Health inspection·April 4, 2024

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 provide care in a manner that maintained or enhance a resident's dignity and respect in full recognition of their individuality during one (Resident 11) of one random observation by failing to ensure the resident's urinary catheter drainage bag (a bag designed to urine drained from the bladder via a catheter) was covered with a privacy bag. This deficient practice had the potential to affect the residents' sense of self-worth and self-esteem. Findings: A review of Resident 11's Face Sheet indicated the facility admitted the resident on 2/14/2024 with diagnoses including neuromuscular dysfunction of bladder (refers to a number of urinary conditions in people who lack bladder control due to a brain, spinal cord or nerve problem), spinal stenosis (narrowing of the spinal column that causes pressure on the spinal cord, and benign prostatic hyperplasia (BPH - a condition in which the prostate gland becomes very enlarged and may cause problems associated with urination). A review of Resident 11's History and Physical (H&P) dated 3/27/2024, indicated the resident was able to make his needs known but did not indicate the capacity to make decisions. A review of Resident 11's Minimum Data Set (MDS - an assessment and care screening tool) dated 10/5/2023, indicated the resident had severely impaired cognition ((mental action or process of acquiring knowledge and understanding) and required supervision or touching assistance with eating; partial or moderate assistance with oral hygiene and roll left and right; substantial or maximal assistance with upper body dressing, personal hygiene sit to lying and lying to sitting o side of bed; dependent with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 11's Physician's Orders indicated the following orders on 12/18/2023. Foley catheter daily as needed. Indwelling foley catheter 18FR- 10 ml to gravity drainage. May replace as needed plugged or bypassing. Page 1 of 70 055034 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0550 Foley catheter every eight hours. Foley catheter care every shift. No intake and output monitoring needed. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 4/1/2024 at 11:30 a.m. in Resident 11's room with Licensed Vocational Nurse 2, (LVN 2) verified the resident's urinary catheter drainage bag was visible from the doorway and did not have a privacy cover. LVN 2 stated the drainage bag should have a privacy cover per facility policy to preserve the resident's dignity and self-worth. Residents Affected - Few During an interview on 4/4/2024 at 1:10 p.m., with the Director of Nursing (DON), the DON stated urinary catheter drainage bags should have privacy covers especially when facing the door to preserve the resident's dignity and self-worth. A review of the facility's policy and procedure titled, Catheter Care, last reviewed 2/3023, indicated all foley catheter drainage bags smut have a dignity bag to ensure privacy for the patient. 055034 Page 2 of 70 055034 04/04/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. A review of Resident 12's Face Sheet (admission Record) indicated the facility admitted the resident on 6/30/2021 with diagnoses that included hemiplegia (total or partial paralysis [unable to make voluntary muscle movements] of one side of the body and hemiparesis (one-sided muscle weakness following cerebral infarction (stroke, when blood flow to the brain is blocked or there is sudden bleeding in the brain), and morbid obesity (body weight that is higher than what is considered healthy for a given height). Residents Affected - Some A review of Resident 12's History and Physical, dated 1/22/2024, indicated the resident's speech was coherent and fluent and the resident was alert and oriented. A review of Resident 12's Minimum Data Set (MDS - an assessment and care screening tool) dated 3/19/2024, indicated the resident's most recent admission was on 3/3/2023 and had the ability to understand others and make herself understood. The MDS further indicated the resident had impairment of one upper extremity and both lower extremities that interfered with daily functions or placed the resident at risk of injury. The MDS indicated the resident was dependent on staff for toileting, bathing, dressing, rolling left and right, and transferring from the bed to chair. A review Resident 12s's Care Plan (CP) titled, Medical Conditions: related to Chronic stoke with Left side hemiplegia; vascular dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life caused by brain damage from impaired blood flow to the brain); .functional dependence, dated 6/30/2021, indicated the resident wanted to be free from complications or problems with medical conditions daily. A review Resident 12s's Care CP titled, Falls/Activities of Daily Living (ADLs)/Incontinence .: related to needs assistance with ADLs .needs assistance with toileting .at risk for fall due to impaired balance and mobility, dated 6/30/2021, indicated an intervention to keep the call light within easy reach of the resident at all times. During a concurrent observation and interview on 4/2/2024 at 10:28 a.m., observed Resident 12 in bed. Observed the call light cord extending from the wall to the left side rail of the bed. The call light was tied to the left upper side rail and dangling on the outside of the bed toward the floor. Resident 12 stated she couldn't use her left arm and she couldn't reach the call light. Resident 12 stated she could use the cell phone to call staff. During an observation and interview on 4/2/2024 at 10:35 a.m. with Certified Nursing Assistant 7 (CNA 7), CNA 7 stood outside Resident 12's room and stated the resident could not move her left arm and everything should be placed on the Resident's right side. CNA 7 stated Resident 12 had a cell phone, but the call light should still be placed on the resident's right side in case the cell phone fell, or the resident was not able to use it. CNA 7 entered Resident 12's room and stated the call light was on the left side rail and out of reach of the resident. CNA 7 stated the call light should have been placed on the other side of the resident. Observed CNA 7 remove the call light from the left side rail and placed on the right side of the bed. During an interview and record review on 4/3/2024 at 3:44 p.m. with the Director of Nursing (DON), reviewed the facility policy and procedure regarding call lights. The DON stated the call should be accessible. The DON stated the call light placed on Resident 12's left side would be hard to reach, and the right side would be better. The DON stated the call light should have been placed on 055034 Page 3 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 12's right side and within reach of the resident. The DON stated it was important to have the call light available in case the resident's cell phone did not work. The DON stated the policy was not followed because Resident 12's call light was not within reach. A review of the facility policy and procedure titled, Call Light, last reviewed 4/2023, indicated the purpose of the policy was to alert nursing that patient has a request or need and to ensure patient access to the call light at all times. The procedure indicated ensure the call light was within reach of the patient. Based on observation, interview, and record review the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach of the resident for four out of five sampled residents (Residents 77, 56, 70 and 13) investigated during review of environment facility task. These deficient practices had the potential for delaying care and services requested by the residents and placing the residents at risk for falls and injuries. Findings: 1. A review of Resident 77's Face Sheet indicated the facility admitted the resident on 12/14/2023, with diagnoses of nontraumatic (not caused by trauma) subdural hemorrhage (a type of bleeding near your brain), seizures (a sudden, uncontrolled burst of electrical activity in the brain), and dementia (the loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 77's History and Physical (H&P), dated 12/14/2023, indicated the resident was alert and oriented to person and place. The H&P indicated the resident had major neurocognitive disorder (decreased mental function due to a medical disease other than a psychiatric illness) with functional dependency and need for protective environment. A review of Resident 77's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/15/2024, indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident was dependent on oral hygiene, toileting, showering/bathing self, lower body dressing, putting on/taking off footwear, and personal hygiene. A review of Resident 77's Fall Risk Evaluation, dated 3/15/2024, indicated the resident was high risk for falls. A review of Resident 77's Care Plan titled, Alteration in safety/safety awareness related to dementia as evidenced by low energy, requiring max assist with ambulation and meals, initiated on 2/27/2024, indicated an intervention to explain and reinforce safety measures (i.e., call light within reach, bed in low position, patient items within reach, skid proof footwear, etc. Responsible discipline: Nurse. During a concurrent observation and interview on 4/2/2024, at 11:25 a.m., with Certified Nursing Assistant/Restorative Nursing Aide 1 (CNA/RNA 1), in Resident 77's room, observed Resident 77's call light on top of the bed, while the resident was sitting on a chair away from the bed. CNA/RNA 1 stated the call light was not within the reach of the resident. CNA/RNA 1 stated the call light should be within reach of the resident so the resident can call for help and to prevent falls. 055034 Page 4 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. A review of Resident 56's Face Sheet indicated the facility admitted the resident on 12/6/2023, with diagnoses including Alzheimer's disease (a brain disorder that slowly destroys memory and thinking and, eventually, the ability to carry out the simplest task), dementia, and glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of the eye called the optic nerve). A review of Resident 56's H&P, dated 12/6/2023, indicated the resident was alert and oriented to self, unaware of his situation, and has severe word finding difficulties. A review of Resident 56's MDS, dated [DATE], indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident required substantial to maximal assistance on toileting hygiene, showering/bathing self, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. A review of Resident 56's Fall Risk Evaluation, dated 3/8/2024, indicated the resident was high risk for falls. A review of Resident 56's Care Plan titled, Cognitive/Communication/Vision/Falls/ activities of daily living (ADL's)/Incontinence (inability to control the flow of urine from the bladder)/Skin Integrity as evidenced by hard of hearing ., initiated on 12/6/2023, indicated an intervention of high fall risk: call light in reach, red identification arm band/tag, remote monitoring devices on bed and chair, non-skid socks/shoes, maintain bed at appropriate height, and keep personal items within reach. During a concurrent observation and interview on 4/2/2024, at 9:50 a.m., with Certified Nursing Assistant 2 (CNA 2), in Resident 56's room, observed Resident 56's call light on top of the bed, while the resident was sitting on a chair away from the bed. CNA 2 stated the call light was not within the reach of the resident. CNA 2 stated the call light should be within reach of the resident so the resident can call for help and to prevent falls. 3. A review of Resident 70's Face Sheet indicated the facility admitted the resident on 12/30/2022, with diagnoses including Alzheimer's disease, abnormalities of gait (a manner of walking or moving on foot) and mobility, and dementia. A review of Resident 70's H&P, dated 12/27/2023, indicated the resident was awake and alert, speech was mostly coherent, but non-fluent at times. A review of Resident 70's MDS, dated [DATE], indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident had moderately impaired vision. The MDS also indicated the resident required partial to moderate assistance on oral hygiene, toileting, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. A review of Resident 70's Fall Risk Evaluation, dated 3/22/2024, indicated the resident was high risk for falls. A review of Resident 70' Care Plan titled, Cognitive/Falls/ADL/Incontinence/ skin integrity related to resident forgetfulness, confusion ., with a target date of 6/30/2024, indicated an intervention of high fall risk: call light in reach, red identification arm band/tag, remote monitoring devices on bed and chair, non-skid socks/shoes, maintain bed at appropriate height, and keep personal items 055034 Page 5 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0558 within reach. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 4/2/2024, at 9:33 a.m., with Certified Nursing Assistant 3 (CNA 3), inside Resident 70's bed, observed Resident 70's call light clipped on a folded blanket at the foot of the bed away from the resident. CNA 3 stated the resident will not be able to reach the call light because it was not within the resident's reach. CNA 3 stated not having the call light within reach could result in the resident not being able to call for help and placed the resident at risk for falling while reaching for the call light. Residents Affected - Some During an interview on 4/4/2024, at 1:30 p.m., with the Director of Nursing (DON), the DON stated it was important to keep the call light within reach to enable the resident to call for help when needed. The DON stated the resident could fall while reaching for the call light. A review of the facility's recent policy and procedure titled, Call light, last reviewed on 4/2023, indicated the purpose of the call light was to alert nursing staff that patient has a request or need. To ensure patient access to call light at all times. Ensure call light is within reach of patient. If patient is ambulatory or mobile in a wheelchair; ensure that there is easy access to the call light. A review of the facility's recent policy and procedure titled, Falls, last reviewed on 3/2023, indicated under general safety interventions to place call light and frequently needed objects within reach. A review of the facility's recent policy and procedure titled, LTC Standard of Care Nursing Protocol, last reviewed on 2/2023, indicated initiate safety measures as indicated: 4. Call bell within reach. 055034 Page 6 of 70 055034 04/04/2024 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 provide the resident and the resident's representative information regarding formulating an advance directive for one of one sampled resident investigated during review of advance directive care area (Resident 38). This deficient practice had the potential for Resident 83 and their responsible person to not be informed of their right to formulate an advance directive and not honor the resident's wishes regarding end-of-life care. Findings: A review of Resident 83's Face Sheet (admission Record) indicated the facility admitted Resident 83 on 6/28/2023. A review of Resident 83's Patient Diagnosis Information, dated 6/28/2023, indicated Resident 83's diagnoses included, but were not limited to, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). A review of Resident 83's History and Physical (H&P), dated 6/29/2023, indicated Resident 83 was awake, alert, and unable to engage in conversation. A review of Resident 83's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/2/2024, indicated Resident 83 had severe cognitive impairment (when a person has problems remembering things and solving problems) and required maximal assistance or was dependent on staff for activities of daily living, such as eating, hygiene, and surface to surface transfers. During a concurrent interview and record review with the Director of Social Services (DSS), on 4/4/2024, at 8:35 a.m., Resident 83's medical record was reviewed and the DSS confirmed that Resident 83's medical record did not contain documentation on whether Resident 83 or Resident 83's representative were asked if the resident had an advance directive or if they were provided information regarding the creation of an advance directive. The DSS stated Resident 83 was non-verbal, not able to make her own decisions, and the responsible person was her husband. The DSS stated upon admission, residents are asked if they have an advance healthcare directive, and a copy is requested if the resident has one. The DSS stated residents and their responsible persons are educated on what an advance healthcare directive is and how to create an advance directive if the resident does not have an advance directive. The DSS stated it is important to provide residents and their responsible persons information regarding advance directives and determine if a resident has an advance directive so that the resident's wishes are carried out. The DSS further stated if residents or their representatives are not provided with information regarding the creation of an advance directive, the facility would not know how to treat residents during end-of-life care. A review of the facility's policy and procedure (P&P) titled, Advance Directives, last reviewed 10/18/2023, indicated upon admission to the facility, the admitting registrar shall give each adult patient or appropriate responsible party a copy of the Department of Health Services pamphlet: Your Right to Make Decisions about Medical Treatment and will inquire of each adult patient or responsible party regarding the existence of previously executed advance directives and/or the desire to execute a new advance directive. The P&P further indicated the existence, amendment, or revocation of an 055034 Page 7 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0578 advance directive (oral or written) is documented in the resident's medical record and social services shall be responsible for documenting on long term care residents. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055034 Page 8 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. 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 ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the patient ' s body that he or she cannot easily remove that restricts freedom of movement or normal access to one ' s body) for four of four sampled residents (Residents 8, 77, 56, and 70) investigated during review of use of restraints by failing to: Residents Affected - Some 1. Ensure side rails (SR, adjustable rigid plastic bars attached to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) were not used without assessing for the need, assessing for risk for entrapment (occurs when a resident is caught between the mattress and bed rail or within the bed rail itself), obtaining informed consent (process in which residents or resident representatives are given important information, including possible risks and benefits, about a procedure or treatment) prior to use, and obtaining an order from the physician for Residents 8, 77, and 70. 2. Ensure the bed was not pushed up against the walls without assessing the need for use, assessing for risk for entrapment prior to use, obtaining informed consent prior to use, and obtaining an order from the physician for Residents 8, 77, 56, and 70. 3. Ensure chair alarms (alerts care givers when a resident leaves their chair or wheelchair) were not used without assessing the need for, obtaining an order from the physician, and obtaining informed consent for Residents 77 and 56. These deficient practices had the potential to result in the restriction of residents ' freedom of movement, a decline in physical functioning, psychosocial harm, physical harm from entrapment, and death of residents. Cross reference to F656 and F700. Findings: 1. A review of Resident 8 ' s Face Sheet (admission Record) indicated the facility admitted the resident on 6/11/2020 with diagnoses that included Alzheimer ' s disease (a type of dementia [a general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life]) with late onset, anxiety disorder (a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear), and abnormalities of gait and mobility. A review of Resident 8 ' s History and Physical (H&P), dated 5/26/2023, indicated the resident had dementia with behavioral disturbances and was unable to follow commands. The H&P indicated the resident had a history of falls resulting in a fractured hip. A review of Resident 8 ' s Minimum Data Set (MDS - an assessment and care screening tool) dated 2/6/2024, indicated the facility most recently readmitted the resident on 5/19/2021 and the resident sometimes was able to understand others and sometimes was able to make herself understood. The MDS 055034 Page 9 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some further indicated the resident was dependent on staff for eating, toileting, bathing, dressing, personal hygiene, and mobility. The MDS indicated the resident did not use SRs as a physical restraint. A review Resident 8 ' s Care Plan (CP) titled, Cognitive / Communication / vision / Falls . related to (Resident 8) has forgetfulness, confusion related to Alzheimer dementia, hard of hearing, impaired vision ., dated 6/11/2020, indicated the resident wanted to be safe, reduce risk for falls and injury and to remain safely in the facility. The CP further indicated an intervention that if the resident was noted as restless and trying to get out of bed, to assist her to the wheelchair and sit her across from the nursing station. During an observation on 4/2/2024 at 11:05 a.m., observed Resident 8 in bed with eyes closed and did not verbally respond to the surveyor. Observed the resident ' s bed with bilateral SRs in raised position and the left side of the bed was placed against a built-in dresser wall cabinet with no access for bed exit on the left side. During a concurrent observation and interview on 4/2/2024 at 11:18 a.m. with Certified Nursing Assistant 6 (CNA 6), observed Resident 8 in bed. CNA 6 stated the Resident had fallen in the past and can move. CNA 6 stated the bed against the dresser and raised upper side rails were used for fall prevention and the resident was safer with the bed against the dresser. During an interview on 4/2/2024 at 11:27 a.m. with Licensed Vocation Nurse 5 (LVN 5), LVN 5 stated the facility does not require a physician ' s order for the use of SRs and Resident 8 did not have an order for SRs. During an interview with Family Member 1 (FM 1) on 4/2/2024 at 2:10 p.m., FM 1 stated Resident 8 has advanced dementia and bruises easily. FM 1 stated Resident 8 is not mobile, but she can slip out of the bed and the facility has found her on the floor. FM 1 stated she was aware that SRs and bed positioning were used to keep Resident 8 in the bed and off the floor, but she does not remember anyone ever discussing the risks of using them. During an interview and record review on 4/3/2024 at 8 a.m. with the Director of Nursing (DON), reviewed the policy and procedure regarding resident rights. The DON stated the facility uses bilateral upper SRs that are connected to the bed. The DON stated the process for using SRs is the Interdisciplinary Team (IDT) decides to use two SRs if the resident is assessed and able to use them and that the SRs do not restrict movement. The DON stated if the resident was not assessed then the SRs