Health inspection·February 16, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to notify the resident's physician (MD 1) for one of 15 sampled residents (Resident 47) for a change in condition (COC) for significant decline in physical functioning and inability to ambulate (walk) with Restorative Nursing Aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) over a 4-week period by failing to: a. Assess, address and report to MD Resident 47's inability to ambulate during RNA treatment and decline in physical function from walking 85 feet with moderate assistance (about 25-50 percent [%] physical assistance) with a platform walker (PFW, a type of walking assistive device with forearm supports to provide extra support during walking) to ambulating zero feet from week of 1/18/24 to 2/12/24. b. Implement the facility's policy and procedures (P&P) titled, Change in a Resident's Condition or Status, for facility staff to notify the resident's attending physician when there was a significant change in the resident's physical status. These deficient practices resulted in the delay in assessment and intervention for Resident 47's significant decline in physical functioning in ambulation. Resident 47's decline in ambulation was identified on 1/13/24 and persisted until 2/16/24. Resident 47 continued to demonstrate decreased ability to ambulate with RNA staff over a 4-week period and these changes in condition were not reported to the attending physician immediately or at any time during the 4-week period while Resident 47 demonstrated an inability to ambulate with RNA. As of 2/12/24 Resident 47 was still unable to ambulate with RNA staff and the order for assisted ambulation with PFW with RNA as tolerated with Resident 47 was discontinued and Resident 47 did not ambulate with staff. Findings: a. During a concurrent observation and interview on 2/14/24 at 10:06 a.m., in Resident 47's room, Resident 47 was in bed. Resident 47 stated he had not walked and wanted to walk again. Resident 47 stated he was walking before but now he was not walking. Resident 47 stated he had not done any walking with RNA and performed exercises on his own in the bed. During a concurrent observation and interview on 2/15/24 at 10:49 a.m., in Resident 47's room, RNA 1was observed to conduct treatment session to Resident 47. Resident 47 was observed sitting at the edge of the bed, RNA 1 stood in front of the resident demonstrating the exercise movement to Resident 47 and the resident was following RNA 1's demonstration without any physical assistance from RNA 1. Page 1 of 40 055070 055070 02/16/2024 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few RNA 1 was observed counting the number of exercise repetition until Resident 47 completed the movement. Resident 47 was observed able to move the right arm up and down to the resident's ear, bend and straighten the right elbow, roll both shoulders backward, touch the left shoulder with right hand, and open and close the right fingers without limitation. Resident 47 was able to lift the left arm to below shoulder level, touch the right shoulder with left hand, able to bend and straight left elbow, and open and close left fingers. Resident 47 was able to bend and straighten right knee but could not fully straighten the right knee, move the right ankle up and down. Resident 47 was able to bend and straighten the left knee but could not fully straighten the left knee and able to move left ankle up and down. The RNA treatment did not include ambulation. During a concurrent observation and interview on 2/16/24 at 9:20 a.m. with Resident 47, in Resident 47's room, the resident was observed in bed on his back. Resident 47 stated that he would love to walk. Resident 47 stated he felt great and stronger when he walked and felt like he could move his body more when he walked. Resident 47 stated now he was in bed and felt like it took a lot of time for his body to get going to do anything since he had not walked. Resident 47 stated he felt like he could not walk right now and would have to get stronger to be able to walk again. During a review of Resident 47's admission Record, the record indicated Resident 47 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (condition in which the body does not metabolize blood sugar correctly), chronic kidney disease (gradual loss of kidney function to filter waste and excess fluid from the blood), unilateral primary osteoarthritis (loss of protective cartilage that cushions the ends of your bones) right knee and left knee, difficulty in walking, and muscle weakness. During review of Resident 47's Minimum Data Set ([MDS] a standardized assessment and care-screening tool) dated 12/19/23 indicated Resident 47 had no impairment in cognitive skills (ability to think, understand, learn, and remember) for daily decision making and did not exhibit behavior of rejection of care. The MDS indicated Resident 47 did not have any functional limitations in range of motion ROM on either side of the upper or lower extremities. The MDS also indicated Resident 47 required partial or moderate assistance (helper does less than half the effort) from staff for eating, oral hygiene, upper and lower body dressing, and lying to sitting on side of the bed. The MDS indicated Resident 47 was dependent on staff assistance (helper does all the effort or the assistance of two (2) or more helpers is required for the resident to complete the activity) to walk 10 feet, walk 50 feet with two turns and walking 150 feet was not attempted. During a review of Resident 47's care plan titled The resident is at risk for injury, pain and discomfort related to right knee chondrocalcinosis (condition in which calcium crystals (mineral) deposit in joints causing pain), right knee osteoarthritis, back pain with bilateral sciatica (type of pain that radiates down both legs from the back), right knee joint effusion (extra fluid around the joint), left knee osteoarthritis, chronic midline low back pain with left sided sciatica, left great toe amputation (surgical removal of a limb), history of laminectomy (surgical procedure that remove a portion of the spinal bone to relieve pressure on nerves) dated 6/15/23 with target date of 3/18/24. This care plan's goal for Resident 47 was to be able to participate in daily activities. The care plan's intervention included the following: 1. RNA to perform active range of motion ([AROM] a movement at a given joint when the person moves voluntarily) exercises to both upper extremities ([BUE], shoulder, elbow, wrist, hand) daily five times a week for four weeks (5x/wk for 4 wks.) as tolerated. 055070 Page 2 of 40 055070 02/16/2024 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0580 Level of Harm - Minimal harm or potential for actual harm 2. RNA to perform AROM to both lower extremities ([BLE], hip, knee, ankle, feet) daily 5x/wk for 4 weeks as tolerated. 3. Encourage exercise as well as rest periods, monitor medication effectiveness and for medication adverse effects (undesirable harmful effect resulting from medication). Residents Affected - Few 4. Notify MD 1 as needed, monitor presence of pain during daily care, transfer, or positioning. During a review of Resident 47's Physician's Order Summary Report dated 2/14/24 indicated an order dated 7/30/23 for RNA to perform AROM exercises to Resident 47's BUE once a day 5x/wk for 4 weeks as tolerated and an order dated 8/1/23 for RNA to perform BLE AROM daily 5x/wk for 4 weeks as tolerated. During a review of Resident 47's physician order indicated an order for RNA program for assisted ambulation using platform walker once a day, five times a week for 4 weeks or as tolerated was discontinued on 2/12/24 with entered date of 2/13/24 (no start date was indicated). During a review of Resident 47's Joint Mobility assessment dated [DATE] indicated Resident 47's BUE and BLE were within functional limits without impairment. The Joint Mobility Assessment indicated the recommendation for RNA for ambulation using platform walker. During a review of Resident 47's Physical Therapy Evaluation and Plan of Treatment dated 12/4/23 indicated Resident 47 required substantial/maximal assistance to roll from left to right, sit to lying, lying to sitting on side of bed, sit to stand, bed to chair transfers, and walking was not attempted due to environmental limitations. During a review of Resident 47's PT Treatment Encounter Note dated 1/3/24 (last PT treatment) indicated Resident 47 required moderate