observed removing gloves and washing his hands before and after removal of gloves. During an interview on 4/10/2023 at 11:48 a.m. with FSW 2 stated he did not remove gloves when he left the kitchen, nor did he change them when he reentered the kitchen. FSW 2 stated he should have taken off his gloves before exiting the kitchen and washed his hands. FSW 2 also stated he should have washed his before applying new gloves and before returning to the tray line. FSW 2 stated not changing gloves and washing his hands is an infection control issue. During an interview on 4/10/2023 at 12:19 p.m. with the Dietary Supervisor (DS) stated the kitchen staff should have removed his gloves and washed hands before exiting the kitchen because of the risk for cross contamination. During an interview on 4/13/2023 at 11:16 a.m. with the Infection Control Coordinator (ICC), the ICC stated kitchen staff should be removing gloves when leaving the kitchen and washing hands in between glove changes to prevent food borne illness in the facility. During an interview on 4/13/2023 at 2:33 p.m. with the Director of Long-Term Care (DLTC), the DLTC stated kitchen staff should be removing gloves before leaving the kitchen and wash their hands before and after glove changes. The DLTC also stated when staff are passing out trays, they do not need to be wearing gloves but if do, they need to change gloves and observe hand hygiene after exiting the resident room. The DLTC stated hand hygiene and changing gloves should be observed in order to prevent cross contamination. A review of the facilities policy and procedures titled Infection Control Manual, last reviewed on 3/3/2023 indicated gloves must be changed between task and procedures on the same patient/resident, and after contact with contaminated material. The policy further indicated gloves must be removed promptly after use and hand hygiene completed before touching ono-contaminated surfaces/items and before contact with another patient/resident. 2. During a dining observation on 4/11/2023 at 8:30 a.m. observed Transportation Coordinator (TC) wearing gloves while passing out breakfast trays. TC was observed wearing gloves while removing tray from meal cart and taking it to room [ROOM NUMBER]. TC was observed wearing gloves coming out of room [ROOM NUMBER], went back into the meal cart, removed another tray and entered room [ROOM NUMBER]. TC was not observed removing gloves and washing hands between residents while passing out food trays. During an interview on 4/11/2023 at 8:47 a.m. with the TC, the TC stated she did not change gloves between residents during tray pass. The TC stated she should have changed gloves between each resident and performed hand hygiene because of the risk for infection During an interview on 4/13/2023 at 11:16 a.m. with the Infection Control Coordinator (ICC), the ICC stated during food tray pass, staff should be changing gloves and washing hands between each resident because of the risk for cross contamination. During an interview on 4/13/2023 at 2:33 p.m. with the Director of Long-Term Care (DLTC), the DLTC stated kitchen staff should be removing gloves before leaving the kitchen and wash their hands 055034 Page 24 of 25 055034 04/14/2023 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some before and after glove changes. The DLTC also stated when staff are passing out trays, they do not need to be wearing gloves but if do, they need to change gloves and observe hand hygiene after exiting the resident room. The DLTC stated hand hygiene and changing gloves should be observed in order to prevent cross contamination. A review of the facilities policy and procedures titled Infection Control Manual, last reviewed on 3/3/2023 indicated gloves must be changed between task and procedures on the same patient/resident, and after contact with contaminated material. The policy further indicated gloves must be removed promptly after use and hand hygiene completed before touching ono-contaminated surfaces/items and before contact with another patient/resident. 3. A review of Resident 75's Face Sheet indicated the facility admitted the resident on 11/1/2022, with diagnoses including Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and type 2 diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, is too high). A review of Resident 75's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/10/2023, indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident had impaired vision and had severe cognitive impairment. The MDS further indicated the resident needed supervision in eating. A review of Resident 75' Care Plan, initiated on 3/22/2023, indicated a care plan for nutrition and hydration, with an intervention for staff to assist at mealtime and between meals with food and fluids as needed. During a concurrent observation and interview on 4/11/2023, at 12 p.m., observed Certified Nursing Assistant 1 (CNA 1) served lunch tray to Resident 75 without asking the resident to perform hand hygiene with either alcohol-based hand rub (ABHR, an alcohol-containing preparation [liquid, gel, or foam] designed for application to the hands to inactivate microorganisms and/or temporarily suppress their growth) or antiseptic (a chemical used for preventing infection) wipes prior to serving the lunch tray. CNA 1 stated that she should have offered an alcohol-based hand rub or antiseptic wipes to the resident prior to serving the food and letting the resident eat because she does not know whether the resident had just gone to the bathroom or touched dirty surfaces in the facility that could cause infection to the resident. During an interview on 4/13/2023, at 2:10 p.m., with the Director of Long-Term Care (DLTC), the DLTC stated the staff should have offered the ABHR/antiseptic wipes before letting the residents eat due to potential for infection that can cause food borne illnesses. During an interview on 4/13/2023, at 3:10 p.m., with the Infection Control Coordinator (ICC), the ICC stated the staff should have offered the hand sanitizer or wipes to the resident before serving the lunch tray to prevent food borne infection. 055034 Page 25 of 25