should not be up. The DON stated the possible adverse effects of using SRs was restriction of movement and entrapment. The DON stated there was no documentation indicating there was an assessment of Resident 8 for use of SRs. The DON stated there was no documentation indicating an assessment for risk of entrapment for Resident 8 prior to using SRs. The DON stated informed consent is usually obtained by the physician from the resident or resident representative when consent is needed for a treatment. The DON stated there was no documentation indicating informed consent was received prior to using the SRs. The DON stated Resident 8 was a high risk for fall and the bed was against the dresser for fall prevention. The DON stated there was no documentation indicating an assessment was done prior to moving the bed against the dresser. The DON stated there was no documentation indicating informed consent was obtained prior to moving Resident 8 ' s bed against the dresser. The DON stated the policy indicated residents had a right to be free from restraints. The DON stated the definition of a restraint 055034 Page 10 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some is anything that restricts resident movement. The DON stated placing the bed against the wall with SRs raised restricts the resident from exiting the bed on the left side and the resident cannot remove the restrictions themselves. The DON stated the risk of placing the bed against the dresser was it restricted removement and could possibly cause a decline in resident ' s movement abilities. The DON stated she could not think of any other possible risk of placing the bed against the wall. The DON stated the facility did not have a policy regarding the use of SRs or restraints because they are a restraint free facility. The DON stated the importance of policies was that they guide the facility to do what is supposed to be done based on the standard of care. During an interview on 4/4/2024 at 8:10 a.m. with the Administrator (ADM), the ADM stated they were now aware of the regulations regarding SRs used in the facility. The ADM stated they now have clarity on the regulation and there should be a specific policy for restraints, and they do not have one. The ADM stated it was her responsibility to ensure policies were in place and the SR policy should include an assessment for SR usage and informed consent for any SRs used in the facility. The ADM Stated they will be developing a policy based on the standards of practice. During a follow up interview on 4/4/2024 at 8:15 a.m. with the DON, the DON stated her previous understanding was that SRs were only considered a restraint when four side rails were up. The DON stated now she was aware that all siderail use should be assessed for risk of injury such as entrapment and consent should be obtained from the resident or resident representative. The DON stated without assessments and consents the resident is also at risk for injury due to entrapment. The DON stated it was important to ensure resident safety, ensure the family is aware, and to respect the resident ' s rights as well. The DON stated Resident 8 ' s family was not informed of the risks of placing the bed against the dresser. The DON stated when the bed was placed against the dresser there was a risk for restriction in mobility and there was a risk for entrapment by the side rail and being squeezed against the wall. The DON stated when residents become entrapped it could possibly lead to fractures, wounds, and skin tears. The DON stated residents have a right to be free from restraints and the bed against the wall was a restraint. The DON stated restraints can only be used if less restrictive methods are attempted, there is an assessment for risk of entrapment, and the risks and benefits are discussed with informed consent obtained. The DON stated Resident 8 did not have any of those completed prior to placing the bed against the wall with the SRs up. A review of the facility provided HB 1 Instructions for Use Service [NAME], dated 2011, indicated to avoid personal injury read all sections pertaining to the bed model before use. Rails are not meant for patients considered as high risk for entrapment (i.e., patients with pre-existing conditions such as confusion, restlessness, lack of muscle control, altered mental status). Additional safety measures should be considered for such high-risk patients. A review of the facility provided policy and procedure titled, Patient Rights and Responsibilities, last reviewed 3/2023, indicated the patient has the right to be free from restraints and seclusion of any form used as a means of convenience. 2. a. A review of Resident 77 ' s Face Sheet indicated the facility admitted the resident on 12/14/2023, with diagnoses including dementia, nontraumatic (not caused by trauma) subdural hemorrhage (a collection of blood between the covering of the brain and the surface of the brain), and seizures (a sudden, uncontrolled burst of electrical activity in the brain). A review of Resident 77 ' s History and Physical (H&P), dated 12/14/2023, indicated the resident was alert and oriented to person and place, with major neurocognitive disorder (decreased mental 055034 Page 11 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some function due to a medical disease other than psychiatric illness) with functional dependency and need for protective environment. A review of Resident 77 ' s MDS, dated [DATE], indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident was dependent on sitting on side of the bed to lying flat on the bed, move from lying on the back to sitting on the side of the bed, come to a standing position from sitting in a chair, wheelchair, or on the side of the bed, transfer to and from a bed to a chair, and to get in and out of a tub/shower. The MDS also indicated the resident had a bed alarm (warns caregivers when patients leave or attempt to leave their beds). A review of Resident 77 ' s Fall Risk Evaluation, dated 3/15/2024, indicated the resident was high risk for falls. A review of Resident 77 ' s Physician ' s Order did not indicate any order for restraint usage. A review of Resident 77 ' s Care Plans did not indicate any plan of care on the safe use of restraint. During an observation and interview on 4/2/2024, at 11:25 a.m., with Certified Nursing Assistant/Restorative Nursing Aide 1 (CNA/RNA 1), in Resident 77 ' s room, observed the resident ' s bed pushed against the wall, with both upper side rails up, and a chair alarm (warn caregivers, and in some cases patients themselves, when a patient leaves or attempts to leave the chair) in place on the resident ' s chair. CNA/RNA 1 stated the bed was pushed against the wall to give space for a transfer aid equipment (a non-powered device that ensures residents can be positioned from sit-to-stand transfers safely, quickly and with ease). CNA/RNA 1 stated the upper side rails of the resident were up and the resident had a chair alarm because the resident was at risk for fall. During an interview and record review on 4/2/2024, at 12 p.m., with Nursing Supervisor 1 (NS 1), reviewed Resident 77 ' s Physician ' s Order and care plans. NS 1 stated the resident does not have orders for restraints. NS 1 stated the bed was pushed against the wall with both upper side rails up and the resident ' s chair has an alarm to prevent falls. NS 1 stated placing the bed against the wall and using side rails and chair alarms are considered nursing interventions and do not require a physician ' s order. 3.b.A review of Resident 56 ' s Face Sheet indicated the facility admitted the resident on 12/6/2023, with diagnoses including Alzheimer ' s disease, dementia, and glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of the eye). A review of Resident 56 ' s H&P, dated 12/6/2023, indicated the resident was alert and oriented to self, unaware of his situation, with severe word finding difficulties. A review of Resident 56 ' s MDS, dated [DATE], indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident required substantial to maximal assistance to roll from lying on back to left and right side, and return to lying on back on the bed, to a standing position from sitting in a chair, wheelchair, or on the side of the bed, transfer to and from a bed to a chair, and to get on and off a toilet or commode. The MDS also indicated the resident had bed and chair alarm (warns caregivers when patients leave or attempt to leave their chairs). 055034 Page 12 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0604 A review of Resident 56 ' s Fall Risk Evaluation, dated 3/8/2024, indicated the resident was high risk for falls. Level of Harm - Minimal harm or potential for actual harm A review of Resident 56 ' s Physician ' s Order did not indicate orders for use of restraints. Residents Affected - Some A review of Resident 56 ' s Care Plans did not indicate a care plan for use of restraints was developed. During an observation and interview on 4/2/2024, at 11:49 a.m., with Nursing Supervisor 1 (NS 1), in Resident 56 ' s room, observed Resident 56 ' s bed pushed against the wall and the resident ' s chair with an alarm in place. NS 1 stated the bed was pushed against the wall and the resident ' s chair has an alarm because the resident was high risk for falls. NS 1 stated placing the bed against the wall and using a chair alarm are considered nursing interventions and do not require a physician ' s order. 3.c. A review of Resident 70 ' s Face Sheet indicated the facility admitted the resident on 12/30/2022, with diagnoses including Alzheimer ' s disease, dementia, and abnormalities of gait (a manner of walking or moving on foot) and mobility. A review of Resident 70 ' s H&P, dated 12/27/2023, indicated the resident was awake and alert, speech was mostly coherent, but non-fluent at times. A review of Resident 70 ' s MDS, dated [DATE], indicated the resident sometimes had the ability to make self-understood and understand others. The resident had moderately impaired vision. The MDS indicated the resident required supervision or touching assistance to roll from lying on back to left and right side, and return to lying back on the bed, move from sitting on side of bed to lying flat on the bed, move from lying on back to sitting on the side of the bed, come to a standing position from sitting in a chair, wheelchair, or on the side of the bed, transfer to and from a bed to a chair, get on and off a toilet or commode, and get in and out of tub/shower. The MDS indicated the resident had a bed alarm. A review of Resident 70 ' s Fall Risk Evaluation, dated 3/22/2024, indicated the resident was high risk for falls. A review of Resident 70 ' s Physician ' s Order did not indicate orders for use of restraints. A review of Resident 70 ' s Care Plans did not indicate a care plan for use of restraints was developed. During an observation and interview on 4/2/2024, at 9:33 a.m., with Certified Nursing Assistant 3 (CNA 3), in Resident 70 ' s room, observed Resident 70 ' s left side of the bed pushed against the wall, with both upper side rails up, and an overbed table placed on the right lower side of the bed. CNA 3 stated the resident ' s bed was pushed against the wall and the side rails were up so the resident can only get out on one side of the bed, preventing a fall. During an interview on 4/3/2024, at 7:54 a.m., with the DON, the DON stated she was not aware that side rails can used as restraints. The DON stated the resident should be assessed on the safe use of bed rails because of entrapment risk. The DON stated they pushed the resident ' s bed against the wall for fall prevention. The DON stated by pushing the bed against the wall, the resident will only 055034 Page 13 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some be getting on one side of the bed and lessen the chances of a fall. The DON stated they used the chair alarm on residents to alert staff if the resident was moving or trying to get out of the bed to prevent falls. The DON stated there was no informed consent obtained from the resident or the resident representative prior to placing the bed against the wall and prior to use of side rails and chair alarm. The DON stated they do not have a policy for restraints because the facility is a restraint free facility. The DON further stated placing the bed against the wall and using side rails and chair alarms are considered nursing interventions and do not require a physician ' s order. During an interview on 4/4/2024 at 8:10 a.m. with the Administrator (ADM), the ADM stated they were now aware of the regulations regarding SR use in the facility. The ADM stated they now have clarity on the regulation and there should be a specific policy for restraints, and they do not have one. The ADM stated it was her responsibility to ensure policies were in place and the SR policy should include an assessment for SR usage and informed consent for any SRs used in the facility. The ADM Stated they will be developing a policy based on the standards of practice. During a follow up interview on 4/4/2024 at 8:15 a.m. with the DON, the DON stated now she was aware that all siderail use should be assessed for risk of injury from entrapment and consent should be obtained from the resident or resident representative. The DON stated without assessments and consents the resident is at risk for injury due to entrapment. The DON stated when the bed was placed against the dresser there was a risk for restriction in mobility and there was a risk for entrapment by the side rail and being squeezed against the wall. The DON stated when residents become entrapped it could possibly lead to fractures, wounds, and skin tears. The DON stated it was important to ensure resident safety, ensure the family is aware, and to respect the resident ' s rights as well. The DON also stated chair alarms was considered a restraint as it restricts resident ' s mobility and should not be used for staff convenience. The DON stated the use of chair alarms requires a physician order, assessment of appropriate use, and a consent from the resident/resident representative. A review of the facility's recent policy and procedure titled, Patients/Residents Rights and Responsibilities, last reviewed on 1/10/2023, indicated you and/or surrogate decision maker have the right to: 14. Be free from restraints and seclusion of any form used as a means of coercion, discipline, convenience, or retaliation by staff. A review of the facility provided Hospital Bed 1 (HB 1) Instructions for Use Service Manual, dated 2011, indicated to avoid personal injury read all sections pertaining to the bed model before use. Rails are not meant for patients considered as high risk for entrapment (i.e., patients with pre-existing conditions such as confusion, restlessness, lack of muscle control, altered mental status). Additional safety measures should be considered for such high-risk patients. 055034 Page 14 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a comprehensive person-centered care plan (CP, a written course of action that helps a patient achieve outcomes that improve their quality of life) reflective of resident preferences and consistent with the resident rights to meet a resident's medical, nursing, mental, and psychosocial needs for four of four sampled residents (Residents 8, 77, 56, and 70) reviewed during investigation of restraint (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) use by failing to: 1. Develop and implement a CP for side rail (SR, adjustable rigid plastic bars attached to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) and placement of bed against a built-in dresser wall cabinet for Resident 8. 2. Develop and implement CPs for use of restraints for Residents 8, 77, 56, and 70. This deficient practice had the potential for residents to not receive the proper and necessary care regarding SRs and restraints with the potential to result in injury of the resident by failing to provide ongoing assessment, monitoring, and re-evaluation of SRs and restraints. Findings: a. A review of Resident 8's Face Sheet (admission Record) indicated the facility admitted the resident on 6/11/2020 with diagnoses that included Alzheimer's disease (a type of dementia [a general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life]) with late onset, anxiety disorder (a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear), and abnormalities of gait and mobility. A review of Resident 8's History and Physical (H&P), dated 5/26/2023, indicated the resident had dementia with behavioral disturbances and was unable to follow commands. The H&P indicated the resident had a history of falls resulting in a fractured hip. A review of Resident 8's Minimum Data Set (MDS - an assessment and care screening tool) dated 2/6/2024, indicated the facility most recently readmitted the resident on 5/19/2021 and the resident sometimes was able to understand others and sometimes was able to make herself understood. The MDS further indicated the resident was dependent on staff for eating, toileting, bathing, dressing, personal hygiene, and mobility. The MDS indicated the resident did not use SRs as a physical restraint. During an observation on 4/2/2024 at 11:05 a.m., observed Resident 8 in bed with eyes closed and did not verbally respond to the surveyor. Observed the resident's bed with bilateral SRs in raised position and the left side of the bed was placed against a built-in dresser wall cabinet with no access for bed exit on the left side. During an observation and interview on 4/2/2024 at 11:18 a.m. with Certified Nursing Assistant 6 (CNA 6), observed Resident 8 in bed. CNA 6 stated the resident had fallen in the past and can move. 055034 Page 15 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few CNA 6 stated the bed against the dresser and raised upper side rails were used for fall prevention and the resident was safer with the bed against the dresser. During an interview and record review on 4/3/2024 at 8 a.m. with the Director of Nursing (DON), the DON stated the definition of a restraint is anything that restricts resident movement. The DON stated placing the bed against the wall with SRs raised restricts the resident from exiting the bed on the left side and the resident cannot remove the restrictions themself. During a follow up interview on 4/4/2024 at 8:15 a.m. with the DON, the DON stated placing the resident bed against the wall was a restraint. During an interview and record review on 4/4/2024 at 11:12 a.m. with the Minimum Data Set Coordinator (MDSC), reviewed Resident 8's care plans. The MDSC stated there were no CPs for the use of SRs or placing the bed against the dresser. The MDSC stated there were no CPs for restraints. During an interview and record review on 4/4/2024 at 1:03 p.m. with the Director of Nursing (DON), reviewed the facility policy regarding CPs. The DON stated the comprehensive CP is an individualized plan of care based on a specific resident that identifies resident problems, goals, and interventions. The DON stated without a CP they are not able to meet the needs of the resident because problems are not identified with interventions in place to solve them. The DON stated there were no CPs for SRs, the bed against the dresser, or restraint usage. The DON stated without the CPs it could potentially lead to the resident not being assessed or monitored for the effectiveness of the SRs and bed against the dresser resulting in accidents and injury to the resident. The DON stated the facility policy was not followed because Resident 8 did not have the CPs. During a review of the facility policy and procedure titled, Care Plan- Resident, last reviewed 3/6/2020, indicated the purpose of the policy was to assure a coordinated and comprehensive written plan is developed based on the resident assessment and the individual needs and preferences of the resident. The CP will be person centered and reflect the preferences and needs of the resident. The CP will include the start date, goals, interventions, and target date for the next review. The comprehensive CP may include problems that are ongoing. A multi-disciplinary care plan meeting will update goals quarterly. 2 .a. A review of Resident 77's Face Sheet indicated the facility admitted the resident on 12/14/2023, with diagnoses including dementia, nontraumatic (not caused by trauma) subdural hemorrhage (a collection of blood between the covering of the brain and the surface of the brain), and seizures (a sudden, uncontrolled burst of electrical activity in the brain). A review of Resident 77's History and Physical (H&P), dated 12/14/2023, indicated the resident was alert and oriented to person and place, with major neurocognitive disorder (decreased mental function due to a medical disease other than psychiatric illness) with functional dependency and need for protective environment. A review of Resident 77's MDS, dated [DATE], indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident was dependent on sitting on side of the bed to lying flat on the bed, move from lying on the back to sitting on the side of the bed, come to a standing position from sitting in a chair, wheelchair, or on the side of the bed, transfer to and from a bed to a chair, and to get in and out of a tub/shower. The MDS also indicated the resident had a bed alarm (warns caregivers when patients leave or attempt to leave their beds). 055034 Page 16 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0656 A review of Resident 77's care plans did not indicate any plan of care on the safe use of restraints. Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 4/2/2024, at 11:25 a.m., with Certified Nursing Assistant/Restorative Nursing Aide 1 (CNA/RNA 1), in Resident 77's room, observed the resident's bed pushed against the wall, with both upper side rails up, and a chair alarm (warn caregivers, and in some cases patients themselves, when a patient leaves or attempts to leave the chair) in place on the resident's chair. CNA/RNA 1 stated the bed was pushed against the wall to give space for a transfer aid equipment (a non-powered device that ensures residents can be positioned from sit-to-stand transfers safely, quickly and with ease). CNA/RNA 1 stated the upper side rails of the resident were up and the resident had a chair alarm because the resident was at risk for fall. Residents Affected - Few safe Patient Handling Equipment 1 (SPH 1, is a non-powered device that ensures residents can be positioned from sit-to-stand transfers safely, quickly and with ease). 2.b.A review of Resident 56's Face Sheet indicated the facility admitted the resident on 12/6/2023, with diagnoses including Alzheimer's, dementia, and glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of the eye). A review of Resident 56's H&P, dated 12/6/2023, indicated the resident was alert and oriented to self, unaware of his situation, with severe word finding difficulties. A review of Resident 56's MDS, dated [DATE], indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident required substantial to maximal assistance to roll from lying on back to left and right side, and return to lying on back on the bed, to a standing position from sitting in a chair, wheelchair, or on the side of the bed, transfer to and from a bed to a chair, and to get on and off a toilet or commode. The MDS also indicated the resident had bed and chair alarm (warns caregivers when patients leave or attempt to leave their chair). A review of Resident 56's Care Plans did not indicate any plan of care on the safe use of restraints. During an observation and interview on 4/2/2024, at 11:49 a.m., with Nursing Supervisor 1 (NS 1), in Resident 56's room, observed Resident 56's bed pushed against the wall and the resident's chair with an alarm in place. NS 1 stated the bed was pushed against the wall and the resident's chair has an alarm because the resident was high risk for falls. NS 1 stated there was no care plan on the use of restraints because they consider pushing the resident's bed against the wall and using side rails and chair alarms as nursing interventions. 