assistance for transfers, was able ambulate 85 feet with moderate assistance and PFW with one person following with a wheelchair (WC) behind. The PT Treatment Encounter Note indicated Resident 47's gait (ambulation) training with RNA was completed using PFW with moderate assistance and required another person following with WC due to resident having episodes of knee buckling (knees feel weak) but resident was able to self-correct and maintain proper base of support (contact points beneath a person and supporting surface to provide balance when walking), step length (how far each step is), and continuity of steps. The PT Treatment Encounter Note indicated Resident 47 was very cooperative and tolerated the treatment session well. During a review of Resident 47's PT Discharge summary dated [DATE] indicated the discharge reason was the resident achieved highest practical level of functioning. The PT Discharge Summary indicated discharge recommendations to see RNA order. During a review of Resident 47's January 2024 Documentation Survey Report (record of nursing assistant tasks) for RNA, the report indicated for RNA to ambulate Resident 47's with PFW 5x/wk for 4 weeks as tolerated indicated on 1/10/24 Resident 47 ambulated 20 feet for 15 minutes and on 1/12/24 Resident 47 ambulated 50 feet for 20 minutes. Resident 47 did not ambulate with RNA during any other treatment session from 1/13/24 through 1/31/24 (18 days). During a review of Resident 47's RNA Weekly Summary dated 1/11/24, the Weekly Summary indicated Resident 47 was seen by RNA five times a week in past week, (1/3/24- 1/10/24) used the assistive device PFW and walked 25 feet. 055070 Page 3 of 40 055070 02/16/2024 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 47's RNA Weekly Summary dated 1/18/24, the Weekly Summary indicated Resident 47 was seen by RNA five times a week in the past week (1/11/24-1/17/24), received ambulation, AROM of BUE and BLE RNA treatment, used the assistive device front-wheeled walker ([FWW] a device to assist with walking that has a wheel on each of the front legs) and walked zero feet. The RNA Weekly Summary also indicated Resident 47 Complains of pain. Not able to walk with the RNA after medicine given. During a review of Resident 47's RNA Weekly Summary dated 1/25/24, the Weekly Summary indicated Resident 47 was seen by RNA five times a week the in past week (1/18/24-1/24/24), received ambulation, AROM of BUE and BLE RNA treatment, used FWW and walked zero feet. The RNA Weekly Summary also indicated the resident Complains of pain. Not able to walk with the RNA after medicine given. During a review of Resident 47's RNA Weekly Summary dated 2/1/24, the Weekly Summary indicated Resident 47 was seen by RNA five times a week the in past week (1/25/24-1/31/24), received ambulation, AROM of BUE and BLE RNA treatment, used FWW platform and walked zero feet. The RNA Weekly Summary also indicated the resident Complains of pain. Not able to walk with RNA. During a review of Resident 47's RNA Weekly Summary dated 2/8/24, the Weekly Summary indicated Resident 47 was seen by RNA five times a week the in past week (2/1/24-2/7/24), received ambulation, AROM of BUE and BLE RNA treatment, used the assistive device platform, and walked zero feet. The RNA Weekly Summary also indicated the resident Complains of pain. Not able to walk after standing up. During a review of Resident 47's February 2024 Documentation Survey Report for RNA to perform Resident 47's ambulation with PFW, as tolerated the report indicated Resident 47 did not walk with any RNA staff from 2/1/24 to 2/14/24 (14 days). During a review of Resident 47's medical record, the record did not indicate there were any change of condition (COC) reports, reports of Resident 47's inability to ambulate with RNA, or any assessment of Resident 47's decline and interventions to address Resident 47's decline during January 2024 and February 2024. During an interview on 2/15/24 at 10:21 a.m., the Rehabilitation Coordinator (RC) stated changes in a resident's function would trigger a change of condition or significant change and nursing would notify therapy. If a resident could walk with RNA and then could not walk, it would require a therapy screen and therapy intervention. During a concurrent interview and record review on 2/15/24 at 11:01 a.m. with RNA 1, the RNA's January 2024 and February 2024 treatment records and RNA's weekly summary were reviewed. RNA 1 stated Resident 47 currently had orders for RNA to provide AROM exercises to BUE and BLE and did not have orders for ambulation with RNA. RNA 1 stated she was not sure when the RNA's ambulation order was discontinued but it was recent. RNA 1 stated Resident 47 was previously on physical therapy and was transferred to RNA program for walking, but Resident 47 was not able to walk much. RNA 1 stated Resident 47 walked with a platform walker with two staff next to him on either side and one staff walking behind with the wheelchair. RNA 1 stated Resident 47 had not been walking with RNAs. RNA 1 reviewed the RNAs Weekly Summary dated 1/25/24, 2/1/24, 2/8/24, and stated Resident 47 did not walk with RNA due to pain. RNA 1 stated she did not remember the last time she was able to walk with Resident 47. RNA 1 stated there were errors on the January 2024 RNA task documentation and confirmed Resident 47 had not walked for a while. 055070 Page 4 of 40 055070 02/16/2024 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review on 2/15/24 at 11:59 a.m., Resident 47's PT records were reviewed. Physical Therapist (PT 1) stated if residents were discharged from PT and PT recommended an RNA program, then orders for RNA were completed and RNAs were trained on how much assistance to provide during transfers, average distance for walking, and how to monitor ambulation. PT 1 reviewed Resident 47's PT 's Treatment Notes and Discharge summary and stated, on 1/3/24 Resident 47 was able to ambulate 85 feet with moderate assistance and PFW. PT 1 stated there should have been an order for RNA for ambulation with PFW and leg exercises. PT 1 stated Resident 47 should be able to walk 85 feet with moderate assistance, PFW and RNA, because that was the distance Resident 47 was able to walk upon discharge from PT therapy on 1/3/2024. PT 1 stated she was not aware that Resident 47 s no longer ambulate with RNA. PT 1 stated if the resident could walk but failed to receive ambulation exercises, then the resident could decline. PT 1 stated that if a resident who could previously ambulate and was no longer ambulating, the resident was at risk for getting weaker which may affect his ability to transfer. PT 1 stated walking 85 feet was a functional distance and a good distance so it would not be good if the resident was no longer walking with RNA. During a concurrent interview and record review on 2/15/24 at 1:51 p.m. the Director of Staff Development (DSD) stated she was the RNAs supervisor. DSD reviewed Resident 47's medical records and stated there was an order dated 11/15/23 for RNA program for assisted ambulation using PFW once a day 5x/wk for 4 weeks or as tolerated and she discontinued the RNA ambulation order on 2/12/24. DSD stated she discontinued the order due to Resident 47 was not able to ambulate. DSD stated Resident 47 was doing well with ambulation with RNA, then had a slow decline and complained of pain. DSD stated Resident 47 was walking a little less and then he did not walk at all. DSD stated when Resident 47, who was able to walk when discharged from physical therapy on 1/3/24, and was no longer able to walk, it was considered a change of condition and a COC should have been completed immediately so that nursing staff could notify the MD to see if there were any interventions or new orders to address the issue. DSD stated if the resident refused to walk with RNA, then RNAs should attempt three times, and then complete a COC. DSD stated she reviewed Resident 47's medical records and there was no documentation indicating RNA staff or DSD reported the decline in ambulation with RNA to nursing staff, therapy staff, or the resident's physician. DSD stated there were no interventions or assessment completed by nursing or physical therapy to address Resident 47's significant decline in mobility. DSD stated if the MD was notified earlier and Resident 47 received an assessment and interventions to address the reason(s) for Resident 47's inability to walk, Resident 47's current inability to walk could have been avoided. During a phone interview on 2/15/24 at 3:07 p.m. MD 1 stated he did not receive any notification from the facility regarding Resident 47's inability to ambulate with RNA. During a concurrent interview and record review on 2/15/24 at 3:16 p.m. with DSD, the RNA Weekly Summary was reviewed. DSD stated on 1/11/24 RNA's Weekly Summary indicated Resident 47 ambulated 25 feet with RNA assistance. DSD stated Resident 47 ambulated zero feet as indicated on RNA's Weekly Summaries dated 1/18/24, 1/25/24, 2/1/24, and 2/8/14. DSD stated she reviewed Resident 47's medical records again and confirmed there were no documented evidence of RNAs reporting to nursing, physical therapy, or MD 1 of Resident 47's inability to walk. DSD stated there were no nursing assessment, interventions, or COCs completed for Resident 47 to address the resident's decline in functional mobility and inability to ambulate. During a phone interview on 2/16/24 at 10:53 a.m. RNA 2, stated Resident 47 did not walk that much with RNAs. RNA 2 stated Resident 47 did not walk 50 feet with RNA 2 on 1/13/24 and 1/14/24 (as documented by RNA 2) and must have been an error. 055070 Page 5 of 40 055070 02/16/2024 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 2/16/24 at 11:41 a.m., the Director of Nursing (DON) stated a COC was a form of communication about any alteration in a resident's condition and could include a decline in function. The DON stated a COC involves includes notification of a resident's MD, family, or responsible party, and to improve a resident's condition. The DON stated the nurses must complete a COC. The DON stated if a resident was walking while on RNA program and declined in mobility, and then stop walking, it should have been reported. The DON stated the nurses had to complete an assessment and refer a resident to a higher level of care such as physical therapy to reassess the resident. During a concurrent interview and record review on 2/16/24 at 2:38 p.m., Registered Nurse Supervisor (RN 1) stated staff were supposed to complete a COC as soon as possible when there was a decline in Resident 47's physical functioning. RN 1 stated waiting two weeks or four weeks was too long to complete a COC. RN 1 stated it was important to complete a COC immediately or the function of the resident would get worse, and the resident could decline and have contractures. RN 1 stated if a resident was previously walking and then no longer walking, this would be a concern and require a COC to be completed. RN 1 stated after a COC was completed, licensed staff would notify the MD, family, assess the resident, monitor the resident, and if MD ordered therapy evaluations, then therapy would complete those evaluations. RN 1 reviewed Resident 47's medical record and confirmed Resident 47 was previously able to ambulate and that there was no COC completed for Resident 47's decline in ambulation. RN 1 stated she was not notified about Resident 47 not being able to ambulate. During a concurrent interview and record review on 2/16/24 at 2:54 p.m., with the DON, Resident 47's medical record was reviewed. The DON stated no one form the facility's staff informed about Resident 47 had not been walking with RNAs. The DON stated there was no documentation regarding RNAs reporting Resident 47 was not walking with RNAs. The DON stated RNAs should have reported to the licensed nurses and PT about Resident 47 was not walking. The DON stated licensed nurses could have assess Resident 47, informed MD and implement interventions including physical therapy. During a review of the facility's policies and procedures (P&P) revised 2/2021, titled, Change in a Resident's Condition or Status, indicated Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician .when there has been a .significant change in the resident's physical/emotional/mental condition. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or station. Cross Reference to F688, F842 055070 Page 6 of 40 055070 02/16/2024 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure one of 15 sampled residents (Resident 41) Minimum Data Set (MDS - a comprehensive assessment and screening tool) was documented accurately to reflect Resident 41's current health condition of dysphagia (difficulty swallowing) and Speech Therapy (assesses and treats speech and language problems including swallowing disorders) daily three times a week for four weeks due to dysphagia. This failure had the potential to result in a delay of Resident 41 not receiving the necessary care and services. Findings: During a review of Resident 41's admission Record Face Sheet, the Face Sheet indicated, Resident 41 was admitted to the facility on [DATE] with diagnoses of but not limited to gastro-esophageal reflux disease (when stomach content repeatedly and regular flows up into the tube connecting the mouth and stomach (esophagus) resulting in symptoms or complications like dysphagia), muscle weakness, dementia (a general term for loss of memory, language, problem-solving and thinking abilities that are severe enough to interfere with daily life), and chronic constipation (problem with passing stool). During a review of Resident 41's MDS, dated [DATE], and signed date of completion on the MDS was on 2/6/2024, the MDS indicated, Resident 41 had a limited ability to make concrete request. The MDS did not indicate Resident 41 had difficulty swallowing and was receiving speech therapy. During a review of Resident 41's Physician Orders, dated 2/2/2024, the Physician Orders indicated Resident 41 had a physician order for Speech Therapy daily three times a week for four weeks for diet texture analysis (compensatory strategies (new or different ways of completing a task), pt/staff/CG training, and education for oropharyngeal dysphagia (a disorder in which a person cannot swallow food, liquid, or saliva, leading to difficulty in swallowing and breathing). During a review of Resident 41's Speech Therapy Progress Notes, dated 2/3/2024, the Speech Therapy Progress Notes indicated Resident 41 was seen at bedside for skilled dysphagia treatment. The Speech Therapy Progress Notes indicated Resident 41 had increased fatigue and difficulty maintaining an upright position in bed. Speech Therapy Progress Notes indicated moderate to severe oral dysphagia characterized by effortful mastication (chewing) and prolonged mastication time. The Speech Therapy Progress Notes indicated Resident 41 had severe oral residue post swallow and the SLP (Speech Language Pathologist) had to spoon out food in the oral cavity. During an interview on 2/16/2024 at 2:27 pm with Registered Nurse (RN 1), RN 1 stated Resident 41 was seen by speech therapy on 2/2/2024. RN 1 stated Resident 41 is seen by the speech therapist three times a week and the speech therapist gives him applesauce. RN 1 stated Resident 41 is on a puree diet and the family wanted to upgrade the diet. RN 1 stated Resident 41 has a history of dysphagia and is at risk for aspiration (accidentally inhaling a foreign substance in the airways) and choking. During an interview on 2/16/2024 at 2:56 pm with Minimum Data Set nurse (MDSN) the MDSN stated to complete the MDSN she looks at medical records medications, and observes the resident during therapy, then records the information in the resident's medical chart. 055070 Page 7 of 40 055070 02/16/2024 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0636 Level of Harm - Minimal harm or potential for actual harm During an interview on 2/16/2024 at 4:26 pm with the Director of Nursing (DON), DON stated the MDS is the residents' assessment and the MDS coordinator oversees making sure the MDS is thorough. DON stated the assessment tool is submitted and determines risk factors of the resident. DON stated the assessment tool is used for quality of care and helps us see potential problem specific to the resident and to provide the best care and the assessment tool provides a comprehensive summary. Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, revised 7/2017, the P&P indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 055070 Page 8 of 40 055070 02/16/2024 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure one of 15 sampled residents (Resident 45) assessment entries on the Minimum Data Set (MDS- an assessment and care screening tool) related to the section in the MDS called Active Diagnoses was accurately documented to reflect Resident 45's diagnosis of schizophrenia (a mental disorder characterized by recurring episodes of psychosis that are corelated to a misconception of reality). Residents Affected - Few This failure had the potential to result in a negative effect of Resident 45's plan of care and delivery of necessary care and services. Findings: During a review of Resident 45's Face Sheet, the Face Sheet indicated, Resident 45 was admitted to the facility on [DATE] with diagnoses of but not limited to schizophrenia, dementia(a general term for loss of memory, language, problem-solving and thinking abilities that are severe enough to interfere with daily life), depression (mental state of low mood and aversion (a strong dislike) to activity), and anxiety (intense, excessive and persistent worry and fear about everyday situations). During a review of Resident 45's MDS dated [DATE], the MDS indicated, Resident 45 did not have a diagnosis of schizophrenia. During a review of Resident 45's MDS dated [DATE], the MDS indicated Resident 45 rarely had the ability to understand and to make herself understood and had a diagnosis of schizophrenia. During an interview on 2/16/2024 at 12:14 pm with Registered Nurse (RNS 1), RNS 1 stated Resident 45 had schizophrenia behavior per daughter, and Resident 45 was admitted to facility taking medication Invega (medication used to treat schizophrenia) upon admission. RNS 1 stated the MDS should be coded for schizophrenia, so we do not have a discrepancy (a lack of compatibility or similarity between two or more facts). During an interview on at 2:56 pm with Minimum Data Set nurse (MDSN), the MDSN stated the process to complete the MDS is based on review of medical record, medications, observing the resident during therapy, going to the diagnosis in the computerized medical records, and from records in the hospital. MDSN stated she should have coded the MDS for Resident 45 with a diagnosis of schizophrenia because the resident is on Invega medication The MDSN stated she reviewed the MDS and changed the diagnosis on Resident 45's MDS to schizophrenia. During an interview on 2/16/2024 at 4:26 pm with the Director of Nursing (DON), DON stated the MDS needs to be documented correctly because it is an assessment tool and is submitted to Center for Medicare & Medicaid Services(CMS to determines risk factors of the resident. DON stated the MDS is a tool used to provide quality care. DON stated the MDS helps us to see potential problems specific to each resident to provide the best care and provide a comprehensive summary. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, revised 7/2017, the P&P indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate 055070 Page 9 of 40 055070 02/16/2024 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0641 communication between the interdisciplinary team regarding the resident's condition and response to care. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055070 Page 10 of 40 055070 02/16/2024 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure two of 15 sampled residents (Resident 41and Resident 256) baseline care plans were developed and implemented. a. The facility failed to address Speech Therapy in the Care Plan for Resident 41 who was receiving Speech Therapy daily three times a week for four weeks due to dysphagia (difficulty swallowing). b. The facility failed to address mood and behavior concerns in the Care Plan for Resident 256 who was diagnosed with anxiety (intense, excessive, and persistent worry and fear about everyday situations) and depression (mental state of low mood and aversion (a strong dislike) to activity) and taking medications for anxiety. These failures had the potential to result in a delay of Resident 41 and Resident 256 not receiving the necessary care and services. Findings: a. During a review of Resident 41's admission Record (Face Sheet), the Face Sheet indicated, Resident 41 was admitted to the facility on [DATE] with diagnoses of but not limited to gastro-esophageal reflux disease(when stomach content repeatedly and regular flows up into the tube connecting the mouth and stomach (esophagus) resulting in symptoms or complications like dysphagia), muscle weakness, dementia (a general term for loss of memory, language, problem-solving and thinking abilities that are severe enough to interfere with daily life), and chronic constipation (problem with passing stool). During a review of Resident 41's Minimum Data Set (MDS - a comprehensive assessment and screening tool) dated 2/1/2024, the MDS indicated, Resident 41 had limited ability to making concrete request. During a review of Resident 41's Physician Orders, dated 2/2/2024, the Physician Orders indicated Resident 41 had a physician order for Speech Therapy daily three times a week for four weeks for diet texture analysis, compensatory strategies (new or different ways of completing a task), pt/staff/CG training, and education for oropharyngeal dysphagia (a disorder in which a person cannot swallow food, liquid, or saliva, leading to difficulty in swallowing and breathing). During a review of Resident 41's Speech Therapy Progress Notes, dated 2/3/2024, the Speech Therapy Progress Notes indicated Resident 41 was seen at bedside for skilled dysphagia treatment. The Speech Therapy Progress Notes indicated Resident 41 had increased fatigue and difficulty maintaining an upright position in bed. Speech Therapy Progress Notes indicated moderate to severe oral dysphagia characterized by effortful mastication (chewing) and prolonged mastication time. The Speech Therapy Progress Notes indicated Resident 41 had severe oral residue post swallow and the SLP (Speech Language Pathologist) had to spoon out food in the oral cavity. During an interview on 2/16/2024 at 2:27 pm with Registered Nurse (RN 1), RN 1 stated Resident 41 is at risk for aspiration and choking and was seen by speech therapy on 2/2/2024 for dysphagia. RN 1 stated Resident 41 does not have a care plan regarding dysphagia or speech therapy. 055070 Page 11 of 40 055070 02/16/2024 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some b. During a review of Resident 256's Face Sheet, the Face Sheet indicated, Resident 256 was originally admitted to the facility on [DATE] with diagnoses of but not limited to depression, anxiety, and insomnia. During a review of Resident 256's MDS dated [DATE], the MDS indicated, Resident 256 had the ability to express ideas and wants and the ability to make himself understood. The MDS indicated Resident 256 was independent with self-care and mobility. During a review of Resident 256's Physician Orders, dated 1/30/2024, the Physician Orders indicated Resident 256 had a Physician Order for lorazepam (Ativan) 1 mg tablet by mouth every four hours as needed for anxiety manifested by the inability to relax for 14 days. The Physician Orders indicated on 1/30/2024 to monitor for antianxiety medication side effects such as sedation, drowsiness, ataxia (drunk walk), dizziness, nausea, vomiting, confusion, headache, blurred vision, skin rash and episodes of inability to relax. During a review of Resident 256's Nursing Progress Notes dated 1/30/2024. The Nursing Progress Notes indicated, Resident 256 was admitted to the facility with a history of depression. During an interview on 2/16/2024 at 11:30 am with Licensed Vocational Nurse (LVN 3), LVN 3 stated Resident 256 had diagnoses of anxiety and depression. LVN 3 stated Resident 256 was receiving Ativan for anxiety. LVN 3 stated Resident 256 does not have a Baseline Care Plan for anxiety or depression. LVN 3 stated the Base line Care Plan is important to monitor the Resident 256's behavior so the staff can come up with ways to lessen the anxiety and depression. During an interview on 2/16/24 at 12:01pm with Registered Nurse (RNS 1), RN 1 stated Resident 256 had depression and anxiety and was receiving Ativan as needed for anxiety. RN 1 stated she could not find a Baseline Care Plan for Resident 256. RN 1 stated any licensed nurse can completes the Baseline Care Plan. The RN 1 stated the Baseline Care Plan is needed to monitor the patient behavior and side effect of medication, residents at risk for injury. RN 1 stated the Care Plan important for safety of the residents. During an interview on 2/16/24 at 3:48 pm with the Director of Nursing (DON), DON stated the Baseline Care Plan is important for resident with diagnoses of depression, anxiety, or dysphagia needs to be care planned so the staff can ensure safety and to monitor the resident's mood and behavior. DON stated the baseline care plan should have been done for Resident 41 and Resident 256. During a review of the facility's policy and procedure (P&P) titled, Baseline Care Plans, revised 2/2022, the P&P indicated A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. 