2.c.A review of Resident 70's Face Sheet indicated the facility admitted the resident on 12/30/2022, with diagnoses including Alzheimer's disease, dementia, and abnormalities of gait (a manner of walking or moving on foot) and mobility. A review of Resident 70's H&P, dated 12/27/2023, indicated the resident was awake and alert, speech was mostly coherent, but non-fluent at times. A review of Resident 70's MDS, dated [DATE], indicated the resident sometimes had the ability to make self-understood and understand others. The resident had moderately impaired vision. The MDS 055034 Page 17 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0656 Level of Harm - Minimal harm or potential for actual harm indicated the resident required supervision or touching assistance to roll from lying on back to left and right side, and return to lying back on the bed, move from sitting on side of bed to lying flat on the bed, move from lying on back to sitting on the side of the bed, come to a standing position from sitting in a chair, wheelchair, or on the side of the bed, transfer to and from a bed to a chair, get on and off a toilet or commode, and get in and out of tub/shower. The MDS indicated the resident had a bed alarm. Residents Affected - Few A review of Resident 70's Care Plans did not indicate any plan of care on the safe use of restraints. During an observation and interview on 4/2/2024, at 9:33 a.m., with Certified Nursing Assistant 3 (CNA 3), in Resident 70's room, observed Resident 70's left side of the bed pushed against the wall, with both upper side rails up, and an overbed table placed on the right lower side of the bed. CNA 3 stated the resident's bed was pushed against the wall and the side rails were up so the resident can only get out on one side of the bed, preventing a fall. During an interview on 4/4/2024, at 10:08 a.m., with the Nurse Informaticist (NI), the NI stated there were no care plans on restraint use for Residents 77, 56, and 70, because they do not consider using side rails and chair alarms and pushing the bed against a wall as restraints. During an interview on 4/4/2024, at 1:04 p.m., with the Director of Nursing (DON), the DON stated there should be a care plan on the use of bilateral side rails and chair alarms and placement of beds against a wall. The DON stated it is important to have an individualized care plan in order to be aware of the resident's problems. The DON stated the care plan should indicate interventions to be implemented to accomplish the goal. The DON further stated failure to develop and implement a care plan can lead to resident injury. A review of the facility's recent policy and procedure titled, Care Plan- Resident, last revised on 1/10/2023, to assure a coordinated and comprehensive written plan is developed based on the resident assessment and the individual needs and preferences of the resident. The comprehensive care plan may include problems that are ongoing. 055034 Page 18 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 ensure residents receive treatment and care in accordance with professional standards of practice by failing to follow the physician's order to apply thromboembolic deterrent (TED hose- stockings that help prevent blood clots and swelling in the legs) in two of twenty-two random observations (Residents 77 and 56) during the initial screening. Residents Affected - Few The deficient practice had the potential for residents to have poor circulation to the extremities that could lead to thrombosis (the formation of a blood clot within blood vessels). Findings: 1. A review of Resident 77's Face Sheet indicated the facility admitted the resident on 12/14/2023, with diagnoses including acute embolism (when a clump of material, most often a blood clot, get stuck in an artery in the lungs, blocking the flow of blood) and thrombosis, and nontraumatic (not caused by, or not causing, trauma) subdural hemorrhage (a type of bleeding near your brain). A review of Resident 77's History and Physical (H&P), dated 12/14/2023, indicated the resident was alert and oriented to person and place. A review of Resident 77's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/15/2024, indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was dependent on sitting on side of the bed and to lying flat on the bed, to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed, and transfer to and from bed to a chair. A review of Resident 77's Physician's Order, dated 3/11/2024, indicated an order for: - TED hose every twelve hours. Request type: Routine. Comments: Apply TED hose (as much as the resident is tolerating it. Indication: both lower (b/l) extremities (ext) deep vein thrombosis (DVT, a medical condition that occurs when a blood clot forms in a deep vein). A review of Resident 77's Care Plan titled, Cognitive/Communication/Falls/activities of daily living (ADL's)/Incontinence (inability to control the flow of urine from the bladder)/Skin integrity as evidenced by forgetfulness, confusion ., initiated on 12/14/2023, indicated an intervention to apply [NAME] hose every twelve hours. Request type: Routine. Comments: Apply TED hose as much as the resident is tolerating it. Indication: bilateral extremities DVT. During an observation and interview on 4/2/2024, at 11:25 a.m., with Certified Nursing Assistant/Restorative Nursing Aide 1 (CNA/RNA 1), in Resident 77's room, observed the resident not wearing TED hose. CNA/RNA 1 stated he is not aware if the resident had an order for TED hose. CNA/RNA 1 stated he cannot find the [NAME] Hose in the resident's room; and stated it is probably in the laundry. During an interview and record review on 4/2/2024, at 12 p.m., with Nursing Supervisor 1 (NS 1), reviewed Resident 77's Physician's Order. NS 1 stated there is an order to apply TED hose on resident as tolerated. NS 1 stated she does not know why the resident was not wearing the TED Hose. NS 1 stated it is important for the resident to wear TED hose to prevent edema (swelling caused by too much fluid trapped in the body's tissues) and DVT. 055034 Page 19 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. A review of Resident 56's Face Sheet indicated the facility admitted the resident on 12/6/2023, with diagnoses including history of venous thrombosis (when the blood clot blocks a vein) and embolism, and atrial fibrillation (an irregular and often very rapid heart rhythm). A review of Resident 56's H&P, dated 12/6/2023, indicated the resident was alert and oriented to self, unaware of the situation, and had severe word finding difficulties. A review of Resident 56's MDS, dated [DATE], indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident required substantial to maximal assistance to roll from lying back to left and right side, come to a standing position from sitting in a chair, wheelchair, or on the side of the bed, transfer to and from bed to a chair, and get on and off a toilet or commode. A review of Resident 56's Physician's Order, dated 4/1/2024, indicated an order of TED hose twice a day. Request type: Routine. Comments: Apply [NAME] hose. Indication: both lower extremities (BLE) edema. A review of Resident 56's Care Plan titled, Alteration in Perfusion (the flow of fluid or blood to cells and tissues) related to possible DVT as evidenced by left lower edema, initiated on 3/17/2024, indicated an intervention for [NAME] hose twice a day. Request type: Routine. Comments: Apply TED hose. Indication: BLE edema. During a concurrent observation and interview on 4/2/2024, at 8:55 a.m., with Certified Nursing Assistant 2 (CNA 2), in Resident 56's room, observed Resident 56 not wearing the TED hose. CNA 2 stated the resident was wearing regular socks. CNA 2 also stated she does not know if the resident ever wore a TED hose. During an interview on 4/4/2024, at 2:10 p.m. with the Director of Nursing (DON), the DON stated staff should apply the TED hose as ordered by the physician. The DON stated the purpose of the TED hose is to promote circulation to the lower extremities to prevent thrombosis and DVT. The DON stated they do not have a policy for use of TED hoses. A review of the facility's recent policy and procedure titled, Processing and Noting of Provider orders, last reviewed on 1/10/2023, indicated to process and note provider orders. The health unit secretary may process ancillary and treatment orders into the electronic medical record (EMR). The licensed nurse must note all provider orders. 055034 Page 20 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm 2. A review of Resident 45's Face Sheet indicated the facility originally admitted the resident on 2/21/2024 with diagnoses including hemiplegia and hemiparesis (weakness and complete loss of strength of one side of the body) following cerebral infarction (stroke - a condition that occurs as a result of disrupted blood flow to the brain), age-related osteoporosis (a condition in which there is a decrease in the amount and thickness of bone tissue causing the bones to become weak and break more easily), and right kidney cancer. Residents Affected - Some A review of resident 45's History and Physical dated 2/21/2024, indicated the resident was able to make her needs known but did not indicate the capacity to make decisions. A review of Resident 45's Minimum Data Set (MDS-a standardized assessment and screening tool) dated 3/14/2024, indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required partial/moderate assistance with eating, oral hygiene, and roll left and right; dependent with tub/shower transfer; substantial/maximal assistance with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 45's Pressure Injury Risk Assessment tool dated 2/21/2024, indicated the resident was a high risk for development of pressure injury. A review of Resident 45's physician's order dated 3/8/2024, indicated an order for alternating pressure (APP) mattress for prophylaxis. A review of Resident 45's care plan on skin integrity at risk for skin breakdown initiated on 2/21/2024 with target date 5/30/2024, indicated APP mattress, assist resident to reposition, offload pressure areas frequently as indicated. During a concurrent observation and interview on 4/2/2024 at 10:41 a.m. inside Resident 45's room, observed resident lying in an APP mattress with the setting at level 5. Resident 45 stated the mattress was a little bit hard and she had mild low back pain. Certified Nursing Assistant 4 (CNA 4) verified the APP mattress setting at level 5 and was at the firmest setting. CNA 4 stated the mattress were set up according to resident's comfort level. During an interview on 4/2/2024 at 11:20 a.m., Licensed Vocational Nurse 2 (LVN 2) APP mattress were set up according to resident comfort level by Central Supply Supervisor (CSS). LVN 4 stated if the mattress was not on the correct setting, it was not doing it's purpose to prevent skin breakdown. During an interview on 4/4/2024 at 1:59 p.m., the Director of Nursing (DON) stated APP mattresses were used if residents were at risk for or has skin breakdown after obtaining an order from the physician and were set up according to resident comfort level. The DON stated that it was important to follow the manufacturer's guideline since the facility did not have a policy on the use of the specialty mattresses to ensure it was effective in preventing pressure injuries. A review of the facility's recent policy and procedure titled, Pressure Injury Monitoring Guidelines, last reviewed on 5/2023, indicated to provide a comprehensive evaluation/treatment for patient/resident with pressure injuries. Assess if pressure alleviating devices would assist and report to medical provider. Devices require a medical provider order. 055034 Page 21 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0686 A review of Low Air Loss Mattress 2 (LALM 2) owner's manual, undated, indicated the following: Level of Harm - Minimal harm or potential for actual harm - Residents Affected - Some LALM 2 models are powered, flotation therapy mattresses providing a pressure management surface for the prevention and treatment of pressure ulcers. Comfort level selection allows selection of air cylinder firmness within a relatively small range. Press softer or firmer button to achieve desired setting. Begin in softest setting, then adjust for comfort as desired. Based on observation, interview, and record review the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcer/pressure injury (ulcers that happen on areas of the skin that are under pressure from lying in bed, sitting in a wheelchair, or wearing a cast for a long period) to two out of three sampled residents (Resident 58 and 45) being investigated under pressure ulcers by failing to: 1. Set Resident 58's low air loss mattress (LALM, designed to distribute the resident's weight over a broad surface area and help prevent skin breakdown) according to resident's weight and apply Heel Protectors 1 (HP 1, have a cushioned bottom that floats the heel off the surface of the mattress, helping to reduce pressure) on both lower extremities of the resident. 2. Set Resident 45's alternating pressure mattress (APP, a mattress used to prevent or treat pressure ulcers/injuries) according to the user manual. The deficient practices had the potential for development and worsening of pressure ulcers/injuries to the residents. Findings: 1. A review of Resident 58's Face Sheet indicated the facility admitted the resident on 9/28/2022, with diagnoses including long term use of anticoagulants (a substance that hinders the clotting of the blood), edema (swelling caused by too much fluid trapped in the body's tissues), and abnormalities of gait (a manner of walking or moving on foot) and mobility. A review of Resident 58's History and Physical (H&P), dated 10/3/2023, indicated the resident was alert and oriented (knows who they are and where they are, but not what time it is or what is happening to them), and the speech was clear. A review of Resident 58's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/19/2024, indicated the resident had the ability to make self-understood and understand 055034 Page 22 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some others. The MDS indicated the resident required substantial to maximal assistance on showering/bathing self, lower body dressing, putting on/taking off footwear, and partial to moderate assistance on toileting hygiene, upper body dressing, and personal hygiene. The MDS also indicated the resident required partial to moderate assistance to move from lying on back to sitting on the side of the bed, come to a standing position from sitting in a chair, wheelchair, or on the side of the bed, to transfer to and from bed to a chair, to get on and off a toilet or commode, and to get in and out of a tub/shower. The MDS further indicated the resident was at risk for developing pressure ulcers/injuries. A review of Resident 58's Pressure Injury Risk Assessment, dated 3/19/2024, indicated the resident was moderate risk for pressure injury. A review of Resident 58's Physician's Order, indicated the following orders: -3/29/2024 HP 1 every shift (qshift). Request type: Routine. Comments: To be worn at all times, may take off during care. Indication: Prophylaxis (attempt to prevent disease). -4/1/2024 Alternating Pressure Mattress LTC (known as air-flow mattresses, alternating pressure mattresses relieve and redistribute pressure through a dynamic lying surface) qshift. Request type: Routine. Indication: Prophylaxis. A review of Resident 58's Care Plan titled Risk for Alteration in Skin Integrity related to (r/t) dry, fragile skin, poor mobility, anticoagulant ., with a target date of 6/30/2024, indicated an intervention to apply alternating positive pressure (APP) mattress, assist resident to reposition, off load pressure areas frequently as indicated. Alternating Pressure Mattress- prophylaxis. Responsible discipline: Nurse, Certified Nursing Assistant. HP 1 qshift. Request type: Routine. Comments: To be worn at all times, may take off during care. Indication: Prophylaxis. During an observation, interview, and record review on 4/2/2024, at 11:12 a.m., with Nursing Supervisor 1 (NS 1), inside Resident 58's room, observed with NS 1, the HP 1 boots was only applied on the right lower extremity of the resident. NS 1 stated the should be on both lower extremities of the resident. NS 1 stated the HP 1 was used to protect the heels of the resident from skin breakdown. Reviewed the order for HP 1 with NS 1, NS 1 stated there was an order to apply HP 1 on both lower extremities to be worn at all times, may take off during care for prophylaxis. NS 1 stated she will order another HP 1 for the left lower extremity of the resident. NS 1 stated the failure to apply the HP 1 on the left extremity of the resident can lead to skin breakdown on the left heel. Observed with the NS 1 the low air loss mattress of the resident was set at 4. NS stated they set the LALM according to resident comfort. NS stated it was Central Supply Staff (CSS) who oversaw the LALM, and the CSS was the one setting the bed for the facility, and nobody touches the setting but him. During an interview and record review on 4/4/2024, at 9:23 a.m., CSS stated they set the LALM according to resident's comfort. CSS stated he just showed the staff on how to use the bed. CSS stated he watched the in-service video online and usually calls the manufacturer company's representative for questions. CSS stated that he was aware that they were not following the manufacturer's guideline to set the bed according to patient height and weight. CSS stated he was trying to clarify with the company on how to set the machine according to patient's height and weight per manufacturer's guideline, but he was not successful because they did not return his calls. CSS stated he did not inform the Administrator (ADM) regarding his issues with the company's responsiveness. CSS stated the failure to follow the manufacturer's guideline could result to ineffective use of the bed in preventing 055034 Page 23 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0686 skin breakdown. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/4/2024, at 1:55 p.m., with the Director of Nursing (DON), the DON stated they do not have a policy on the use of the low air loss mattress. The DON also stated they need to get an order for the LALM. The DON stated CSS sets the bed up for the facility and checks them, and she was not sure on how often he checks the settings of the LALM. The DON stated that it was important to follow the manufacturer's guideline since they do not have a policy on the use of the LALM to make sure it was effective in preventing pressure injuries. The DON stated the HP 1 should be applied to the resident as ordered by the physician to offload the heels to prevent skin breakdown or pressure injuries. Residents Affected - Some A review of the facility's recent policy and procedure titled, Pressure Injury Monitoring Guidelines, last reviewed on 5/2023, indicated to provide a comprehensive evaluation/treatment for patient/resident with pressure injuries. Assess if pressure alleviating devices would assist and report to medical provider. Devices require a medical provider order. A review of the facility's recent policy and procedure titled, LTC Standard of Care Nursing Protocol, last reviewed on 3/2023, indicated implementation of specialty beds as ordered. All regular beds are weight redistributing dense foam mattresses. A review of the facility provided Manufacturer's User Manual for LALM 1, Alternating Pressure Low Air Loss Mattress System, undated, indicated when the mattress is fully inflated, set the dial in accordance with the patient's size and weight. -Run the system check. -The system is ready for use. -Now the patient can be transferred onto the mattress. 055034 Page 24 of 70 055034 04/04/2024 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** Based on observation, interview, and record review, the facility failed to provide services and treatments to monitor and maintain joint range of motion (ROM, full movement potential of a joint) for four of five sampled residents by failing to: 1. Provide Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatments as ordered for two of five sampled residents (Residents 2 and 12) and 2. Provide a baseline upper extremity (UE, shoulder, elbow, wrist, hand) range of motion assessment for two of five sampled residents (Residents 45 and 63) upon admission to monitor ROM decline. These deficient practices had the potential to cause decline in ROM, mobility, and overall quality of life for Resident 2, 12, 45, and 63. Cross reference to F725 and F825 Findings: 1a. A review of Resident 2's Face Sheet indicated the facility admitted Resident 2 to the facility on 9/17/2020. A review of Resident 2's Patient Diagnosis Information indicated Resident 2 had diagnoses including, but not limited to Alzheimer's disease (a type of disease that affects memory, thinking, and behavior) and abnormalities of gait (walking) and mobility. A review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 1/9/2024 indicated Resident 2 had moderate cognitive impairment (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving) and had the ability to express ideas and wants. The MDS also indicated Resident 2 had no impairment in functional limitation in ROM on both of the upper extremity (BUE) and had impairments on one side of the lower extremity (LE, hip, knee, ankle, foot). The MDS indicated Resident 2 required supervision assistance with eating and oral hygiene, substantial assistance (helper does more than half the effort) with lower body dressing, toileting hygiene, chair transfer, sit to stand, and walking 50 feet with two turns. The MDS indicated Resident 2 required partial assistance (helper does less than half the effort) with walking 10 feet. The MDS indicated Resident 2 received one (1) day of Restorative Nursing Program (RNP) for active range of motion (AROM, movement at a given joint when the person moves voluntarily) and zero (0) days of RNP for walking. A review of Resident 2's physician's orders indicated an order dated 12/3/2023 for RNA for ambulation with two-wheeled walker (2WW, type of mobility aid with wide base of support and 2 wheels in the front) three (3) to five (5) days a week as tolerated. A review of Resident 2's care plan dated 9/12/2020 with target date of 4/30/2024, indicated Resident 2 had problems of cognitive/falls/ activities of daily living (ADL, basic activities such as eating, dressing, toileting)/incontinence (inability to control bowel or bladder)/skin integrity: related 055034 Page 25 of 70 055034 04/04/2024 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 to Resident 2 has forgetfulness, still able to direct her daily care schedule, needs partial/maximum assistance with ADL's, incontinent of bladder and at risk for skin breakdown. The interventions for the care plan indicated RNA for ambulation with 2WW 3 to 5 days a week as tolerated, indication was maintenance. During a concurrent observation and interview on 4/2/2024 at 9:32 a.m., Resident 2 was sitting up in a wheelchair in an area near the nursing station. Resident 2 stated she wished she could do more exercises and walking. Resident 2 stated she walked when staff had time to walk with her which was not every day. Resident 2 was able to lift both knees up and down, and able to lift both arms up but not past shoulder level. Resident 2 required the use of the left hand to hold the right wrist to help move the right arm higher up. During a concurrent interview and record review on 4/3/2024 at 3:12 p.m., with Nursing Supervisor 1 (NS 1), reviewed Resident 2's physician's orders and RNA documentation. NS 1 stated Resident 2 had orders for RNA for ambulation 3 to 5 times a week as tolerated. NS 1 stated the RNA orders have a range of days to allow for staff to see the residents for three times a week in case the RNA staff could not see the residents for five times a week. After review of Resident 2's RNA documentation during January 2024, February 2024, and March 2024, NS 1 stated Resident 2 missed the following RNA treatments: -3 RNA treatments week of 1/1/2024 -1 RNA treatment week of 1/8/2024 -2 RNA treatments week of 1/15/2024 -1 RNA treatment week of 1/22/2024 -1 RNA treatment week of 2/5/2024 -1 RNA treatment week of 2/19/2024 -1 RNA treatment week of 3/4/2024 1b. During a record review of Resident 12's Face Sheet indicated the facility admitted Resident 12 to the facility on 6/30/2021. A review of Resident 12's Patient Diagnosis Information indicated Resident 12 had diagnoses including, but not limited to hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following cerebral infarction (blockage of the flow of blood brain, causing or resulting in brain tissue death) and osteoarthritis (swelling and tenderness of a joint causing pain and stiffness). A review of Resident 12's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 3/19/2024 indicated Resident 12 was cognitively intact (sufficient judgement, planning, organization to manage average demands in one's environment), had impairment in functional limitation in ROM on one side of the upper extremity and had impairments on both side of the lower extremity. The MDS indicated Resident 2 required set up assistance with eating, supervision assistance with oral hygiene, dependent assistance (helper does all the of the effort) with toileting hygiene, bathing, 055034 Page 26 of 70 055034 04/04/2024 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 dressing, rolling left to right, and chair transfers. The MDS indicated the activities of walking 10 feet and sit to stand was not attempted. A review of Resident 12's physician's orders indicated an order dated 11/29/2023 for RNA to provide passive range of motion (PROM, movement at a given joint with full assistance from another person) to left UE (LUE) and left LE (LLE) as tolerated 3 to 5 days a week, active versus passive ROM to right LE (RLE) as tolerated 3 to 5 days a week, 2 pound weights on RUE exercises 3 to 5 days a week as tolerated, and right knee splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) on for six (6) to seven (7) hours as tolerated 3 to 5 days a week. A review of Resident 12's care plan dated 6/30/2021 with target date of 6/30/2024 indicated Resident 12 had problems of falls/ADL/incontinence/skin integrity: related to Resident 12 is alert and oriented to self, time, situation, needs assistance with ADL's, incontinent of bladder and at risk for skin breakdown, braces and impaired ambulation, at risk for fall due to impaired balance and mobility. The interventions for the care plan indicated RNA to provide passive range of motion to LUE and LLE extremities as tolerated 3 to 5 days a week, active versus passive ROM to RLE as tolerated 3 to 5 days a week, 2 pound weights on RUE exercises 3 to 5 days a week as tolerated, and right knee splint on for 6 to 7 hours as tolerated 3 to 5 days a week. During a concurrent observation and interview on 4/2/2024 at 9:01 a.m., Resident 12 was lying on her back in bed. Resident 12 stated she needed more RNA. Resident 12 stated in the last two weeks, she received RNA about once a week. Resident 12 stated that her RNA sometimes was switched to a Certified Nursing Assistant (CNA) so she did not get any RNA exercises on those days. Resident 12 stated she could not move her left arm or leg and needed RNA to help her move her arm and leg. Resident 12 stated she also need a splint for the left hand. Resident 12 was able to bring the right arm up past shoulder level and bend the right elbow, wrist, and fingers. Resident 12 was able to move the right leg up and down. Resident 12 stated the facility needed more RNA staff and said there was only about one or two RNA staff. No splints were observed on Resident 12's left hand. During a concurrent interview and record review on 4/3/2024 at 3:20 p.m., with NS 1, reviewed Resident 12's physician's orders and RNA documentation. NS 1 stated Resident 12 had orders for RNA for 3 to 5 times a week for PROM to LUE and LLE, AROM versus PROM RLE, 2 pound weight exercises to RUE, put on right knee splint, and left resting hand splint. After review of Resident 12's RNA documentation during January 2024, February 2024, and March 2024, NS 2 stated Resident 12 missed the following RNA treatments: -3 RNA treatments week of 1/1/2024 -1 RNA treatment week of 1/8/2024 -2 RNA treatments week of 1/22/2024 -2 RNA treatments week of 1/29/2024 -2 RNA treatments week of 2/5/2024 -1 RNA treatment week of 2/19/2024 -2 RNA treatments week of 2/26/2024 055034 Page 27 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0688 -2 RNA treatments week of 3/4/2024 Level of Harm - Minimal harm or potential for actual harm -1 RNA treatment week of 3/18/2024 -2 RNA treatments week of 3/25/2024 Residents Affected - Some During an interview on 4/3/2024 at 8:45 a.m., with Restorative Nursing Aide (RNA 2), RNA 2 stated there were 2 RNAs working today. RNA 2 stated RNA duties include doing RNA treatments such as ROM, ambulation, transferring, put on splints, helping with feeding residents, passing out meal trays, putting in weights in the system, and anything else that was needed including attending appointments with residents. RNA 2 stated RNAs worked Mondays to Fridays only and there were no RNAs on the weekend. RNA 2 stated they try to put on the splints in the morning and sometimes there was not enough time. During an interview on 4/3/2024 at 1:55 p.m., with NS 1, NS 1 stated the purpose of RNA was to maintain the resident's mobility, improve ambulation and ROM. NS 1 stated it is important for residents to receive their RNA treatments to maintain their overall well-being and quality of life and that residents should receive their RNA treatments as ordered. NS 1 stated that if the residents did not receive their RNA orders as ordered, then the residents were at risk for deconditioning, getting weaker, and their ROM and contractures (loss of motion of a joint) could get worse. During an interview on 4/3/2024 at 2:37 p.m., with the Director of Nursing (DON), the DON stated that RNAs were short-staffed. DON stated the facility was aware that residents with RNA orders were not receiving RNA treatments at least 3 to 5 times a week as ordered. DON also stated that sometimes RNAs were pulled to be CNAs if the CNAs did not have enough staff and then RNA treatments would not be done that day. DON stated RNA treatments were important to help prevent contractures and to help residents have full mobility. DON stated the current RNA staff was not enough to meet the needs of residents who required RNA treatments and services. During an interview on 4/4/2024 at 8:30 a.m. with Nursing Supervisor 2 (NS 2), NS 2 stated she was the RNA supervisor, and her role was to oversee the RNA care provided to the residents. NS 2 stated they were trying to ensure that the residents received RNA 3 to 5 times a week, but it was challenging to make that happen. NS 2 stated the residents were not getting enough RNA, missing treatments, and that the facility needed more RNA staff. During an interview on 4/4/2024 at 10:28 a.m., with Restorative Nursing Aide (CNA/RNA 1), CNA/RNA 1 sated she saw residents in multiple nursing stations at the facility because they needed to help cover other areas for RNA treatments. CNA/RNA 1 stated CNA/RNA 1 tried to see as many residents as they could, but there were residents that were not seen because there were too many residents, and they did not have enough time to see all the residents. During a review of the facility's policies and procedures dated 6/2023, titled Restorative Nursing Program, indicated the Restorative Nursing Program is designed to promote/improve/maintain strength, endurance, balance and mobility .responsibilities of the RNA include: administer restorative activities specific to resident needs and order of the physical therapist. The goal of these activities is performed 3 - 5 times a week as ordered. The Performance Improvement Plan indicated a Registered Nurse will review the Range of Motion exercises with the RNAs at least every month to ensure that orders are appropriate and are being provided to the residents. 055034 Page 28 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0688 2a. A review of Resident 45's Face Sheet indicated Resident 45 was admitted to the facility on [DATE]. Level of Harm - Minimal harm or potential for actual harm A review of Resident 45's Patient Diagnosis Information indicated Resident 45 had diagnoses including, but not limited to hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following cerebral infarction (blockage of the flow of blood brain, causing or resulting in brain tissue death). Residents Affected - Some A review of Resident 45's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 3/1/2024 indicated Resident 45 was cognitively intact (sufficient judgement, planning, organization to manage average demands in one's environment) and had no functional limitations in ROM in both upper and lower extremities lower extremity (LE, hip, knee, ankle, foot). The MDS also indicated Resident 45 required partial assistance (helper does less than half the effort) for eating, oral hygiene and substantial assistance (helper does more than half the effort) with dressing, toileting, chair transfers, and did not walk. A review of Resident 45's medical records indicated there was no Occupational Therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Initial Evaluation completed. A review of Resident 45's Physical Therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) Initial Evaluation dated 2/21/2024 indicated the ROM assessment was completed for the hip, knee, and ankle and did not include ROM assessment of the upper extremities. During a concurrent observation and interview on 4/3/2024 at 1:18 p.m., Resident 45 was sitting up in a wheelchair in the resident's room. Resident 45 was able to move the right arm up and down, and the right leg up and down. Resident 45 stated the left side was the problem side and was able to move the left arm and leg up and down a little. Resident 45 stated she never received any OT services and did not know that OT was offered here. During an interview on 4/4/2024 at 8:30 a.m., with Nursing Supervisor (NS 2), NS 2 stated all residents received an OT and PT evaluation upon admission in order to complete a range of motion assessment for both upper and lower extremities. NS 2 stated the facility had not been writing OT evaluation orders recently because there had not been an OT available to evaluate and see residents. NS 2 reviewed Resident 45's medical records and confirmed there was no OT evaluation completed. NS 2 reviewed a PT evaluation and confirmed that the PT evaluation did not include a range of motion assessment for the upper extremities. NS 2 confirmed Resident 45 did not receive a baseline ROM assessment upon admission. NS 2 stated it was important to establish a baseline for the resident's ROM in order to see where our residents were at so we know how to care for them and how to monitor them, so we could know if the residents declined in their ROM. NS 2 stated the facility would not know if the residents declined in their ROM or got better because the facility did not complete an assessment upon admission to know what the ROM was when the residents were admitted . NS 2 stated it was important to continue to monitor the resident's ROM and mobility to ensure that the residents were maintaining their quality of life and that their body was at their optimal functioning. 2b. A review of Resident 63's Face Sheet indicated Resident 63 was admitted to the facility on [DATE]. 055034 Page 29 of 70 055034 04/04/2024 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 63's Patient Diagnosis Information indicated Resident 45 had diagnoses including, but not limited to morbid (severe) obesity (disorder involving excessive body fat that increased risk for health problems) and chronic obstructive pulmonary disease (lung disease that causes obstruction of airflow and can limit normal breathing). A review of Resident 63's Minimum Data Set, dated [DATE] indicated Resident 63 was cognitively intact and had no functional limitations in range of motion in both upper and lower extremities. The MDS also indicated Resident 63 required supervision assistance for eating, oral hygiene and substantial assistance (helper does more than half the effort) with lower body dressing, toileting, chair transfers, and to walk 10 feet. A review of Resident 63's medical records indicated there was no Occupational Therapy Initial Evaluation completed. A review of Resident 63's Physical Therapy Initial Evaluation dated 3/6/2024 indicated the ROM assessment was completed for the hip, knee, and ankle and did not include ROM assessment of the upper extremities. During a concurrent observation and interview on 4/2/2024 at 3:00p.m., Resident 63 was sitting up in a wheelchair wearing a dress and Resident 63's spouse present in the resident's room. Resident 63 required extra time to verbalize needs. Resident 63 was able to move both arms and legs a little. During an interview on 4/4/2024 at 8:30 a.m., with NS 2, NS 2 stated all residents received an OT and PT evaluation upon admission in order to complete a range of motion assessment for both upper and lower extremities. NS 2 stated the facility had not been writing OT evaluation orders recently because there had not been an OT available to evaluate and see residents. NS 2 reviewed Resident 63's medical records and confirmed there was no OT evaluation completed. NS 2 reviewed a PT evaluation and confirmed that the PT evaluation did not include a range of motion assessment for the upper extremities. NS 2 confirmed Resident 63 did not receive a baseline ROM assessment upon admission. NS 2 stated it was important to establish a baseline for the resident's ROM in order to see where our residents were at so we know how to care for them and how to monitor them, so we could know if the residents declined in their ROM. NS 2 stated the facility would not know if the residents declined in their ROM or got better because the facility did not complete an assessment upon admission to know what the ROM was when the residents were admitted . NS 2 stated it was important to continue to monitor the resident's ROM and mobility to ensure that the residents were maintaining their quality of life and that their body was at their optimal functioning. During an interview on 4/3/2024 at 1:55 p.m., with NS 1, NS 1 stated for new admissions there was usually an order for OT and PT evaluation, but right now there was no OT to provide OT services. NS 1 stated the baseline ROM assessments were completed by PT and OT upon admission to the facility. NS 1 stated she was not aware of who was completing the UE ROM assessments for new admissions since there was no OT at this time. NS 1 stated it was important for the facility to monitor the residents' ROM and mobility to make sure any changes were reported to the physician to see if there were any interventions the residents may need. NS 1 stated declines in ROM and mobility could impact the residents such as their walking could get worse, and residents could develop contractures. During an interview on 4/3/2024 at 2:23 p.m., with NS 1, NS 1 confirmed the residents were only receiving PT evaluation for baseline ROM and there was no staff completing the baseline assessment for BUE ROM, because there was no OT right now. 055034 Page 30 of 70 055034 04/04/2024 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 phone interview on 4/4/2024 at 11:16 a.m., with Physical Therapist (PT 1), PT 1 stated the PT evaluation documentation only included the lower extremities and the PT did not complete a baseline evaluation of range of motion assessment for the upper extremities. During an interview on 4/4/2024 at 11:30 a.m., with Nurse Practitioner (NP 1), NP 1 stated it is the facility's protocol and standard to order OT and PT evaluations for all residents upon admission to establish a baseline for the resident's function, ADLs, mobility, and to see if there were any opportunities for skilled therapy such as positioning, splinting needs, and if a RNA program was appropriate. NP 1 stated Resident 45 was not ordered OT evaluation because there was no OT available at the facility. NP 1 stated at minimum, an OT evaluation should have been completed to establish a baseline. During an interview on 4/4/2024 at 12:36 p.m., with the DON, the DON stated the facility had no system to formally monitor ROM and mobility for residents and depend on RNA, CNA, or LVN reporting any changes in ROM to staff. The DON stated at the minimum there should be a baseline assessment of ROM completed by PT and OT for all extremities in order for the facility to use the baseline ROM assessment to monitor and compare if the residents declined or got better. DON stated the newer residents that were admitted when the OT was not available did not receive baseline ROM assessments for the UE. The DON stated these residents were at risk for decline in the UE abilities and the facility would not be aware if the resident declined, because there would not be an assessment to compare it to. A review of the facility's policy and procedure dated 3/2023, titled, Long Term Care Standard of Care Nursing Protocol, indicated, provide measures to increase mobility per medical provider order: 1. ROM exercises, 3. Physical therapy consult as ordered. 4. Occupational therapy consults as ordered. During an interview on 4/4/2024 at 3:06 p.m., DON reviewed the Long Term Care Standard of Care Nursing Protocol policy and stated there were no other facility policies to provide rehabilitative therapy services to residents. 055034 Page 31 of 70 055034 04/04/2024 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 provide an environment free from accidents and hazards by: Residents Affected - Few 1. Failing to ensure Certified Nursing Assistant 5 (CNA 5) did not transfer one out of one sampled resident (Resident 82) from bed to wheelchair while using a Hoyer lift (a patient lift used by caregivers to safely transfer patients) without another staff assistance investigated during a random observation. This deficient practice placed Resident 82 at risk for falls and serious injuries that include possible fractures and bleeding. 2. Failing to ensure residents did not have lidocaine (a topical [placed on the skin] medication used to treat pain) 4 percent (%, concentration of medication in a solution) roll-on bottle at bedside for one of one sampled resident (Resident 24) investigated under the care area Pain Management. This deficient practice had the potential to result in residents self-administering medications without staff knowledge resulting in overdose, loss of resident medication, or a delay in care and services. Findings: 1. A review of Resident 82's Face Sheet indicated the facility admitted the resident on 4/27/2023 with diagnoses including polyosteoarthritis (a joint condition that involves four or more joints characterized by joint stiffness and pain), abnormalities of gait and mobility, and presence of right artificial knee joint. A review of Resident 82's History and Physical dated 5/2/2023, indicated the resident was pleasant and cooperative but unable to provide meaningful history. A review of Resident 82's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 1/19/2024 indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision or touching assistance with eating; partial/moderate assistance with oral hygiene, and upper body dressing; dependent with toileting hygiene, and putting on/taking off footwear; substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 82's care plan on cognitive/falls/ADLs/incontinence/skin integrity related to forgetfulness and confusion, high risk for fall initiated on 4/27/2023 with target date of 4/27/2023, indicated a goal that resident will be safe and have no falls or injury and will remain safe within the facility. The interventions included: Resident 82 uses wheelchair for locomotion. 055034 Page 32 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0689 Resident 82 is up on wheelchair daily, needs extensive assistance for transfers Level of Harm - Minimal harm or potential for actual harm A review of Resident 82's CNA Shift Note, dated 4/1/2024 to 4/4/2024, indicated Resident 82 was dependent with the ability to transfer to and from a bed to chair or wheelchair and required the assistance of two or more helpers for the resident to complete the activity. Residents Affected - Few A review of Medical Equipment 1 (ME 1) user manual, undated, indicated the company recommends 2 assistants for all lifting preparation, transferring from and transferring to procedures, the equipment permits proper operation by 1 assistant based on the evaluation of the healthcare professional. During an observation on 4/2/2024 at 10:32 a.m., observed CNA 5 transferring Resident 82 from bed to a wheelchair using a Hoyer lift without another staff member present in the room. Observed Licensed Vocational Nurse 4 (LVN 4) enter the room at 10:35 a.m. and assisted CNA 5 by holding the wheelchair when Resident 82's transfer was almost completed. During an interview on 4/2/2024 at 2:46 p.m., CNA 5 verified that she transferred Resident 82 from bed to wheelchair using the Hoyer lift by herself during most of the task. CNA 5 stated LVN 4 entered the room to assist when Resident 82's transfer was almost completed. CNA 5 stated transfers with Hoyer lift were supposed to be with two (2) staff members. CNA 5 stated other staff were busy with their own tasks and were unable to assist her. CNA 5 stated she should have waited for LVN 4 to come prior to completing the transfer from bed to wheelchair while using the Hoyer lift as it placed the resident at risk to fall. During an interview on 4/4/2024 at 10:10 a.m., the Minimum Data Set Coordinator (MDSC) stated mechanical lift or Hoyer lift transfers of residents from bed to wheelchair or wheelchair to bed requires 2-person assist. The MDSC stated CNA 5 should have transferred Resident 82 with another staff member for resident safety to prevent falls and/or injury. During an interview on 4/4/2024 at 2 p.m. the Director of Nursing (DON) stated mechanical lift transfers require 2-person assist at all times. The DON stated CNA 5 should have transferred Resident 82 from bed to wheelchair with another CNA or licensed nurse for resident safety as it placed the resident at risk for accidents, falls, and/or injury. A review of the facility's policy and procedure titled, Mechanical Lift - Use of for Patients/Residents, last reviewed 1/10/2023 indicated a purpose to provide safe transfers for residents/patients. The policy indicated to use 2-person assist when using mechanical lift for transfer - one person to operate lift and one person to guide patient/resident in sling. A review of the facility's policy and procedure titled, Accident Prevention, last reviewed and revised 3/2024, indicated a statement to ensure the environment is free form accident hazards as is possible and identify residents who require supervision and/or assistive devices to prevent accidents. The policy indicated to identify types of accident hazards including transferring assistance/safety. 