055070 Page 12 of 40 055070 02/16/2024 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 interview and record review the facility failed to ensure two of 15 sampled residents (Resident 41 and Resident 256) Comprehensive Care Plan was developed to address speech therapy, mood, and behavior concerns. a. the facility failed to address speech therapy in the Care Plan for Resident 41 who was receiving Speech Therapy daily three times a week for four weeks due to dysphagia (difficulty swallowing). b. the facility failed to address mood and behavior concerns in the Care Plan for Resident 256 who was diagnosed with anxiety and depression and taking medications for anxiety. These failures had the potential to result in a delay of Resident 41 and Resident 256 not receiving the necessary care and services. Findings: a. During a review of Resident 41's admission Record (Face Sheet), the Face Sheet indicated, Resident 41 was admitted to the facility on [DATE] with diagnoses of but not limited to gastro-esophageal reflux disease, muscle weakness, dementia, and chronic constipation. During a review of Resident 41's Minimum Data Set (MDS - a comprehensive assessment and screening tool) dated 2/1/2024, the MDS indicated, Resident 41 had limited ability to making concrete request. During a review of Resident 41's Physician Orders, dated 2/2/2024, the Physician Orders indicated Resident 41 had a physician order for Speech Therapy daily three times a week for four weeks for diet texture analysis, compensatory strategies, patient/staff/Caregiver training, and education for oropharyngeal dysphagia. During a review of Resident 41's Speech Therapy Progress Notes, dated 2/3/2024, the Speech Therapy Progress Notes indicated Resident 41 was seen at bedside for skilled dysphagia treatment. The Speech Therapy Progress Notes indicated Resident 41 had increased fatigue and difficulty maintaining an upright position in bed. Speech Therapy Progress Notes indicated moderate to severe oral dysphagia characterized by effortful mastication and prolonged mastication time. The Speech Therapy Progress Notes indicated Resident 41 had severe oral residue post swallow and SLP had to spoon out food in the oral cavity. During an interview on 2/16/2024 at 2:27 pm with Licensed Vocational Nurse (LVN 3), LVN 3 stated Resident 41 is at risk for aspiration and choking and was seen by speech therapy on 2/2/2024 for dysphagia. LVN 3 stated Resident 41 does not have a care plan regarding dysphagia or speech therapy. b. During a review of Resident 256's Face Sheet, the Face Sheet indicated, Resident 256 was admitted to the facility on [DATE] with diagnoses of but not limited to depression (mental state of low mood and aversion (a strong dislike) to activity), and anxiety (intense, excessive, and persistent worry and fear about everyday situations and insomnia (a sleep disorder that causes difficulty falling or staying asleep). During a review of Resident 256's Physician Orders, the Physician Orders indicated on 1/30/2024 055070 Page 13 of 40 055070 02/16/2024 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0656 Level of Harm - Minimal harm or potential for actual harm Resident 256 had a Physician Order for lorazepam (Ativan) 1 mg tablet by mouth every four hours as needed for anxiety manifested by the inability to relax for 14 days. The Physician Orders indicated on 1/30/2024 to monitor for antianxiety medication side effects such as sedation, drowsiness, ataxia (drunk walk), dizziness, nausea, vomiting, confusion, headache, blurred vision, skin rash and episodes of inability to relax. Residents Affected - Some During a review of Resident 256's Nursing Progress Notes dated 1/30/2024. The Nursing Progress Notes indicated; Resident 256 was admitted to the facility with a history of depression. During a review of Resident 256's MDS dated [DATE], the MDS indicated, Resident 256 had the ability to express ideas and wants and the ability to make himself understood. The MDS indicated Resident 256 was independent with self-care and mobility. During an interview on 2/16/2024 at 11:30 am with Licensed Vocational Nurse (LVN 3), LVN 3 stated Resident 256 had diagnoses of anxiety and depression. LVN 3 stated Resident 256 was receiving Ativan for anxiety. LVN 3 stated Resident 256 does not have a Comprehensive Care Plan for anxiety or depression. LVN 3 stated the Comprehensive Care Plan is important to monitor the Resident 256's behavior so the staff can come up with ways to lessen the anxiety and depression. . During an interview on 2/16/24 at 12:01 pm with Registered Nurse (RNS 1), RN 1 stated Resident 256 had depression and anxiety and was receiving Ativan as needed for anxiety. RN 1 stated she could not find a Comprehensive Care Plan for Resident 256. RN 1 stated any licensed nurse can completes the Comprehensive Care Plan. The RN 1 stated the Comprehensive Care Plan is needed to monitor the residents' behavior and side effect of medication, and residents at risk for injury. RN 1 stated the Comprehensive Care Plan is important for the resident's safety. During an interview on 2/16/24 at 3:48 pm with the Director of Nursing (DON), DON stated the Comprehensive Care Plan is important for resident with diagnoses of depression or anxiety needs to be care planned so the staff can ensure safety and to monitor the resident's mood and behavior. DON stated the Comprehensive Care Plan should have been done for Resident 256. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plans, revised 2/2022, the P&P indicated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Cross referenced F-655 055070 Page 14 of 40 055070 02/16/2024 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to reviewed and revised care plans to reflect the changes in the Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) services for one of 15 sampled residents (Resident 15). This deficient practice had the potential to inaccurate provision of services for Resident 15. Findings: During a review of Resident 15's admission Record indicated Resident 15 admitted to the facility on [DATE] with diagnoses including but not limited to, contracture (loss of motion of a joint) right knee, contracture left knee, and type 2 diabetes mellitus (condition in which the body does not metabolize (process) blood sugar correctly). During a review of Resident 15's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 12/3/23 indicated Resident 15 had severe cognitive (ability to learn, remember, understand, and make decision) impairment and required substantial/maximum assistance (helper does more than half the effort) with rolling left to right, sit to lying, oral hygiene. The MDS also indicated Resident 15 required dependent assistance (helper does all of the effort) with bed to chair transfers. The MDS indicated Resident 15 had no functional limitations in range of motion of both upper extremities (BUE, shoulder, elbow, wrist, hand) and impairment on both sides of lower extremities (BLE, hip, knee, ankle, feet). During a review of Resident 15's care plan on 2/13/24 indicated a care plan dated 9/6/19 with target date of 3/11/24 for alteration in physical functioning related to impaired mobility and functional quadriplegia (weakness or paralysis to all four extremities). The care plan goal indicated Resident 15 will be able to develop some area in physical function and achieve some degree of independence. The care plan interventions and tasks included RNA to perform active assistive range of motion exercises (AAROM, movement at a given joint with a person's own effort and assistance from an external force or another person) on left lower extremity (LLE) and gentle passive range of motion (PROM, movement at a given joint with full assistance from another person) exercise on right lower extremity (RLE) five times a week daily as tolerated. During a review of Resident 15's Order Summary Report dated 2/14/24 did not indicate an order for RNA treatment. During an observation on 2/13/24 at 3:30 p.m., in Resident 15's room, observed Resident 15 lying in bed and wearing a hospital gown. Resident 15 was able to lift the left shoulder up and down, bend and straighten the left elbow, and open and close the left hand/fingers. Resident 15 was able to lift the right shoulder about less than shoulder level, bend and straighten the right elbow, and open and close the right hand/fingers. During a concurrent interview and record review on 2/15/24 at 1:16 p.m., with the Director of staff Development (DSD), DSD stated she was the RNA supervisor. DSD stated that all RNA treatment should be care planned and that if RNA services changed or were discontinued, then the care plan needed to be reviewed and revised to reflect the current plan of care and services the resident was receiving. 