2. A review of Resident 24's Face Sheet indicated the facility admitted the resident on 9/6/2023 with diagnoses that included Parkinson's disease (a progressive disorder that affects the nervous system that causes unintended or uncontrollable movements), osteoarthritis (a disease of the joints [area where two bones make contact] that causes pain), insomnia (difficulty sleeping), and chronic pain. A review of Resident 24's History and Physical (H&P), dated 9/12/2023, indicated the resident had a 055034 Page 33 of 70 055034 04/04/2024 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 history of progressive functional decline complicated by cognitive decline and was dependent on staff for activities of daily living but was generally able to feed himself. A review of Resident 24's Minimum Data Set (MDS - an assessment and screening too) dated 3/15/2024, indicated the resident was able to understand others and make himself understood. The MDS further indicated the resident was dependent on staff for eating, toileting, bathing, dressing, personal hygiene, and transferring between the bed to chair. A review Resident 24's Care Plan (CP) titled, Cognitive / vision / falls / activities of daily living (ADLs) / ., dated 9/6/2023, indicated the resident was alert with some forgetfulness. A review of Resident 24's physician orders indicated an order for lidocaine 4% pain relief roll-on: apply to affected areas, indication: pain, order dated 1/23/2024. During a concurrent observation and interview, on 4/2/2024 at 9:25 a.m., with Resident 24 and Assistant Activities Coordinator 1 (AAC 1), observed AAC 1 sitting at bedside and assisting Resident 24 with feeding. Observed a bottle of lidocaine 4% roll-on sitting on the bedside table next to the resident's meal tray. AAC 1 stated the lidocaine bottle was labeled with the resident's name and she did not know why the bottle was on the table. Resident 24 stated it was his medication and the staff applied it on his foot last night. During a concurrent interview and record review on 4/2/2024 at 10 a.m., with Licensed Vocational Nurse 2 (LVN 2), reviewed Resident 24's Medication Administration Record (MAR- a record of all medications taken by a resident on a day-to-day basis). LVN 2 stated she was the medication nurse for Resident 24 and she did not leave the lidocaine bottle in the resident's room. LVN 2 stated the MAR indicated the lidocaine was last documented as administered on 3/3/2024. LVN 2 stated she did not know how long the lidocaine bottle was in Resident 24's room or when it was last administered. LVN 2 stated medications should not be left in a resident's room for safety issues. LVN 2 stated the resident, or another resident, could have used the medication when it was left in the room. During a concurrent interview and record review, on 4/4/2024 at 8:15 a.m., with the Director of Nursing (DON), reviewed the facility policy and procedure regarding medication administration. The DON stated Resident 24 was forgetful, confused, and not safe for medication self-administration. The DON stated medication should not be left at Resident 24's bedside. The DON stated she spoke with staff and does not know when the lidocaine was left in the resident's room or if it was administered. The DON stated the facility policy indicates to not leave medications at bedside because it could potentially cause harm if the medication is not appropriately used. The DON stated there was also potential harm to other residents if they took and used the medication when it was not indicated. The DON stated there was an additional risk for medication to go missing and not be available for the next time it was needed for administration. A review of the facility policy and procedure titled, Medication Administration, last reviewed 6/2023, indicated medications shall be accurately and safely administered to facility residents by authorized personnel. Do not leave medications unattended with the resident. 055034 Page 34 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the safe and appropriate use of side rails (SR, adjustable rigid plastic bars attached to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) for three of four sampled residents (Resident 8, 77 and 70) investigated during review of restraints by failing to: 1. Conduct an assessment including the risk for entrapment (occurs when a resident is caught between the mattress and bed rail or within the bed rail itself) from side rails. 2. Review the risk and benefits of side rails with the resident or resident representative and obtain informed consent (process in which residents or resident representatives are given important information, including possible risks and benefits, about a procedure or treatment). These deficient practices had the potential to result in psychosocial harm and physical harm from entrapment and death of residents. Cross refernec to F604 and F656. Findings: 1. A review of Resident 8's Face Sheet (admission Record) indicated the facility admitted the resident on 6/11/2020 with diagnoses that included Alzheimer's disease (a type of dementia [a general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life]) with late onset, anxiety disorder (a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear), and abnormalities of gait (the pattern or style of movement involved in walking) and mobility. A review of Resident 8's History and Physical (H&P), dated 5/26/2023, indicated the resident had dementia with behavioral disturbances and was unable to follow commands. The H&P indicated the resident had a history of falls resulting in a fractured hip. A review of Resident 8's Minimum Data Set (MDS - an assessment and care screening tool) dated 2/6/2024, indicated the facility most recently readmitted the resident on 5/19/2021 and the resident sometimes was able to understand others and sometimes was able to make herself understood. The MDS further indicated the resident was dependent on staff for eating, toileting, bathing, dressing, personal hygiene, and mobility. The MDS indicated the resident did not use SRs as a physical restraint. A review Resident 8's Care Plan (CP) titled, Cognitive / Communication / vision / Falls . related to (Resident 8) has forgetfulness, confusion related to Alzheimer dementia, hard of hearing, impaired vision ., dated 6/11/2020, indicated the resident wanted to be safe, reduce risk for falls and injury and to remain safely in the facility. The CP further indicated an intervention that if the resident was noted as restless and trying to get out of bed, to assist her to the wheelchair and sit her across from the nursing station. During an observation on 4/2/2024 at 11:05 a.m., observed Resident 8 in Hospital Bed 1 (HB 1) with 055034 Page 35 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some eyes closed and did not verbally respond to the surveyor. Observed the bed with bilateral SRs in raised position and the left side of the bed was placed against a built-in wall dresser cabinet with no access for bed exit on the left side. During an observation and interview on 4/2/2024 at 11:18 a.m. with Certified Nursing Assistant 6 (CNA 6), observed Resident 8 in bed. CNA 6 stated the Resident had fallen in the past and can move. CNA 6 stated the bed against the dresser and raised upper side rails were used for fall prevention. During an interview on 4/2/2024 at 11:27 a.m. with Licensed Vocation Nurse 5 (LVN 5), LVN 5 stated the facility does not require a physician's order for the use of SRs and Resident 8 did not have an order for SRs. During an interview with Family Member 1 (FM 1) on 4/2/2024 at 2:10 p.m., FM 1 stated Resident 8 has advanced dementia and bruises easily. FM 1 stated Resident 8 is not mobile, but she can slip out of the bed and the facility has found her on the floor. FM 1 stated she was aware that SRs and bed positioning were used to keep Resident 8 in the bed and off the floor, but she does not remember anyone ever discussing the risks of using them. During an interview and record review on 4/3/2024 at 8 a.m. with the Director of Nursing (DON), reviewed Resident 8's clinical record. The DON stated the facility uses bilateral upper SRs that are connected to the bed. The DON stated the process for using SRs is the Interdisciplinary Team (IDT) decides to use two SRs if the resident is assessed and able to use them and that the SRs do not restrict movement. The DON stated if the resident is not assessed then the SRs should not be up. The DON stated the possible adverse effects of using SRs was restriction of movement and entrapment. The DON stated there was no documentation indicating there was an assessment of Resident 8 for use of SRs. The DON stated there was no documentation indicating an assessment for risk of entrapment for Resident 8 prior to using SRs. The DON stated informed consent is usually obtained by the physician from the resident or resident representative when consent is needed. The DON stated there was no documentation indicating informed consent was received prior to using the SRs. The DON stated the facility did not have a policy regarding the use of SRs. The DON stated the importance of policies was that they guide the facility to do what is supposed to be done based on standards of care. During an interview on 4/4/2024 at 8:10 a.m. with the Administrator (ADM), the ADM stated they were now aware of the regulations regarding SR use in the facility. The ADM stated they now have clarity on the regulation and there should be a specific policy for restraints, and they do not have one. The ADM stated it was her responsibility to ensure policies were in place and the SR policy should include an assessment for SR usage and informed consent for any SRs used in the facility. The ADM Stated they will be developing a policy based on the standards of practice. During a follow up interview on 4/4/2024 at 8:15 a.m. with the DON, the DON stated now she was aware that all siderail use should be assessed for risk of injury from entrapment and consent should be obtained from the resident or resident representative. The DON stated without assessments and consents the resident is at risk for injury due to entrapment. The DON stated when the bed was placed against the dresser there was a risk for restriction in mobility and there was a risk for entrapment by the side rail and being squeezed against the wall. The DON stated when residents become entrapped it could possibly lead to fractures, wounds, and skin tears. The DON stated it was important to ensure resident safety, ensure the family is aware, and to respect the resident's rights as well. A review of the facility provided HB 1 Instructions for Use Service [NAME], dated 2011, indicated 055034 Page 36 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to avoid personal injury read all sections pertaining to the bed model before use. Rails are not meant for patients considered as high risk for entrapment (i.e., patients with pre-existing conditions such as confusion, restlessness, lack of muscle control, altered mental status). Additional safety measures should be considered for such high-risk patients. A review of the facility provided policy and procedure titled, Policy Review and Approval, last reviewed on 4/2023, indicated the policy was to maintain a standardized process for the development, review, revise, approval, implementation and maintenance of the facility policies and related standards, procedures, plans, and guidelines. The responsible person drafts policy consistent with the facility standards of policy design. The draft policy is submitted to [NAME] President, Legal Affairs, ADM, or designee who reviews the policy and ensure distribution to appropriate parties for review and comment. The routing for approval of policies is the Policy and Forms Committee, Medical Executive Committee, and Governing Body. [NAME] President, Legal Affairs, ADM or designee coordinates preparation of final draft policy for approval by the Chief Executive Officer and Governing Body. The approved policy is posted on the facility intranet. 2. A review of Resident 77's Face Sheet indicated the facility admitted the resident on 12/14/2023, with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), nontraumatic (not caused by trauma) subdural hemorrhage (a collection of blood between the covering of the brain and the surface of the brain), and seizures (a sudden, uncontrolled burst of electrical activity in the brain). A review of Resident 77's History and Physical (H&P), dated 12/14/2023, indicated the resident was alert and oriented to person and place, with major neurocognitive disorder (decreased mental function due to a medical disease other than psychiatric illness) with functional dependency and need for protective environment. A review of Resident 77's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/15/2024, indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident was dependent on sitting on side of the bed to lying flat on the bed, move from lying on the back to sitting on the side of the bed, come to a standing position from sitting in a chair, wheelchair, or on the side of the bed, transfer to and from a bed to a chair, and to get in and out of a tub/shower. A review of Resident 77's Fall Risk Evaluation, dated 3/15/2024, indicated the resident was high risk for falls. A review of Resident 77's Physician's Order did not indicate orders for use of side rails. During an observation and interview on 4/2/2024, at 11:25 a.m., with Certified Nursing Assistant/Restorative Nursing Aide 1 (CNA/RNA 1), in Resident 77's room, observed the resident's bed pushed against the wall, with both upper side rails up. CNA/RNA 1 stated the bed was pushed against the wall to give space for a transfer aid equipment (a non-powered device that ensures residents can be positioned from sit-to-stand transfers safely, quickly and with ease). CNA/RNA 1 stated the upper side rails of the resident were up because the resident was at risk for fall. During an interview and record review on 4/2/2024, at 12 p.m., with Nursing Supervisor 1 (NS 1), reviewed the Physician's Order and Care Plans of the resident with NS 1. NS 1 stated the resident does not have any orders for side rails. NS 1 stated the bed was pushed against the wall with both upper 055034 Page 37 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0700 side rails up to prevent falls. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/4/2024, at 8:15 a.m., with the DON, the DON stated all side rail use should be assessed for risk of injury from entrapment and consent should be obtained from the resident or the resident representative. The DON stated a physician's order is needed for use of side rails. Residents Affected - Some 3. A review of Resident 70's Face Sheet indicated the facility admitted the resident on 12/30/2022, with diagnoses including Alzheimer's disease, dementia, and abnormalities of gait (a manner of walking or moving on foot) and mobility. A review of Resident 70's H&P, dated 12/27/2023, indicated the resident was awake and alert, speech was mostly coherent, but non-fluent at times. A review of Resident 70's MDS, dated [DATE], indicated the resident sometimes had the ability to make self-understood and understand others. The resident had moderately impaired vision. The MDS indicated the resident required supervision or touching assistance to roll from lying on back to left and right side, and return to lying back on the bed, move from sitting on side of bed to lying flat on the bed, move from lying on back to sitting on the side of the bed, come to a standing position from sitting in a chair, wheelchair, or on the side of the bed, transfer to and from a bed to a chair, get on and off a toilet or commode, and get in and out of tub/shower. A review of Resident 70's Fall Risk Evaluation, dated 3/22/2024, indicated the resident was high risk for falls. A review of Resident 70's Physician's Order did not indicate orders for use of side rails. During an observation and interview on 4/2/2024, at 9:33 a.m., with Certified Nursing Assistant 3 (CNA 3), in Resident 70's room, observed Resident 70's left side of the bed pushed against the wall, with both upper side rails up, and an overbed table placed on the right lower side of the bed. CNA 3 stated the resident's bed was pushed against the wall and the side rails were up so the resident can only get out on one side of the bed, preventing a fall. During an interview on 4/4/2024, at 8:15 a.m., with the DON, the DON stated all side rail use should be assessed for risk of injury from entrapment and consent should be obtained from the resident or the resident representative. The DON stated a physician's order is needed for use of side rails. A review of the facility provided Hospital Bed 1 (HB 1) for Use Service Manual, dated 2011, indicated to avoid personal injury read all sections pertaining to the bed model before use. Rails are not meant for patients considered as high risk for entrapment (i.e., patients with pre-existing conditions such as confusion, restlessness, lack of muscle control, altered mental status). Additional safety measures should be considered for such high-risk patients. 055034 Page 38 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on interview and record review, the facility failed to provide adequate and sufficient nursing staff to provide care for residents requiring Restorative Nursing Aide (RNA, nursing aide program that helps residents to maintain their function and joint mobility) services. This deficient practice had the potential for 70 residents with physician's orders for RNA to experience a decline in range of motion (ROM, full movement potential of a joint), mobility, and activities of daily living (ADL, basic activities such as eating, dressing, toileting) function. Cross Reference to F688 and F825 Findings: A review of the physician's orders for residents on RNA services dated 4/3/2024 indicated 70 residents had physician's orders for RNA to provide treatments and services including but not limited to, ROM exercises to upper extremities (UE, shoulder, elbow, wrist, hand) and lower extremities (LE, hip, knee, ankle, foot), application of splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) or braces (an external device to support, align, or correct a movable part of the body), ambulation (walking), strengthening exercises with weights, and transfers (moving from one surface to another). A review of the facility's Posting of Long Term Care (LTC/Skilled Nursing Facility[SNF]) Hours (nurse staffing hours worked for each day) for January 2024 indicated the following RNA staff assignments for the 7 a.m. to 3 p.m. shift from Monday to Friday: -Monday, 1/1/2024: zero (0) RNA -Tuesday, 1/2/2024: one (1) RNA -Wednesday, 1/3/2024: 0 RNA -Thursday, 1/4/2024: two (2) RNAs -Friday, 1/5/2024: 0 RNA -Monday, 1/8/2024: 2 RNAs -Tuesday, 1/9/2024: 2 RNAs -Wednesday, 1/10/2024: 1 RNA -Thursday, 1/11/2024: 2 RNAs -Friday, 1/12/2024: 2 RNAs -Monday, 1/15/2024: 1 RNA 055034 Page 39 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0725 -Tuesday, 1/16/2024: 1 RNA Level of Harm - Minimal harm or potential for actual harm -Wednesday, 1/17/2024: three (3) RNAs -Thursday, 1/18/2024: 1 RNA Residents Affected - Some -Friday, 1/19/2024: 3 RNAs -Monday, 1/22/2024: 3 RNAs -Tuesday, 1/23/2024: 1 RNA -Wednesday, 1/24/2024: 1 RNA -Thursday, 1/25/2024: 2 RNAs -Friday, 1/26/2024: 2 RNAs -Monday, 1/29/2024: 2 RNAs -Tuesday, 1/30/2024: 2 RNAs -Wednesday, 1/31/2024: 2 RNAs A review of the facility's Posting of LTC Hours for February 2024 indicated the following RNA assignments for the 7 a.m. to 3 p.m. shift from Monday to Friday: -Thursday, 2/1/2024: 2 RNAs -Friday, 2/2/2024: 1 RNA -Monday, 2/5/2024: 2 RNAs -Tuesday, 2/6/2024: 1 RNA -Wednesday, 2/7/2024: 1 RNA -Thursday, 2/8/2024: 2 RNAs -Friday, 2/9/2024: 2 RNAs -Monday, 2/12/2024: 1 RNA -Tuesday, 2/13/2024: 2 RNAs -Wednesday, 2/14/2024: 2 RNAs -Thursday, 2/15/2024: 3 RNAs 055034 Page 40 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0725 -Friday, 2/16/2024: 2 RNAs Level of Harm - Minimal harm or potential for actual harm -Monday, 2/19/2024: 2 RNAs -Tuesday, 2/20/2024: 2 RNAs Residents Affected - Some -Wednesday, 2/21/2024: 1 RNA -Thursday, 2/22/2024: 1 RNA -Friday, 2/23/2024: 2 RNAs -Monday, 2/26/2024: 1 RNAs -Tuesday, 2/27/2024: 1 RNA -Wednesday, 2/28/2024: 3 RNAs -Thursday, 2/29/2024: 2 RNAs A review of the facility's Posting of LTC Hours for March 2024 indicated the following RNA assignments for the 7 a.m. to 3 p.m. shift from Monday to Friday: -Friday, 3/1/2024: 1 RNA -Monday, 3/4/2024: 3 RNAs -Tuesday, 3/5/2024: 3 RNAs -Wednesday, 3/6/2024: 2 RNAs -Thursday, 3/7/2024: 2 RNAs -Friday, 3/8/2024: 2 RNAs -Monday, 3/11/2024: 3 RNAs -Tuesday, 3/12/2024: 3 RNAs -Wednesday, 3/13/2024: 3 RNAs -Thursday, 3/14/2024: 3 RNAs -Friday, 3/15/2024: 3 RNAs -Monday, 3/18/2024: 2 RNAs -Tuesday, 3/19/2024: 3 RNAs 055034 Page 41 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0725 -Wednesday, 3/20/2024: 3 RNAs Level of Harm - Minimal harm or potential for actual harm -Thursday, 3/21/2024: 3 RNAs -Friday, 3/22/2024: 3 RNAs Residents Affected - Some -Monday, 3/25/2024: 1 RNA -Tuesday, 3/26/2024: 2 RNAs -Wednesday, 3/27/2024: 3 RNAs -Thursday, 3/28/2024: 2 RNAs -Friday, 3/29/2024: 0 RNA A review of the facility's Posting of LTC Hours for April 2024 indicated the following RNA assignments for the 7 a.m. to 3 p.m. shift from Monday to Friday: -Monday, 4/1/2024: 1 RNA -Tuesday, 4/2/2024: 2 RNAs -Wednesday, 4/3/2024: 2 RNAs During an interview, on 4/3/2024 at 8:45 a.m., Restorative Nursing Aide (RNA 2) stated there were 2 RNAs including RNA 2 working that day. RNA 2 stated RNA duties including doing RNA treatments such as ROM, ambulation, transferring, put on splints, helping with feeding residents, passing out meal trays, putting in weights in the system, and anything else that was needed including attending appointments with residents. RNA 2 stated RNAs worked Mondays to Fridays only and there were no RNAs on the weekend. RNA 2 stated they try to put on the splints in the morning and sometimes there was not enough time. During an interview, on 4/3/2024 at 1:55 p.m., Nursing Supervisor (NS 1) stated the purpose of RNA was to maintain the resident's mobility, improve ambulation and ROM. NS 1 stated it was important for residents to receive their RNA treatments to maintain their overall well-being and quality of life and that residents should receive their RNA treatments as ordered. NS 1 stated that if the residents did not receive their RNA orders as ordered, then the residents were at risk for deconditioning, getting weaker, and their ROM and contractures could get worse. During an interview, on 4/3/2024 at 2:37 p.m., the Director of Nursing (DON) stated there should be five RNAs staffed Monday to Friday, one for each nursing station. The DON stated that RNAs were short-staffed and that the facility was aware that the posting of LTC hours of nurse staffing indicated there were 0 to 3 RNAs staffed each day from January 2024 to present. The DON stated the facility was aware that residents with RNA orders were not receiving RNA treatments at least 3 to 5 times a week as ordered. DON also stated that sometimes RNAs were pulled to be CNAs if the CNAs did not have enough staff and then RNA treatments would not be done that day. The DON stated RNA treatments were important to help prevent contractures and to help residents have full mobility. The DON stated the current RNA staff was not enough to meet the needs of residents who required RNA treatments and 055034 Page 42 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0725 services. Level of Harm - Minimal harm or potential for actual harm During an interview, on 4/4/2024 at 8:30 a.m., Registered Nursing Supervisor (NS 2) stated that she was the RNA supervisor and oversaw the RNA services provided to the residents with RNA orders. NS 2 stated the facility was trying to ensure that residents received RNA treatments 3 to 5 times a week and that it was challenging to make that happen. NS 2 stated residents were not getting enough RNA treatments and that the facility needed more RNA staff. Residents Affected - Some During an interview, on 4/4/2024 at 10:28 a.m., Restorative Nursing Aide (CNA/RNA 1) stated CNA/RNA 1 saw residents multiple areas at nursing stations at the facility because they needed to help cover other areas for RNA treatments. CNA/RNA 1 stated CNA/RNA 1 tried to see as many residents as they could, but there were residents that were not seen because there were too many residents and they did not have enough time to see all the residents. During a review of the facility's policies and procedures dated 6/2023, titled Restorative Nursing Program, indicated the Restorative Nursing Program is designed to promote/improve/maintain strength, endurance, balance and mobility .responsibilities of the RNA include: administer restorative activities specific to resident needs and order of the physical therapist. The goal of these activities is to performed 3 - 5 times a week as ordered. The Performance Improvement Plan indicated a Registered Nurse will review the Range of Motion exercises with the RNAs at least every month to ensure that orders are appropriate and are being provided to the residents. 055034 Page 43 of 70 055034 04/04/2024 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 label the valproic acid (used to treat seizure disorders [a sudden, uncontrolled burst of electrical activity in the brain], mental/mood conditions) 250 milligrams (mg, a unit of mass or weight) / 5 milliliter (ml, a unit of volume) 125 mg (2.5 ml) solution bottle with an expiration date, affecting Resident 70 in one out of three inspected medication carts (Med Cart A). The deficient practice of failing to label the medication with the expiration date increased the risk that Resident 70 could have received medication that had become ineffective or toxic and could result in health complications. Findings: A review of Resident 70's Face Sheet indicated the facility admitted the resident on 12/30/2024, with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest tasks), 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 [NAME] joy). A review of Resident 70's History and Physical (H&P), dated 12/27/2023, indicated the resident was awake and alert, speech was mostly coherent, but non-fluent at times. A review of Resident 70's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/22/2024, indicated the resident sometimes had the ability to make self-understood and understand others. A review of Resident 70's Physician's Order indicated an order for: -10/29/2023 Valproic acid (As Sodium Salt) (Depakene oral solution) 250 mg/5 ml. Give 125 mg (2.5 ml) by mouth daily. Indication: Dementia related behavior monitor for behavior (m/b) physical aggression. -10/28/2023 Valproic acid (As Sodium Salt) (Depakene oral solution) 250 mg/5 ml. Give 250 mg (5 ml) by mouth at bedtime. Indication: Dementia related behavior m/b physical aggression. During a concurrent observation and interview on 4/4/2024, at 12:35 p.m., with Licensed Vocational Nurse 1 (LVN 1), observed in Med Cart A Resident 70's valproic acid 250 mg/5 ml, 125 mg (2.5 ml) solution bottle without an expiration date. LVN 1 stated it is important to label the medication with an expiration date, so the nursing staff know when to discard the medication. During an interview on 4/4/2024, at 2:06 p.m., with the Director of Nursing (DON), the DON stated the valproic acid solution bottle should be labeled with an expiration date, so the nursing staff know when to use the medication by. 055034 Page 44 of 70 055034 04/04/2024 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 A review of the facility's policy and procedure titled, General Administrative, last reviewed on 3/2024, indicated all drugs are labeled in accordance with state and federal requirements. Containers with worn illegible or missing labels are returned from the nursing units to the pharmacy for proper disposition. Residents Affected - Few 055034 Page 45 of 70 055034 04/04/2024 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 Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to ensure proper storage, preparation, and distribution of food in accordance with professional standards for food service safety by failing to: 1. Ensure a sandwich labeled with a use by date (the date a food item should be discarded) of 3/31/2024 was not readily available for consumption in the resident's room for one of two sampled residents (Resident 24) investigated under the food care area. This deficient practice had the potential to place residents at increased risk of experiencing foodborne illness (an illness that comes from eating contaminated food or drinks). 2. Ensure food was served at a warm temperature for one of two sampled residents (Resident 38) investigated under the food care area and for one of nine residents (Resident 4) present during the Resident Council task. This deficient practice had the potential to affect residents' palatability leading to weight loss or malnutrition. 3. Dispose of a box of lemons containing mold in the walk-in refrigerator. This deficient practice had the potential for residents to be served contaminated food and potentially cause food poisoning. 4. Ensure soup kept in the kitchen food warmer maintained a temperature of 135 degrees Fahrenheit (a unit of measure for temperature) or higher. This deficient practice had the potential for bacterial growth and decrease the palatability of the food served to the residents. 5. Maintain an air gap between the kitchen ice machine drainpipe and the drain. This deficient practice had the potential for backflow in the ice machine and cause cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). Findings: 1. A review of Resident 24's Face Sheet (admission Record) indicated the facility admitted the resident on 9/6/2023 with diagnoses that included Parkinson's disease (a progressive disorder that affects the nervous system) with dyskinesia (uncontrollable and involuntary movements), osteoarthritis (a disease of the joints [area where two bones make contact] that causes pain), and insomnia (difficulty sleeping). A review of Resident 24's History and Physical (H&P) dated 9/12/2023 indicated the resident had a history of progressive functional decline complicated by cognitive (relating to or involving the processes of thinking and reasoning) decline and was dependent on staff for activities of daily living 055034 Page 46 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0812 but was generally able to feed himself. Level of Harm - Minimal harm or potential for actual harm A review of Resident 24's Minimum Data Set (MDS - an assessment and care screening tool), dated 3/15/2024, indicated the resident was originally admitted to the facility on [DATE] and was able to understand others and make himself understood. The MDS further indicated the resident was dependent on staff for eating, toileting, bathing, dressing, personal hygiene, and transferring between the bed to chair. Residents Affected - Some A review Resident 24's Care Plan (CP) titled, Nutrition and hydration: chronic medical conditions that have the potential to affect nutrition and hydration, dated 9/6/2023, indicated the resident would receive assistance with foods / fluids. The CP further indicated an intervention for staff to assist at mealtime and between meals with food and fluids as needed. During an observation, on 4/2/2024, at 9:25 a.m., Assistant Activities Coordinator 1 (AAC 1) assisted Resident 24 with breakfast in the resident's room. Observed a sandwich in a plastic bag on Resident 24's nightstand labeled with a use by date of 3/31/2024, 8:14 a.m. During a concurrent observation and interview, on 4/2/2024, at 9:37 a.m., with AAC 1, observed AAC 1 exit Resident 24's room with a sandwich. AAC 1 stated she removed the peanut butter and jelly sandwich from Resident 24's nightstand and it was labeled with a use by date of 3/31/2024, 8:14 a.m. AAC 1 stated it was two days past the date the sandwich should have been used by. AAC 1 stated she did not know why the sandwich was still in Resident 24's room. During an interview, on 4/2/2024, at 10 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated sometimes Resident 24 eats at night and an expired sandwich was possibly delivered from the kitchen or the sandwich was left in the resident's room. LVN 2 stated the sandwich should not have been in the resident's room because it was expired and could have become hard. LVN 2 stated the sandwich could have also poisoned the resident leading to diarrhea. During a concurrent interview and record review, on 4/4/2024, at 8:15 a.m., with the Director of Nursing (DON), reviewed the facility policy and procedure (P&P) regarding food storage. The DON stated she was made aware Resident 24 had a sandwich with a use by date of 3/31/2024 in his room. The DON stated she did not think the kitchen would deliver expired food, and the staff assigned to the resident should have checked the date and removed the expired food. The DON stated the facility policy indicated to follow the use by date and the policy was not followed. The DON stated there was a potential for harm to the resident if he ate an expired sandwich resulting in stomach issues and food poisoning. A review of the facility P&P titled, Food Handling Guidelines, last revised 1/2023, indicated food is handled using a Hazard Analysis Critical Control Point (HACCP, a management system in which food safety is addressed) process in accordance with regulatory guidelines. All foods must be identified with the Company's label. A review of the facility P&P titled, Food and Supply Storage, last revised 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. Most, but not all, products contain an expiration date. The words sell-by, best-by, enjoy-by or use-by should precede the date. Foods past the use by date should be discarded. 055034 Page 47 of 70 055034 04/04/2024 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 2. a. A review of Resident 38's Face Sheet indicated the facility admitted the resident on 5/31/2023 with diagnoses that included diastolic heart failure (a condition in which the heart cannot pump enough blood to meet the body's needs), morbid (severe) obesity (body weight that is higher than what is considered healthy for a given height), chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Residents Affected - Some A review of Resident 38's H&P, dated 6/1/2023, indicated the resident was alert and oriented to name, time, and place. A review of Resident 38's MDS, dated [DATE], indicated the resident was able to understand others and make himself understood. The MDS further indicated the resident was dependent on staff for toileting, bathing, lower body dressing, and chair / bed transfers. A review Resident 38's CP titled, Nutrition and Hydration as evidenced by several chronic medical conditions that have potential to affect (Resident 38) nutrition and hydration dated 5/31/2023, indicated the resident was to be comfortable with the foods / fluids provided. During an observation and interview, on 4/2/2024, at 11:43 a.m. with Resident 38, observed the resident sitting up in bed. Resident 38 stated the facility food was not that great and it was rarely delivered warm. 2.b. A review of Resident 4's Face Sheet indicated the facility admitted the resident on 12/8/2022 with diagnosis that included heart failure (a condition in which the heart cannot pump enough blood to meet the body's needs), anemia (low levels of healthy red blood cells), and type two diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]). A review of Resident 4's MDS, dated [DATE], indicated the resident's Brief Interview for Mental Status (a brief cognitive screening measure that focuses on orientation and short-term word recall) screening indicated the resident had intact cognition. A review of the Resident Council Minutes, dated 1/31/2024, indicated the meeting was canceled but resident comments were noted to include one of eight residents indicated the food is always cold. A review of the Resident Council Minutes, dated 2/28/2024, indicated 2 of nine residents indicated the food still comes cold. A review of the Resident Council Minutes, dated 3/27/2024, indicated two of ten residents stated food still comes cold. The minutes indicated to please remind residents that they can ask for food to be reheated. During a Resident Council interview, on 4/3/2024, at 9:56 a.m., Resident 4 stated the facility food was still delivered cold, no residents disagreed. During a concurrent observation and interview, on 4/3/2024, at 11:24 a.m., inside the kitchen, with the Trayline Manager (TM), a food warmer (kitchen device that maintains food temperatures above safe temperatures) indicated a temperature of 165 degrees Fahrenheit. The TM measured the temperature of a bowl of cream-colored soup inside the food warmer and the thermometer indicated a temperature of 128 degrees Fahrenheit. The TM stated residents would not like the soup if it is not served hot and if soup is served to residents at a low temperature, the residents can possibly get an upset 055034 Page 48 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0812 stomach. Level of Harm - Minimal harm or potential for actual harm During an interview, on 4/3/2024, at 12:30 p.m. with the Registered Dietician (RD), the RD stated he was aware there were two residents in the Resident Council who had concerns about the food not being warm. The RD stated those residents have their trays kept at the top of the metal delivery cart. Residents Affected - Some During an interview, on 4/4/2024, at 8:15 a.m. with the Director of Nursing (DON), the DON stated she had heard there were complaints about the temperature of food. The DON stated the meal cart is delivered to the units and the trays should remain in the cart with the doors closed. The DON stated residents are just like everyone else and they want their food to be warm because it tastes better. The DON stated serving food warm is for resident satisfaction and when residents are not satisfied that can lead to depression. A review of the facility P&P titled, Food Handling Guidelines, last revised 1/2023 indicated foods should be held hot for service at a temperature of 135 degrees or higher. 3. During a concurrent observation and interview, on 4/2/2024, at 8:01 a.m., inside the kitchen's walk-in refrigerator, with the Director of Hospitality (DOH), a shelf held a box of lemons on the bottom shelf. The box of lemons contained multiple lemons with white and gray patches. The DOH stated there is some mold on some of the lemons. The DOH stated the lemons were delivered to the facility on 3/29/2024 and were supposed to be returned on 3/31/2024. The DOH stated the box of lemons should have been placed in the returns section of the kitchen. The DOH stated moldy foods should not be stored in the refrigerator because there is a possibility that the mold can spread inside the refrigerator. During an interview with the RD, on 4/2/2024, at 8:43 a.m., the RD stated moldy foods need to be thrown away and the area should be sanitized to make sure the mold does not spread to other areas in the fridge. The RD further stated moldy food items should not be served to residents since it can possibly cause food poisoning, which could potentially lead to death. During an interview with the DON, on 4/4/2024, at 1:36 p.m., the DON stated moldy lemons should be thrown away so that residents do not consume them and do not get sick from consuming the lemons. A review of the facility's P&P titled, Food Handling Guidelines, last reviewed 10/18/2023, indicated to inspect the produce and discard any spoiled, bruised, or damaged produce. The P&P further indicated if a contaminant is found in food, do not serve the food and remove all affected food from service, place is a covered container and label DO NOT SERVE. 4. During a concurrent observation and interview, on 4/3/2024, at 11:24 a.m., inside the kitchen, with the TM, a food warmer indicated a temperature of 165 degrees Fahrenheit. The TM measured the temperature of a bowl of cream-colored soup inside the food warmer and the thermometer indicated a temperature of 128 degrees Fahrenheit. The TM stated residents would not like the soup if it is not served hot and if soup is served to residents at a low temperature, the residents can possibly get an upset stomach. During an interview with the RD, on 4/3/2024, at 11:38 a.m., the RD stated the temperature on hot foods should be at least 140 degrees. The RD stated foods served below that temperature have a higher risk for bacterial growth and if served to residents, can possibly cause foodborne illness in residents. The RD further stated if foods are not served at appropriate temperatures, residents might not 055034 Page 49 of 70 055034 04/04/2024 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 eat the food and can possibly cause malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat). During an interview with the DON, on 4/4/2024, at 1:36 p.m., the DON stated that food delivered to residents should stay warm to satisfy the needs of the residents. Residents Affected - Some A review of the facility's P&P titled, Food Handling Guidelines, last reviewed 10/18/2023, indicated foods should be held hot for service at a temperature of 135 degrees or higher. 5. During a concurrent observation and interview, on 4/2/2024, at 8:21 a.m., inside the kitchen, with the DH, the drainpipe connected to the kitchen ice machine touched the drainage grate on the floor. The DH confirmed the drainpipe was touching the drain grate on the floor and stated the drainpipe should not be touching the drain grate. The DH stated the drainpipe should be elevated above the drain to prevent the possibility of flow reversal and cause cross-contamination between water in the drain and the ice machine. During an interview with the RD, on 4/4/2024, at 10:05 a.m., the RD stated there should be at least a one-inch gap between the ice machine drainpipe and the drain to prevent backflow. The RD further stated if there is backflow, the water from the drain would contaminate the ice and can possibly cause foodborne illness. During an interview with the DON, on 4/4/2024, at 1:36 p.m., the DON stated there should be a gap between the ice machine drainpipe and the drain to prevent backflow. The DON further stated if there is backflow, the ice can get contaminated and possibly cause illness to residents. A review of the U.S. Food and Drug Administration Food Code 2022, dated 1/18/2023, provided by the facility, indicated under backflow prevention methods, an air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch. 055034 Page 50 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly by not covering the garbage container next to the hand washing station in the kitchen during the initial tour of the kitchen conducted on 4/2/2024 between 7:54 a.m. to 9:00 a.m. Residents Affected - Few This deficient practice had the potential for the spread of bacteria and cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) after hand washing. Findings: During a concurrent observation and interview with the Director of Hospitality (DH), on 4/2/2024, at 7:54 a.m., inside the kitchen, the garbage container next to the sink did not have a lid and contained crumpled white paper towels. The DH stated the observed sink was used in the kitchen as the hand washing station. The DH confirmed the garbage container next to the hand washing station did not have a lid. The DH further stated he was unsure if the garbage container next to the hand washing station should be lidded. During an interview with the Registered Dietitian (RD), on 4/2/2024, at 8:34 a.m., the RD stated there should be a lid on the garbage container next to the hand washing station to prevent the possible spread of bacteria after hand washing. During an interview with the RD, on 4/4/2024, at 11:00 a.m., the RD stated the garbage container next to the hand washing station is not in constant use and should be covered. During an interview with the Director of Nursing (DON), on 4/4/2024, at 1:36 p.m., the DON stated the garbage container next to the hand washing in the kitchen should have a lid to contain the dirty contents from coming out of the garbage. The DON further stated without a lid on the garbage container, cross-contamination can possibly occur, and the residents can possibly get sick if cross-contamination occurs. A review of the facility's policy and procedure (P&P) titled, Solid Waste Disposal, last reviewed 10/18/2024, indicated garbage containers are clean, lined, and covered at all times. The P&P further indicated during periods of constant use in food production, food services and dish room areas, garbage cans may remain uncovered if local jurisdiction allows this practice. 055034 Page 51 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0825 Provide or get specialized rehabilitative services as required for a resident. 