055070 Page 15 of 40 055070 02/16/2024 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few DSD reviewed Resident 15's care plan and confirmed the care plan for alteration in physical functioning still included as an intervention RNA to perform AAROM exercises on LLE and gentle PROM exercise on RLE 5 times a week daily as tolerated. DSD stated the RNA intervention should have been revised and removed from the care plan. DSD stated all active care plans should reflect the resident's current care. During an interview on 2/16/24 at 11:24 a.m. with the Director of Nursing (DON) stated a care plan was based on assessments and it needed to be developed and changed or improved on as care was reassessed. DON stated a care plan was like a picture of the resident and what the facility was providing for the resident. DON stated a care plan should change as the resident changes and what the facility provided for the resident. During a review of the facility's policies and procedures (P&P) revised 3/2022, titled, Care Plans, Comprehensive Person-Centered, indicated assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions [NAME] 055070 Page 16 of 40 055070 02/16/2024 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0688 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. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident, who was walking 85 feet with moderate assistance (about 25-50 percent [%] physical assistance) with a platform walker ([PFW] a type of assistive device with forearm supports to provide extra support during walking), did not decline in walking and subsequently stopped walking, and failed to ensure the resident, who had limited ROM to both lower extremities received restorative nursing treatment to prevent potential decline in ROM for two of 15 sampled residents (Resident 3 and Resident 47). The facility failed to: 1. Assist Resident 47 with ambulation during Restorative Nursing Aide ([RNA] nursing aide program that help residents to maintain their function and joint mobility) treatment to maintain function and ability to move (walking) in accordance with the Physical Therapy ([PT], profession aimed in the restoration, maintenance, and promotion of optimal physical function) Discharge Recommendation and Treatment Note dated 1/3/24. 2. Ensure Resident 47's physician (MD 1) was notified of the resident's decline in his function to walk and subsequently stopped walking. 3. Ensure RNAs notified nursing and physical therapy staff of Resident 47's decline in walking. 4. Ensure RNA 1 and RNA 2 followed the facility's Policy and Procedure (P&P) titled, Resident Mobility and Range of Motion, by ambulating Resident 47 as ordered to maintain or improve mobility. 5. Ensure RNAs 1 provided Resident 3 with ROM to minimize decline in range of motion and mobility. 6. Ensure RNA 1 provided Active Range of Motion ([AROM] a movement at a given joint when the person moves voluntarily) to Resident 3 to both upper extremities (BUE) including shoulder, elbow, wrist, and hand and to both lower extremities (BLE) including hip, knee, ankle, and feet, five (5) times a week in February 2024 as ordered by the physician. These deficient practices resulted in: 1. Resident 47's significant decline in mobility from being able to walk 85 feet with moderate assistance with a PFW to not being able to walk. 2. Resident 3's potential further decline in ROM and physical function such as rolling, dressing, walking, and transferring. Findings: A. During a review of Resident 47's admission Record, the record indicated Resident 47 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (condition in which the body does not metabolize blood sugar correctly), chronic kidney disease (gradual loss of kidney function to filter waste and excess fluid from the blood), unilateral primary osteoarthritis (loss of protective cartilage that cushions the ends of your bones) right knee and left knee, difficulty in walking, and muscle weakness. 055070 Page 17 of 40 055070 02/16/2024 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0688 Level of Harm - Actual harm Residents Affected - Few During a review of Resident 47's Joint Mobility Assessment ([JMA] assessment of joints to monitor joint range of motion) dated 10/10/23, the Joint Mobility Assessment indicated Resident 47 had both upper extremities (BUE) and both lower extremities (BLE) within functional limits and had no impairment in upper or lower extremities. The Joint Mobility Assessment indicated, recommendation for Resident 47 to ambulate with RNA using a platform walker. During review of Resident 47's Minimum Data Set ([MDS] a standardized assessment and care-screening tool) dated 12/19/23 indicated Resident 47 had no impairment in cognitive skills (ability to think, understand, learn, and remember) for daily decision making and did not exhibit behavior of rejection of care. The MDS indicated Resident 47 did not have any functional limitations in range of motion ROM on either side of the upper or lower extremities. The MDS also indicated Resident 47 required partial or moderate assistance (helper does less than half the effort) from staff for eating, oral hygiene, upper and lower body dressing, and lying to sitting on side of the bed. The MDS indicated Resident 47 was dependent on two staff assistance (staff does all the effort or the assistance for the resident to complete the activity) to walk 10 feet, walk 50 feet with two turns and walking 150 feet was not attempted. During a review of Resident 47's care plan titled The Resident is at Risk for Injury, Pain and Discomfort related to right knee chondrocalcinosis (condition in which calcium crystals (mineral) deposit in joints causing pain), right knee osteoarthritis, back pain with bilateral sciatica (type of pain that radiates down both legs from the back), right knee joint effusion (extra fluid around the joint), left knee osteoarthritis, chronic midline low back pain with left sided sciatica, left great toe amputation (surgical removal of a limb), history of laminectomy (surgical procedure that remove a portion of the spinal bone to relieve pressure on nerves) dated 6/15/23 with target date of 3/18/24 indicated the goal for Resident 47 was to be able to participate in daily activities. The care plan's intervention included the following: 1. RNA to perform AROM exercises to BUE daily five times a week for four weeks (5x/wk for 4 wks.) as tolerated. 2. RNA to perform AROM to BLE daily 5x/wk for 4 weeks as tolerated. 3. Encourage exercise as well as rest periods, monitor medication (unspecified) effectiveness and for medication adverse effects (undesirable harmful effect resulting from medication). 4. Notify MD 1 as needed, monitor presence of pain during daily care, transfer, or positioning. During a review of Resident 47's care plan titled Resident Has Alteration in Physical Functioning Related to Disease Condition .at Risk for Decline in Joint Mobility .Decline in Activities of Daily Living ([ADL] basic activities such as eating, dressing, toileting), dated 6/15/23 with a target date of 3/18/24, indicated a goal for Resident 47 was to develop some area in physical function and achieve some degree of independence and be able to meet ADL needs with staff assistance. During a review of Resident 47's Physician's Order Summary Report dated 2/14/24 indicated an order dated 7/30/23 for RNA to perform AROM exercises to Resident 47's BUE once a day 5x/wk for 4 weeks as tolerated and an order dated 8/1/23 for RNA to perform BLE AROM daily 5x/wk for 4 weeks as tolerated. During a review of Resident 47's physician's order discontinued on 2/12/24, indicated an order for 055070 Page 18 of 40 055070 02/16/2024 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0688 RNA program for assisted ambulation using platform walker once a day, five times a week for 4 weeks or as tolerated. This order was entered on 2/13/24 with no start date indicated. Level of Harm - Actual harm Residents Affected - Few During a review of Resident 47's Physical Therapy (PT) Evaluation and Plan of Treatment dated 12/4/23 indicated Resident 47's prior level of function (before PT's evaluation on 12/4/23) was independent with rolling, sit to lying, lying to sitting on side of bed, supervision or touching assistance with sit to stand, bed to chair transfer, and walking 10 feet. The PT Evaluation and Plan of Treatment indicated Resident 47's discharge plan was to live at home with support from others. The PT Evaluation and Plan of Treatment indicated Resident 47 required substantial/maximal assistance to roll from left to right, sit to lying, lying to sitting on side of bed, sit to stand, bed to chair transfers, and walking was not attempted due to environmental limitations. During a review of Resident 47's PT Treatment Encounter Note dated 12/29/23 indicated Resident 47 required contact guard (physical steadying assistance) minimal assistance (less than 25% physical assistance) with bed mobility, moderate assistance for transfers and that the resident was able to ambulate 85 feet with moderate assistance and PFW. During a review of Resident 47's PT Treatment Encounter Note dated 1/2/24 indicated Resident 47 required contact guard/minimal assistance with bed mobility, moderate assistance for transfers, and that the resident was able to ambulate 85 feet with moderate assist with PFW. During a review of Resident 47's PT Treatment Encounter Note dated 1/3/24 (last PT treatment) indicated Resident 47 required moderate assistance for transfers, was able to ambulate 85 feet with two persons moderate assistance using PFW and with one person following with a wheelchair (WC) behind. The PT Treatment Encounter Note indicated Resident 47's gait (ambulation) training with RNA was completed using PFW with moderate assistance and required another person following with WC due to resident having episodes of knee buckling (knees feel weak) but resident was able to self-correct and maintain proper base of support (contact points beneath a person and supporting surface to provide balance when walking), step length (how far each step is), and continuity of steps. The PT Treatment Encounter Note indicated Resident 47 was very cooperative and tolerated the treatment session well. During a review of Resident 47's PT Discharge summary dated [DATE] indicated the discharge reason was the resident achieved highest practical level of functioning. The PT Discharge Summary indicated discharge recommendations to see RNA order. During a review of Resident 47's Joint Mobility assessment dated [DATE] indicated Resident 47's BUE and BLE were within functional limits without. The Joint Mobility Assessment indicated the recommendation for RNA for ambulation using platform walker. During a review of Resident 47's January 2024 Documentation Survey Report (record of nursing assistant tasks) for RNA, the report indicated for RNA to ambulate Resident 47's with PFW 5x/wk for 4 weeks as tolerated. Resident 47's January 2024 Documentation Survey Report indicated on 1/10/24 Resident 47 ambulated 20 feet for 15 minutes and on 1/12/24 Resident 47 ambulated 50 feet for 20 minutes. The January 2024 Documentation Survey Report indicated RNAs did not ambulate Resident 47 from 1/13/24 through 1/31/24, a total of 18 days. During a review of Resident 47's RNA Weekly Summary dated 1/11/24, the Weekly Summary indicated RNA walked Resident 47 five times a week from 1/3/24 to 1/10/24, used PFW as the assistive device and walked 25 feet. 055070 Page 19 of 40 055070 02/16/2024 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0688 Level of Harm - Actual harm Residents Affected - Few During a review of Resident 47's RNA Weekly Summary dated 1/18/24, the Weekly Summary indicated Resident 47 was seen by RNA five times the week of 1/11/24 to 1/17/24, and provided the resident with ambulation, AROM of BUE and BLE treatment, used a front-wheeled walker ([FWW] a device to assist with walking that has a wheel on each of the front legs) as the assistive device and walked zero feet. The RNA Weekly Summary also indicated Resident 47 Complains of pain. Not able to walk with the RNA after medicine (unspecified) given. During a review of Resident 47's RNA Weekly Summary dated 1/25/24, the Weekly Summary indicated Resident 47 was seen by RNA five times the week of 1/18/24 to 1/24/24, provided the resident with ambulation, AROM of BUE and BLE treatment, used FWW and walked zero feet. The RNA Weekly Summary also indicated the resident Complains of pain. Not able to walk with the RNA after medicine (unspecified) given. During a review of Resident 47's RNA Weekly Summary dated 2/1/24, the Weekly Summary indicated Resident 47 was seen by RNA five times the week of 1/25/24 to 1/31/24, provided the resident with ambulation, AROM of BUE and BLE treatment, used FWW platform and walked zero feet. The RNA Weekly Summary indicated the resident Complains of pain. Not able to walk with RNA. During a review of Resident 47's RNA Weekly Summary dated 2/8/24, the Weekly Summary indicated Resident 47 was seen by RNA five times the week of 2/1/24 to 2/7/24, provided the resident with ambulation, AROM of BUE and BLE RNA, used PFW as the assistive device and walked zero feet. The RNA Weekly Summary indicated the resident Complains of pain. Not able to walk after standing up. During a review of Resident 47's February 2024 Documentation Survey Report for RNA to perform Resident 47's ambulation with PFW, 5x/wk for 4 weeks as tolerated, the report indicated Resident 47 did not walk with any RNA from 2/1/24 to 2/14/24, a total of 14 days. During a review of Resident 47's medical record, the record indicate there were not any change of condition (COC) reports or reports of Resident 47's inability to ambulate with RNA, or any assessment of Resident 47's decline and interventions to address Resident 47's decline during January 2024 and February 2024. During a concurrent observation and interview on 2/13/24 at 10:15 a.m., in Resident 47's room, Resident 47 was in bed and was observed able to move a little bit both legs underneath the blankets. Resident 47 stated he was walking using a walker with PT, but it had been about a month since the last time he walked. Resident 47 stated no staff had been walking with him since physical therapy stopped on 1/3/2024. During a concurrent observation and interview on 2/14/24 at 10:06 a.m., in Resident 47's room, Resident 47 was in bed. Resident 47 stated he had not walked and wanted to walk again. Resident 47 stated he was walking before but now he was not walking. Resident 47 stated he had not done any walking with RNA and performed exercises (unspecified) on his own in the bed. During a concurrent observation and interview on 2/14/24 at 3:13 p.m., in Resident 47's room, Resident 47 was in bed on his back and stated he did not receive any RNA treatment today (2/14/24). During a concurrent observation and interview on 2/15/24 at 10:49 a.m., in Resident 47's room, RNA 1was observed to conduct treatment session to Resident 47. Resident 47 was observed sitting at the edge of the bed. RNA 1 was observed standing in front of the resident demonstrating the exercise 055070 Page 20 of 40 055070 02/16/2024 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0688 Level of Harm - Actual harm Residents Affected - Few movement to Resident 47 and the resident was following RNA 1's demonstration without any physical assistance from RNA 1. RNA 1 was observed counting the number of exercise repetition until Resident 47 completed the exercise. Resident 47 was observed able to move the right arm up and down to the resident's ear, bend and straighten the right elbow, roll both shoulders backward, touch the left shoulder with right hand, and open and close the right fingers without limitation. Resident 47 was able to lift the left arm to below shoulder level, touch the right shoulder with left hand, able to bend and straight left elbow, and open and close left fingers. Resident 47 was able to bend and straighten right knee but could not fully straighten the right knee, move the right ankle up and down. Resident 47 was able to bend and straighten the left knee but could not fully straighten the left knee and able to move left ankle up and down. RNA 1's was observed not ambulating Redesign 47 during observed treatment session on 2/15/24 at 10:49 a.m. During a concurrent interview and record review on 2/15/24 at 11:01 a.m. with RNA 1, the RNA's January 2024 and February 2024 treatment