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 provide rehabilitative therapy services, including occupational therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) and physical therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) services to two of five sampled residents by failing to: Residents Affected - Some 1. Provide OT services to any residents from 10/7/2023 to present, 2. Provide Residents 45 and 63 with an OT evaluation upon admission per the facility's stated standard of care for all admissions, 3. Provide adequate physical therapy treatments and services to meet Resident 45 and Resident 63's PT care plans and goals. These failures prevented residents from receiving OT evaluation and services to address residents' ROM (ROM, full movement potential of a joint), performance in activities of daily living (ADL, basic activities such as eating, dressing, toileting), and create a baseline of ROM for upper extremities (UE, shoulder, elbow, wrist, hand) upon admission. These failures also had the potential to delay progress in restoring Resident 45 and 63's ability to walk, transfer, and overall strength and mobility. Cross Reference to F688 and F725 Findings: 1. During an interview, on 4/2/2024 at 2:08 p.m., Physical Therapist 1 (PT 1) stated he was the only PT for the long-term care (LTC, skilled nursing facility [SNF]) part of the facility's campus. PT 1 stated he also saw patients in the outpatient part of the campus as well as the behavioral therapy part of the campus. PT 1 stated he was at the SNF part of the campus from 1:00 p.m. to 3:00 p.m. only and there was no director of rehabilitation for rehabilitation services here. PT 1 stated there was no OT at this time, because the previous OT left on leave and did not return to work. PT 1 stated he had no idea what would happen if a resident in the SNF needed OT services because there was no OT available. PT 1 stated he did not remember exactly when the OT left on leave, but it may have been about four months ago. During an interview, on 4/4/2024 at 9:27 a.m., the Administrator (ADM) stated the facility was aware that there had been no OT available for residents since October 2023 when the OT was out on leave. The ADM stated the facility had a contract with a company to provide PT and OT services to the residents in the facility and stated the company still had not provided an OT. 055034 Page 52 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview, on 4/4/2024 at 11:30 a.m., the Nurse Practitioner (NP 1) stated she was the NP for residents who were under Medical Doctor's (MD 1) care. NP 1 stated she did not write any orders for OT services, because NP 1 knew there was no OT available to see the residents at this time. NP 1 stated that OTs helped to establish a baseline for all residents for their function, ADLs, and mobility and help to address issues like positioning and splinting (assessing need for splints [rigid material or apparatus used to support and immobilize a broken bone or impaired joint]). During an interview, on 4/4/24 at 2:23 p.m., the ADM stated the last date an OT was available to SNF residents was on 10/6/2023. ADM confirmed there had been no OT available since 10/7/2023 to present. A review of the facility's policy and procedure dated 3/2023, titled, Long Term Care Standard of Care Nursing Protocol, indicated, provide measures to increase mobility per medical provider order: 1. ROM exercises, 4. Occupational therapy consults as ordered. During an interview, on 4/4/2024 at 3:06 p.m., the DON reviewed the Long Term Care Standard of Care Nursing Protocol policy and stated there were no other facility policies to provide rehabilitative therapy services to residents. 2a. A review of Resident 45's Face Sheet indicated the resident was admitted to the facility on [DATE]. A review of Resident 45's Patient Diagnosis Information indicated Resident 45 had diagnoses including, but not limited to hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following cerebral infarction (blockage of the flow of blood brain, causing or resulting in brain tissue death). A review of Resident 45's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 3/1/2024 indicated Resident 45 was cognitively intact (sufficient judgement, planning, organization to manage average demands in one's environment) and had no functional limitations in ROM in both upper and lower extremities lower extremity (LE, hip, knee, ankle, foot). The MDS also indicated Resident 45 required partial assistance (helper does less than half the effort) for eating, oral hygiene and substantial assistance (helper does more than half the effort) with dressing, toileting, chair transfers, and did not walk. A review of Resident 45's medical records indicated there was no Occupational Therapy Initial Evaluation completed. During an observation and interview, on 4/3/2024 at 1:18 p.m., Resident 45 was sitting up in a wheelchair in the resident's room with eyes closed. Resident 45 stated she was sleepy. Resident 45 was able to move the right arm up and down, and the right leg up and down. Resident 45 stated the left side was the problem side and was able to move the left arm and leg up and down a little. Resident 45 stated she never received any OT services and did not know that OT was offered here. During an interview, on 4/3/2024 at 1:55 p.m., Nurse Supervisor (NS 1) stated for new admissions there was usually an order for OT and PT evaluation, but right now there was no OT to provide OT services. NS 1 stated the baseline ROM assessments were completed by PT and OT. NS 1 stated she was not aware of who was completing the UE ROM assessments for new admission since there was no OT at this time. 055034 Page 53 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0825 Level of Harm - Minimal harm or potential for actual harm During an interview, on 4/4/2024 at 8:30 a.m., Nurse Supervisor (NS 2) stated all residents received an OT and PT evaluation upon admission in order to complete a range of motion assessment for both upper and lower extremities. NS 2 stated the facility had not been writing OT evaluation orders recently because there had not been an OT available to evaluate and see residents. NS 2 reviewed Resident 45's medical records and confirmed there was no OT evaluation completed. Residents Affected - Some During an interview, on 4/4/2024 at 11:30 a.m., Nurse Practitioner (NP 1) stated it was the facility's protocol and standard to order OT and PT evaluations for all residents upon admission to establish a baseline for the resident's function, ADLs, mobility, and to see if there were any opportunities for skilled therapy such as positioning, splinting needs, and if a RNA program was appropriate. NP 1 stated Resident 45 was not ordered OT evaluation because there was no OT available at the facility. NP 1 stated at minimum, an OT evaluation should have been completed. 2b. A review of Resident 63's Face Sheet indicated Resident 63 was admitted to the facility on [DATE]. A review of Resident 63's Patient Diagnosis Information indicated Resident 45 had diagnoses including, but not limited to morbid (severe) obesity (disorder involving excessive body fat that increased risk for health problems) and chronic obstructive pulmonary disease (lung disease that causes obstruction of airflow and can limit normal breathing). A review of Resident 63's Minimum Data Set, dated [DATE] indicated Resident 63 was cognitively intact and had no functional limitations in range of motion in both upper and lower extremities. The MDS also indicated Resident 63 required supervision assistance for eating, oral hygiene and substantial assistance (helper does more than half the effort) with lower body dressing, toileting, chair transfers, and to walk 10 feet. A review of Resident 63's medical records indicated there was no Occupational Therapy Initial Evaluation completed. During an observation and interview, on 4/2/2024 at 3:00p.m., Resident 63 was sitting up in a wheelchair. Resident 63 required extra time to verbalize needs. Resident 63 was able to move both arms and legs a little. During an interview, on 4/3/2024 at 1:55 p.m., NS 1 stated for new admissions there was usually an order for OT and PT evaluation, but right now there was no OT to provide OT services. NS 1 stated the baseline ROM assessments were completed by PT and OT. NS 1 stated she was not aware of who was completing the UE ROM assessments for new admission since there was no OT at this time. During an interview, on 4/4/2024 at 8:30 a.m., NS 2 stated all residents received an OT and PT evaluation upon admission to complete a range of motion assessment for both upper and lower extremities. NS 2 stated the facility had not been writing OT evaluation orders recently because there had not been an OT available to evaluate and see residents. NS 2 reviewed Resident 63's medical records and confirmed there was no OT evaluation completed. During an interview, on 4/4/2024 at 11:30 a.m., NP 1 stated it was the facility's protocol and standard to order OT and PT evaluations for all residents upon admission to establish a baseline for the resident's function, ADLs, mobility, and to see if there were any opportunities for skilled therapy such as positioning, splinting needs, and if a RNA program was appropriate. NP 1 stated Resident 63 055034 Page 54 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was not ordered OT evaluation because there was no OT available at the facility. NP 1 stated at minimum, an OT evaluation should have been completed. A review of the facility's policy and procedure dated 3/2023, titled, Long Term Care Standard of Care Nursing Protocol, indicated, provide measures to increase mobility per medical provider order: 1. ROM exercises, 4. Occupational therapy consults as ordered. During an interview, on 4/4/2024 at 3:06 p.m., the DON reviewed the Long Term Care Standard of Care Nursing Protocol policy and stated there were no other facility policies to provide rehabilitative therapy services to residents. 3a. A review of Resident 45's Face Sheet indicated Resident 45 was admitted to the facility on [DATE]. A review of Resident 45's Patient Diagnosis Information indicated Resident 45 had diagnoses including, but not limited to hemiplegia and hemiparesis following cerebral infarction. A review of Resident 45's MDS dated [DATE] indicated Resident 45 was cognitively intact and had no functional limitations in range of motion in both upper and lower extremities. The MDS also indicated Resident 45 required partial assistance (helper does less than half the effort) for eating, oral hygiene and substantial assistance (helper does more than half the effort) with dressing, toileting, chair transfers, and did not walk. A review of Resident 45's Physical Therapy Initial Evaluation, dated 2/21/2024, indicated Resident 45 required moderate assistance (resident requires assistance with about 50 percent of task) with bed mobility, sit to stand, chair/bed to wheelchair transfer, and to walk 10 feet. The PT Initial Evaluation indicated the functional mobility discharge goals were to be independent (no assistance from another person necessary) in bed mobility, sit to stand, chair/bed to wheelchair transfer, and supervision assist to walk 10 feet, walk 50 feet with two turns, and to walk 150 feet. The PT Initial eval indicated resident was able to walk 20 feet with four-wheeled walker (4WW, type of mobility aid with wide base of support and 4 wheels) with moderate assistance of one person on level surface. The PT Initial Evaluation indicated a treatment plan of care for gait (walking) training, therapeutic activities, neuromuscular re-education (rehabilitation techniques to restore muscle function and movement), functional skills (transfers/bed mobility), and resident/family education/training. The PT Initial Evaluation indicated a frequency of treatment for one (1) to two (2) times a week for four (4) weeks. The PT Initial Evaluation indicated the resident's/family's goal for rehabilitation was to be independent with gait with 4WW and indicated recommendations was PT 1 to 2 times a week for 4 weeks for bed mobility, transfers, gait training with 4WW and LE strengthening. A review of the PT Daily Note, dated 2/26/2024, indicated Resident 45 had leg weakness and difficulty getting up from sitting and required moderate assistance for sit to stand. The PT Daily Note indicated resident performed sit to stand five times and was unable to ambulate. The PT Daily Note indicated Therapy Time spent with resident was a total of 15 minutes. A review of the PT Daily Note, dated 3/5/2024, indicated Resident 45 had leg weakness and difficulty getting up from sitting and required moderate assistance for sit to stand. The PT Daily Note indicated Resident 45 was unable to ambulate, and presented with impaired bed mobility, transfers, and gait with 4WW. The PT Daily Note indicated plan for pre-gait training with 4WW. PT Daily Note did not indicate Therapy Time spent with resident. 055034 Page 55 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the PT Daily Note, dated 3/14/2024, indicated Resident 45 had leg weakness and difficulty getting up from sitting and required moderate assistance for sit to stand. The PT Daily Note indicated Resident 45 was unable to ambulate, and presented with impaired bed mobility, transfers, and gait with 4WW. The PT Daily Note did not indicate Therapy Time spent with resident. A review of the PT Daily Note, dated 3/20/2024, indicated Resident 45 had leg weakness and difficulty getting up from sitting and required moderate assistance for sit to stand. The PT Daily Note indicated Resident 45 was unable to ambulate, and presented with impaired bed mobility, transfers, and gait with 4WW. The PT Daily Note did not indicate Therapy Time spent with resident. A review of the PT Daily Note dated 3/25/2024 indicated Resident 45 had leg weakness and difficulty getting up from sitting and required moderate assistance for sit to stand. The PT Daily Note indicated Resident 45 was unable to ambulate, and presented with impaired bed mobility, transfers, and gait with 4WW. The PT Daily Note indicated Therapy Time spent with resident was a total of 15 minutes. A review of the PT Daily Note dated 4/1/2024 indicated Resident 45 had leg weakness and difficulty getting up from sitting and required moderate assistance for sit to stand. The PT Daily Note indicated Resident 45 was unable to ambulate, and presented with impaired bed mobility, transfers, and gait with 4WW. The PT Daily Note indicated Therapy Time spent with resident was a total of 15 minutes. During an interview on 4/2/2024 at 11:25 a.m., the ADM stated the rehabilitation therapy was provided through an outside contracted therapy company and PT 1 came to the SNF area of the campus every day from 1:00 p.m. to 3:00 p.m. During an observation and interview, on 4/3/2024 at 1:18 p.m., Resident 45 was sitting up in a wheelchair in the resident's room. Resident 45 was able to move the right arm up and down, and the right leg up and down. Resident 45 stated the left side was the problem side and was able to move left arm and leg up and down a little. Resident 45 stated she only received PT about once a week and for about 10 minutes. Resident 45 stated she wanted to walk again but the PT session was the same every time and they just moved the arms and legs up and down and did not do any walking. Resident 45 stated she did not feel like she was making any progress with her goals, because she was not getting enough therapy. Resident 45 stated she used to get a lot of therapy at another place, but she had not received a lot of therapy since she came here to the facility. During an interview on 4/4/2024 at 8:55 a.m., NS 2 stated PT was an issue at the facility. NS 2 stated the PT was only at the SNF from 1:00 p.m. to 3:00 p.m. and stated that the residents needed more PT. NS 2 stated she was not sure why the PT was not available for more hours for the SNF residents. NS 2 stated that PT 1 indicated the 2 hours of PT also included time for documentation, so PT 1 sees the SNF residents only 1 to 2 times a week and for a very short amount of time. NS 2 stated that residents had expressed concerns regarding their time spent with PT. During an interview, on 4/4/2024 at 9:27 a.m., the ADM stated the facility was aware of some performance issues with the PT provided through the contract rehabilitation company. During a phone interview, on 4/4/2024 at 11:17 a.m., PT 1 stated he was seeing Resident 45 for PT and the goals were to maintain Resident 45's ROM and transfers and not for walking. PT 1 stated he wrote a PT frequency for treatment for one to two times a week because that was all the time he had to complete the PT sessions. PT 1 stated he was only available to complete PT services at the SNF for 2 hours a day (between 1:00 p.m. and 3:00 p.m.) four days a week. PT 1 stated he had to complete 055034 Page 56 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some evaluations, see RNA residents, document, and did not have time to see residents for more than 1 to 2 times a week. PT 1 stated he also only spent 15 minutes during PT treatments, because that was all the time PT 1 had time for. PT 1 stated all the residents on PT services, including Resident 45, needed more PT, but PT 1 stated he could not provide more. PT 1 stated he was not sure why he was the only PT scheduled to work at the campus, but he had to see patients in the outpatient part, SNF, and behavioral health units. 3b. A review of Resident 63's Face Sheet indicated Resident 63 was admitted to the facility on [DATE]. During a review of Resident 63's Patient Diagnosis Information indicated the resident had diagnoses including, but not limited to morbid (severe) obesity and chronic obstructive pulmonary disease. A review of Resident 63's MDS dated [DATE] indicated Resident 63 was cognitively intact and had no functional limitations in range of motion in both upper and lower extremities. The MDS also indicated Resident 63 required supervision assistance for eating, oral hygiene and substantial assistance (helper does more than half the effort) with lower body dressing, toileting, chair transfers, and to walk 10 feet. A review of Resident 63's PT Initial Evaluation, dated 3/6/2024, indicated Resident 63 required moderate assist with bed mobility, supervision assist for sit to stand, chair/bed to wheelchair transfer, and to walk 10 feet. The PT Initial Evaluation indicated the functional mobility discharge goals were to be independent in bed mobility, sit to stand, chair/bed to wheelchair transfer, and supervision assist to walk 10 feet, walk 50 feet with two turns, and to walk 150 feet. The PT Initial Evaluation indicated Resident 63 was able to walk 10 feet with front-wheeled walker (FWW, type of mobility aid with wide base of support and two wheels in the front) with contact guard assistance (CGA, physical steadying assistance) on a level surface. The PT Initial Evaluation indicated a treatment plan of care for gait training, therapeutic activities, functional skills (transfers/bed mobility), resident/family education/training, and assess equipment needs. The PT Initial Evaluation indicated a frequency of treatment for 1 to 2 times a week for 4 weeks. The PT Initial Evaluation indicated the resident's/family's goal for rehabilitation was to be independent with gait with FWW for 150 feet on a level surface. The PT Initial Evaluation indicated recommendations was PT 1 to 2 times a week for 4 weeks for functional mobility training with FWW. A review of Resident 63's PT Daily Note dated 3/7/2024 indicated Resident 63 required minimal assist for sit to stand, completed sit to stand 5 times. The PT Daily Noted indicated Resident 63 completed transfers with minimal assistance (resident requires less than 25% of assistance to perform the task) from wheelchair, performed walking for 15 feet with FWW with CGA, and transferred to the commode (portable toilet) in the room. The PT Daily Note did not indicate Therapy Time spent with resident. A review of Resident 63's PT Daily Note dated 3/11/2024 indicated Resident 63 required minimal assist for sit to stand, completed sit to stand 5 times. The PT Daily Noted indicated Resident 63 completed transfers with minimal assistance from wheelchair, performed walking for 20 feet with FWW with CGA, and transferred to the commode in the room. The PT Daily Note did not indicate Therapy Time spent with resident. A review of Resident 63's PT Daily Note dated 3/19/2024 indicated Resident 63 required minimal assist for sit to stand, completed sit to stand 5 times. The PT Daily Noted indicated Resident 63 055034 Page 57 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some completed transfers with minimal assistance from wheelchair, performed walking for 30 feet with FWW with CGA, and transferred to the commode in the room. The PT Daily Note did not indicate Therapy Time spent with resident. During a review of Resident 63's PT Daily Note dated 3/21/2024 indicated Resident 63 required minimal assist for sit to stand. The PT Daily Noted indicated Resident 63 completed transfers with minimal assistance from wheelchair and bed, performed walking for 20 feet with FWW with CGA, and transferred to the commode in the room. The PT Daily Note did not indicate Therapy Time spent with resident. A review of Resident 63's LTC note, dated 4/2/202m4 indicated Resident 63 refused PT that day stating she had a prior activity to attend at this time. During an interview, on 4/2/2024 at 11:25 a.m., the ADM stated the rehabilitation therapy was provided through an outside contracted therapy company and PT 1 came to the SNF area of the campus every day from 1 p.m. to 3 p.m. During an observation and interview, on 4/2/2024 at 3 p.m., Resident 63 was sitting up in a wheelchair in the resident's room. Resident 63 required extra time to verbalize complaints. Resident 63 was able to move both arms and legs a little. Resident 63 stated she was not getting enough PT and stated she was getting less than 30 minutes each time. Resident 63 stated she needed more PT and was not walking or doing much of anything during the therapy sessions. Resident 63 stated she felt like she was not getting what she needed in therapy to get better. During an interview, on 4/4/2024 at 8:55 a.m., NS 2 stated PT was also an issue at the facility. NS 2 stated the PT was only at the SNF from 1:00 p.m. to 3:00 p.m. and stated that the residents needed more PT. NS 2 stated she was not sure why the PT was not available for more hours for the SNF residents. NS 2 stated that PT 1 indicated the 2 hours of PT also included time for documentation, so PT 1 sees the SNF residents only 1 to 2 times a week and for a very short amount of time. NS 2 stated that residents had expressed concerns regarding their time spent with PT 1. During an interview, on 4/4/2024 at 9:27 a.m., ADM stated the facility was aware of some performance issues with the PT provided through the contract rehabilitation company. During a phone interview, on 4/4/2024 at 11:17 a.m., PT 1 stated he was seeing Resident 63 for PT. PT 1 stated he wrote a PT frequency for treatment for one to two times a week because that was all the time he had to complete the PT sessions. PT 1 stated he was only available to complete PT services at the SNF for 2 hours a day (between 1:00 p.m. and 3:00 p.m.) four days a week. PT 1 stated he had to complete evaluations, see RNA residents, document, and did not have time to see residents for more than 1 to 2 times a week. PT 1 stated he also only spent 15 minutes during PT treatments, because that was all the time PT 1 had time for. PT 1 stated all the residents on PT services, including Resident 63, needed more PT, but PT 1 stated he could not provide more. PT 1 stated he was not sure why he was the only PT scheduled to work at the campus, but he had to see patients in the outpatient part, SNF, and behavioral health units. A review of the facility's policy and procedure dated 3/2023, titled, Long Term Care Standard of Care Nursing Protocol, indicated, provide measures to increase mobility per medical provider order: 1. ROM exercises .3. Physical therapy consult as ordered. During an interview on 4/4/2024 at 3:06 p.m., the DON reviewed the Long Term Care Standard of Care 055034 Page 58 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0825 Nursing Protocol policy and stated there were no other facility policies to provide rehabilitative therapy services to residents. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 055034 Page 59 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. Based on interview, and record review the facility failed to establish and implement policies and procedures regarding the use of side rails (SR, adjustable rigid plastic bars attached to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) and physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body). This deficient practice had the potential to result in psychosocial harm, decline in physical functioning, physical harm from entrapment (occurs when a resident is caught between the mattress and SR or wall, or within the SR itself), and death of residents affecting 87 of 87 residents residing in the facility. Cross refernce to F604 and 700. Findings: During an interview and record review on 4/3/2024 at 8:00 a.m., with the Director of Nursing (DON), the DON stated the facility did not have a policy regarding the use of SRs or restraints because they are a restraint free facility. The DON stated the importance of policies was that the policies guide the facility to do what is supposed to be done based on the standard of care. During an interview on 4/4/2024 at 8:10 a.m. with the Administrator (ADM), the ADM stated they were now aware of the regulations regarding SRs used in the facility. The ADM stated they now have clarity on the regulation and there should be a specific policy for restraints, and they do not have one. The ADM stated it was her responsibility to ensure policies were in place and the SR policy should include an assessment for SR usage and informed consent for any SRs used in the facility. The ADM Stated they will be developing a policy based on the standards of practice. A review of the facility provided policy and procedure titled, Policy Review and Approval, last reviewed 4/2023, indicated the policy was to maintain a standardized process for the development, review, revise, approval, implementation and maintenance of the facility policies and related standards, procedures, plans, and guidelines. The responsible person drafts policy consistent with the facility standards of policy design. The draft policy is submitted to [NAME] President, Legal Affairs, ADM, or designee who reviews the policy and ensure distribution to appropriate parties for review and comment. The routing for approval of policies is the Policy and Forms Committee, Medical Executive Committee, and Governing Body. [NAME] President, Legal Affairs, ADM or designee coordinates preparation of final draft policy for approval by the Chief Executive Officer and Governing Body. The approved policy is posted on the facility intranet. 055034 Page 60 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain timely resident medical records for one of four (Resident 38) when Resident 38's Physical Therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function)) Initial Evaluation dated 11/8/2023 was not documented until 4/4/2024. This deficient practice had the potential for inaccurate medical documentation and cause a delay in provision of appropriate interventions for Resident 38. Findings: A review of Resident 38's Face Sheet indicated the facility admitted Resident 38 admitted on [DATE]. A review of Resident 38's Patient Diagnosis Information indicated Resident 38 had diagnoses including, but not limited to polyosteoarthritis (swelling and tenderness of a joint causing pain and stiffness), morbid (severe) obesity due to excess calories (disorder involving excessive body fat that increased risk for health problems), abnormalities of gait (walking) and mobility. A review of Resident 38's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 2/27/2024 indicated Resident 38 was cognitively intact (sufficient judgement, planning, organization to manage average demands in one's environment), had no impairment in functional limitation in range of motion (ROM, full movement potential of a joint) in both sides of the upper extremity (UE, shoulder, elbow, wrist, hand) and had impairments on both sides of the lower extremity (LE, hip, knee, ankle, foot). The MDS indicated Resident 38 required set up assistance with eating, partial assistance (helper does less than half the effort) oral hygiene, substantial assistance (helper does more than half the effort) with upper body dressing, personal hygiene, and dependent assistance (helper does all of the effort) for lower body dressing, shower, toileting hygiene, chair/bed to chair transfer. A review of Resident 38's PT Initial Evaluation dated 11/8/2023 indicated the PT Initial Evaluation was signed on 4/4/2024 (about five months later). During a phone interview on 4/4/2024 at 11:16 a.m., with Physical Therapist (PT 1), PT 1 confirmed he did not complete and sign the PT Initial Evaluation for Resident 38 until today (4/4/2024) even though the resident was seen on 11/8/2023. PT 1 stated the documentation was completed late and should have been completed on 11/8/2023. PT 1 stated that all documentation should be completed timely. During an interview on 4/4/2024 at 12:36 p.m., with the Director of Nursing (DON), the DON stated all documentation should be completed within the day or as soon as it happened. The DON stated documentation should be completed timely to make sure that the documentation was accurate because if staff waited too long, the information could be inaccurate, and staff could forget something to document. A review of the facility's policies and procedures dated 9/7/2018, titled, Inter-disciplinary Long Term care Resident Assessment and Reassessment, indicated under Physical Therapy, that documentation 055034 Page 61 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0842 must be completed within 24 hours of service. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055034 Page 62 of 70 055034 04/04/2024 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 to help prevent the development and transmission of communicable diseases and infections for two of four sampled residents observed during medication administration (Resident 2 and 87) and one of two residents investigated for respiratory care (Resident 38) when: Residents Affected - Some 1. Licensed Vocational Nurse 3 (LVN 3) failed to perform hand hygiene prior to preparing Resident 2's medications. 2. LVN 4 failed to perform hand hygiene prior to donning (to put on) gloves and administering eye drops to 3. The facility failed to ensure nasal cannulas (NC, flexible plastic tubing with prongs fitted to the nose that is used to deliver supplemental oxygen or increased airflow to a resident in need of respiratory health) was labeled and dated within the last seven days. These deficient practices had the potential for residents to experience cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) during medication administration and had the potential to cause contamination of the oxygen tubing by infectious microorganisms leading to respiratory distress. Findings: 1. A review of Resident 2's Face Sheet (admission Record) indicated the facility admitted Resident 2 on 9/12/2020. A review of Resident 2's Patient Diagnosis Information, dated 4/4/2024, indicated Resident 2's diagnoses included, but were not limited to, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), acute atopic conjunctivitis (allergic condition of the eyelids and front surface of the eyes), allergic rhinitis (also known as seasonal allergies, an allergic reaction that causes sneezing, congestion, itchy nose and watery eyes), chronic atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), chronic congestive heart failure (CHF - condition in which the heart doesn't pump blood as well as it should), chronic obstructive pulmonary disease (COPD - A group of lung diseases that block airflow and make it difficult to breathe), and type 2 diabetes mellitus (long-term condition in which the body has trouble controlling blood sugar and using it for energy). A review of Resident 2's History and Physical (H&P), dated 10/20/2023, indicated Resident 2 was alert and oriented. A review of Resident 2 Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/9/2024, indicated Resident 2 had moderate cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions), required supervision with eating, oral hygiene, rolling left and right, required moderate assistance with upper body dressing, sit to lying, and walking 10 feet, required maximal assistance with toileting hygiene, lower body dressing, personal hygiene, sit to stand, chair or bed-to-chair transfer, toilet transfer, tub or shower 055034 Page 63 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0880 transfers, and walking 50 feet with two turns, and was dependent on staff for putting on or taking off footwear. Level of Harm - Minimal harm or potential for actual harm A review of Resident 2's Physician Orders indicated Resident 2 was ordered the following: Residents Affected - Some On 10/29/2023, metformin (medication used to treat diabetes mellitus type two) extended release (ER) 500 milligrams (mg - a unit of measure for mass) give 500 mg one tablet by mouth daily for type two diabetes mellitus. On 11/22/2023, furosemide (medication used to treat CHF) 40 mg, give 40 mg one tablet by mouth daily for CHF. On 2/1/2024, dabigatran etexilate mesylate (medication used to thin the blood for residents with atrial fibrillation) 75 mg, give one capsule by mouth every twelve hours, do not open capsule for atrial fibrillation. On 2/1/2024, fluticasone propion/salmeterol (medication used to control and prevent symptoms caused by COPD) 100-50 micrograms (mcg - a unit of measure for mass), inhale one blister with inhalation device twice a day, rinse mouth with water after use for COPD. On 2/1/2024, magnesium oxide (a type of mineral supplement) 400 mg, give 400 mg, one tablet by mouth twice a day for hypomagnesemia (low levels of magnesium in the blood). On 2/1/2024, lactobacillus rhamnosus Gg (a type of bacteria that is naturally found in the gut and used to digestive symptoms) 15 billion cells, give 15 billion cells, give one capsule by mouth twice a day for Clostridioides difficile (a germ that can cause diarrhea and inflammation of the colon) prophylaxis (action taken to prevent disease, especially by specified means or against a specified disease). On 2/1/2024, potassium chloride (a type of electrolyte that helps with nerve function, muscle movement, and heartbeat regulation) 20 milliequivalent (meq - a unit of measure), give 20 meq, one tablet, by mouth twice a day, do not crush, may mix with slurry with water, for hypokalemia (blood level that is below normal in potassium). 055034 Page 64 of 70 055034 04/04/2024 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 On 2/1/2024, guaifenesin (medication used to this mucus to make it easier to clear from the head, throat, and lungs) 600 mg, give 600 mg, one tablet by mouth twice a day, do not crush, for COPD. On 2/18/2024, gabapentin (medication used to treat nerve pain) 300 mg, give 300 mg, one capsule, by mouth twice a day for neuropathic (relating to the nerves) pain. On 2/19/2024, Ketotifen fumarate (medication used to prevent and treat itching of the eyes caused by allergies) 0.025 percent (%), instill one drop into both eyes twice a day for allergic conjunctivitis (eye inflammation caused by allergies). During a concurrent observation and interview, with LVN 3, on 4/3/2024, at 8:55 a.m., at the nursing station close to Resident 2's room, LVN 3 stated she was going to give Resident 2 her medications. LVN 3 moved the medication cart in front of Resident 2's room. LVN 3 placed the following medications into separate small clear cups: Metformin 500 mg one tablet Guaifenesin ER 600 mg one tablet Magnesium oxide 400 mg one tablet Lactobacillus rhamnosus one capsule Furosemide 40 mg one tablet Dabigatran etexilate mesylate 75 mg one tablet Potassium chloride 20 meq one tablet 055034 Page 65 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0880 Gabapentin 300 mg one tablet Level of Harm - Minimal harm or potential for actual harm LVN 3 opened the medication cart and took out the following medications and placed them onto a tray: - Residents Affected - Some Fluticasone propion/salmeterol 100-50 mcg one inhalation. Ketotifen fumarate 0.025% one drop on both eyes, Observed LVN 3 did not perform hand hygiene after moving the medication cart from the nursing station to the front of Resident 2's room. LVN 3 did not perform hand hygiene prior to preparing Resident 2's medications. LVN 3 administered the prepared medications to Resident 2. During an interview with LVN 3, on 4/3/2024, at 9:15 a.m., LVN 3 stated she did not perform hand hygiene prior to preparing Resident 2's medication outside the resident's room. LVN 3 stated she should have performed hand hygiene prior to preparing Resident 2's medications to prevent cross-contamination. LVN 3 further stated if cross-contamination occurs, there is a possibility that the residents could get sick from exposure to possibly infected surfaces. 2. A review of Resident 87's Face Sheet indicated the facility admitted Resident 87 on 1/18/2024. A review of Resident 87's Patient Diagnosis Information, dated 4/4/2024, indicated Resident 87's diagnoses included, but were not limited to, Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors, slow movement, stiffness, and loss of balance), mild intermittent asthma (condition in which a person's airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe), and cataracts (clouding of the normally clear lens of the eye that can result in blurry vision). A review of Resident 87's H&P, dated 1/19/2024, indicated Resident 87 was alert and oriented to himself. A review of Resident 87's MDS, dated [DATE], indicated Resident 87 had severe cognitive impairment, required setup assistance with rolling left and right, and required supervision or moderate assistance with activities of daily living, including eating, hygiene, and surface to surface transfers. A review of Resident 87's Physician Orders indicated Resident 87 was ordered the following: On 1/18/2024, amantadine hydrochloride (a medication used to treat Parkinson's disease and its symptoms) 100 mg, give 100 mg, one tablet by mouth, twice a day for Parkinson's disease. 055034 Page 66 of 70 055034 04/04/2024 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 On 3/6/2024, budesonide (medication used to treat asthma) 90 mcg, inhale 90 mcg, one puff, inhalation twice a day for mild intermittent asthma. On 3/9/2024, bromfenac sodium (medication used to treat eye swelling, redness, and pain after cataract surgery) 0.07%, instill one drop in the right eye, daily, after surgery, for post op (being in the period following surgery) cataract. On 4/2/2024, ropinirole hydrochloride (medication used to treat Parkinson's disease) four mg, give four mg, one tablet by mouth, daily, do not crush, for Parkinson's disease. During a concurrent observation and interview, with LVN 4, in the nursing station close to Resident 87's room, LVN 4 stated he will be giving Resident 87 his medications. LVN 4 placed the following medications in a small cup: Amantadine 100 mg one capsule. Ropinirole four mg one capsule. LVN 4 removed the following meds from the medication cart and placed them on top of the medication cart: Budesonide 90 mcg inhaler. Bromfenac sodium 0.07% eye drops. Observed LVN 4 did not perform hand hygiene prior to preparing Resident 87's medication. LVN 4 entered Resident 87's room and administered the capsules and inhaler to Resident 87. LVN 4 donned gloves without performing hand hygiene prior to donning. LVN 4 asked Resident 87 if the resident had tissue paper for the resident's eye drops in the room and Resident 87 informed LVN 4 he did not. LVN 4 walked out of the Resident 87's room, while wearing gloves, entered a room around the nursing station, came out of the room with a box of tissues, entered Resident 87's room, and gave the box of tissues to Resident 87. LVN 4 did not doff (to take off) the gloves prior to leaving Resident 87's room to get the tissue box. LVN 4 administered eye drops to Resident 87's right eye and gave Resident 87 tissues to dab at the resident's eye. During an interview with LVN 4, on 4/3/2024, at 9:39 a.m., LVN 4 stated he did not perform hand hygiene prior to donning gloves and administering Resident 87's eye drops. LVN 4 stated hand hygiene is 055034 Page 67 of 70 055034 04/04/2024 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 performed prior to donning gloves for infection control. LVN 4 stated there is a possibility of cross-contamination between surfaces if hand hygiene is not performed. LVN 4 further stated if cross-contamination occurs, bacteria can possibly be introduced to the resident during medication administration. During an interview with the Director of Nursing (DON), on 4/4/2024, at 1:36 p.m., the DON stated hand hygiene should be performed before preparing medications, before giving medications to residents, before donning gloves, and after glove use to prevent infection and cross-contamination. The DON further stated if cross-contamination occurs, residents might get sick. A review of the facility's policy and procedure (P&P) titled, Hand Hygiene, last reviewed 10/18/2023, indicated all healthcare staff should comply with hand hygiene practices as defined in this policy. The P&P further indicated if hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in the following clinical situations: Before having direct contact with patients. After contact with the resident's intact skin. After contact with potentially infective material such as bodily fluids, excretions, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the resident. Before putting on gloves and after removing gloves. 3. A review of Resident 38's Face Sheet indicated the facility admitted the resident on 5/31/2023 with diagnoses that included diastolic heart failure (a condition in which the heart cannot pump enough blood to meet the body's needs), morbid (severe) obesity (body weight that is higher than what is considered healthy for a given height), chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of Resident 38's H&P, dated 6/1/2023, indicated the resident was alert and oriented to name, time, and place. A review of Resident 38's MDS, dated [DATE], indicated the resident was able to understand others and make himself understood. The MDS further indicated the resident was dependent on staff for toileting, bathing, lower body dressing, and chair / bed transfers. 055034 Page 68 of 70 055034 04/04/2024 Motion Picture and T.V. Hosp D/P Snf 23388 Mulholland Dr. Woodland Hills, CA 91364

F 0880 A review of Resident 38's physician orders indicated the following orders: Level of Harm - Minimal harm or potential for actual harm - Residents Affected - Some Albuterol sulfate (a medication to open the air passages in the lungs) 2.5 mg / 3 milliliters (mL, a unit of measurement), inhale (breath in) 2.5 mg by mouth every four hours as needed via mask (a device of soft plastic designed to fit over the mouth that delivers medication for inhalation via a long hollow tube) for shortness of breath / wheezing, dated 10/24/2023. Oxygen two liters (liters per minute [LPM], a unit of measurement) per NC as needed if saturation (amount of oxygen in the blood) is below 92 percent (%, a unit of measurement) for hypoxemia (low level of oxygen in the blood), dated 11/1/2023. Oxygen two LPM per NC at bedtime for hypoxemia, dated 12/7/2023. A review of Resident 38's Care Plan (CP) titled, Medical Condition: related to . morbid obesity, .COPD with hypoxemia, .CHF, dated 5/31/2023, indicated (Resident 38) wants to be free of respiratory distress / discomfort / shortness of breath. The CP indicated an intervention to administer oxygen as ordered, to administer nebulizer (a device used for the inhalation of medication treatments) as ordered, and to observe for sign and symptoms of respiratory distress and notify the physician as indicated. During a concurrent observation and interview on 4/2/2024 at 11:50 a.m. with Resident 38, observed the resident lying in bed wearing a NC with the oxygen rate set to 2 LPM. Observed the NC with no labeled date. Resident 38 stated they do not label the oxygen tubing and they do not change it as often as he would like. Resident 38 stated he would like the tubing changed weekly, but they change the tubing about every three weeks, and the tubing gets hard. During a concurrent observation and interview on 4/2/2024 at 12:04 p.m. with Certified Nursing Assistant 4 (CNA 4), observed Resident 38's NC. CNA 4 stated Resident 38's oxygen tubing gets changed when he needs it. CNA 4 stated Resident 38's oxygen tubing was not labeled with the date. During a concurrent observation and interview on 4/2/2024 at 12:29 p.m. with Licensed Vocational Nurse 2 (LVN 2), observed Resident 38's NC and a bag labeled (Resident 38) .Albuterol .Date Issued 3/25/2024 hanging on the wall. LVN 2 stated Resident 38's NC was not labeled, and the bag contained an additional unlabeled mask with oxygen tubing. LVN 2 stated the bag was last changed 3/25/2024, but it should have been changed on 3/31/2024. LVN 2 stated the oxygen tubing should be changed every Sunday night by the licensed nurse, but the date on the bag indicated it was not changed. LVN 2 stated all oxygen tubing should be changed weekly because it gets dirty and can obstruct oxygen flow. LVN 2 stated there was also a concern for bacterial growth in the tubing that could go to the resident's lungs resulting in pneumonia (infection in the lungs). During a concurrent interview and record review on 4/4/2024 at 8:15 a.m. with the DON, reviewed the facility policy and procedure regarding oxygen. The DON stated every Sunday night oxygen tubing is changed by the licensed nurse. The DON stated the bag the oxygen tubing is placed in is labeled with 055034 Page 69 of 70 055034 04/04/2024 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 the date, but staff does not label the oxygen tubing. The DON stated if the oxygen tubing itself was not labeled there was the potential that it would not be changed weekly. The DON stated the facility policy was not followed because the oxygen tubing was not changed weekly or labeled with the date. The DON stated not changing the tubing weekly could potentially result in respiratory infection because bacteria can grow in the tubing. Residents Affected - Some A review of the facility P&P titled, Oxygen Therapy, last reviewed 1/2023, indicated to safely administer oxygen via mask or nasal cannula to treat and prevent the symptoms of hypoxia. Oxygen tubing is dated and replaced weekly. A review of the facility P&P titled, Infection Control Program, last reviewed 10/2023 indicated infections occur in skilled nursing facilities because residents who are vulnerable to infections are gathered in close quarters, frequent contacts are made between people, and pathogenic (harmful) microorganisms are present. Infection control is everyone's responsibility. Each employee is responsible for infection control. The overall goals of the facility Infection Control Program are to limit unprotected exposures to pathogens, limit the transmission of infections associated with procedures, and limit the transmission of infections associated with the use of medical equipment, devices, and supplies. 055034 Page 70 of 70