records and RNA's Weekly Summary were reviewed. RNA 1 stated Resident 47 currently had orders for RNA to provide AROM exercises to BUE and BLE and did not have an order for ambulation with RNA. RNA 1 stated she was not sure when the RNA's ambulation order was discontinued but it was recent. RNA 1 stated Resident 47 was previously on physical therapy and was transferred to RNA program for walking, but Resident 47 was not able to walk much. RNA 1 stated Resident 47 has to walk with a platform walker with two staff next to him on either side and one staff walking behind with a wheelchair. RNA 1 stated Resident 47 had not been walking with RNAs. RNA 1 reviewed the RNAs Weekly Summary dated 1/25/24, 2/1/24, 2/8/24, and stated Resident 47 did not walk with RNA due to pain (location not specified). RNA 1 stated she did not remember the last time she was able to walk with Resident 47. RNA 1 stated there were errors on the January 2024 RNA task documentation and confirmed Resident 47 had not walked for a while. During a concurrent interview and record review on 2/15/24 at 11:59 a.m. with PT 1, Resident 47's PT's records were reviewed. PT 1 stated if residents were discharged from PT with recommendations for RNA program, then orders for RNA were completed and RNAs were trained on how much assistance to provide during transfers, average distance for walking, and how to monitor ambulation. PT 1 reviewed Resident 47's PT's Treatment Notes and Discharge summary and stated, on 1/3/24 Resident 47 was able to ambulate 85 feet with moderate assistance and PFW. PT 1 stated there should have been an order for RNA for ambulation with PFW and leg (BLE) exercises. PT 1 stated Resident 47 should be able to walk 85 feet with moderate assistance, PFW and RNA, because that was the distance Resident 47 was able to walk upon discharge from PT therapy on 1/3/2024. PT 1 stated if Resident 47 could walk and did not receive ambulation exercises, then Resident 47 would decline in walking. PT 1 stated RNAs or nurses would report to physical therapy if a resident stopped walking with RNA or if a resident refused RNA. PT 1 stated PT would try to reassess the resident to see if they could benefit from therapy or assess if the resident really did not want to do any RNA. PT 1 stated walking 85 feet was a functional distance and a good distance so it would not be good if the resident was no longer able to walk this distance anymore. PT 1 stated that if a resident, who could previously ambulate, was no longer ambulating, the resident was at risk for getting weaker which may affect his ability to transfer. PT 1 stated Resident 47 would need to be reassessed by PT. PT 1 stated she was not aware Resident 47 was no longer walking with RNA. During a concurrent interview and record review on 2/15/24 at 1:51 p.m. the Director of Staff Development (DSD) stated she was the RNAs supervisor. DSD reviewed Resident 47's medical records and stated there was an order dated 11/15/23 for RNA program for assisted ambulation using PFW once a day 5x/wk for 4 weeks or as tolerated and she discontinued the RNA ambulation order on 2/12/24. DSD stated she discontinued the order due to Resident 47 was not able to 055070 Page 21 of 40 055070 02/16/2024 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0688 Level of Harm - Actual harm Residents Affected - Few ambulate. DSD stated Resident 47 was doing well with ambulation with RNA, then had a slow decline and complained of pain. DSD stated Resident 47 was walking a little less and then he did not walk at all. DSD stated if Resident 47, who was able to walk when discharged from physical therapy on 1/3/24, no longer able to walk, it considered a change of condition, and a COC should have been completed immediately so that nursing staff could notify the MD to see if there were any interventions or new orders to address the issue. DSD stated if the resident refused to walk with RNA, then RNAs should attempt treatments three times, and then complete a COC. DSD stated she reviewed Resident 47's medical records and there was no documentation indicating RNA staff or DSD reported the decline in ambulation with RNA to nursing staff, therapy staff, or the resident's physician. DSD stated there were no interventions or assessment completed by nursing or physical therapy to address Resident 47's significant decline in mobility. DSD stated if the MD was notified earlier and Resident 47 received an assessment and interventions to address the reason(s) for Resident 47's inability to walk, Resident 47's current inability to walk could have been avoided. During a phone interview on 2/15/24 at 3:07 p.m., with Medical Doctor (MD 1) stated he did not receive any notification from the facility regarding Resident 47's decline in mobility and inability to ambulate with RNA. During a concurrent interview and record review on 2/15/24 at 3:16 p.m. with DSD, the RNA Weekly Summaries was reviewed. DSD stated on 1/11/24 RNA's Weekly Summary indicated Resident 47 ambulated 25 feet with RNA assistance. DSD stated Resident 47 ambulated zero feet as indicated on RNA's Weekly Summaries dated 1/18/24, 1/25/24, 2/1/24, and 2/8/14. DSD stated she reviewed Resident 47's medical record again and confirmed there were no documented evidence of RNAs reporting to nursing, physical therapy, or MD 1 of Resident 47's inability to walk. DSD stated there were no nursing assessment, interventions, or COCs completed for Resident 47 to address the resident's decline in functional mobility and inability to ambulate. During a concurrent observation and interview on 2/16/24 at 9:20 a.m. with Resident 47, in Resident 47's room, the resident was observed in bed on his back. Resident 47 stated he would love to walk. Resident 47 stated he felt great and stronger when he walked and felt like he could move his body more when he walked. Resident 47 stated now he was in bed and felt like it took a lot of time for his body to get going to do anything since he had not walked. Resident 47 stated he felt like he could not walk right now and would have to get stronger to be able to walk again. During a phone interview on 2/16/24 at 10:53 a.m. RNA 2, stated Resident 47 did not walk that much with RNAs. RNA 2 stated Resident 47 did not walk 50 feet with RNA 2 on 1/13/24 and 1/14/24 (as documented by RNA 2) and it must have been an error. During an interview on 2/16/24 at 11:41 a.m., the Director of Nursing (DON) stated a COC was a form of communication about any alteration in a resident's condition and would include a decline in function. The DON stated a COC includes notification of a resident's MD, family, or responsible party, and interventions to improve a resident's condition. The DON stated the nurses must complete a COC. The DON stated if Resident 47 was walking while on RNA program and declined in mobility, and then stop walking, it should have been reported. The DON stated the nurses had to complete an assessment and refer Resident 47 to a higher level of care such as physical therapy to reassess the resident. During an interview on 2/16/24 at 2:38 p.m., the Registered Nurse Supervisor (RN 1) stated the licensed nurses were supposed to complete a COC as soon as possible when there was a decline in Resident 47's physical functioning. RN 1 stated waiting two weeks or four weeks was too long to complete a 055070 Page 22 of 40 055070 02/16/2024 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0688 Level of Harm - Actual harm Residents Affected - Few COC. RN 1 stated it was important to complete a COC immediately or the function of the resident would get worse, and the resident could decline and have contractures. RN 1 reviewed Resident 47's medical record and confirmed Resident 47 was previously able to ambulate and that there was no COC completed for Resident 47's decline in ambulation. RN 1 stated she was not notified about Resident 47 not being able to ambulate. During a concurrent interview and record review on 2/16/24 at 2:54 p.m., with the DON, Resident 47's medical record was reviewed. The DON stated no one from the facility's staff informed about Resident 47's had not been walking with RNAs. The DON stated walking 10 feet and taking a few steps with nursing staff considered a decline from walking 85 feet with moderate assistance. The DON stated Resident 47 should continue to walk 85 feet with RNAs because that was the distance the resident was walking with PT. The DON stated there was no documentation regarding RNAs reporting Resident 47 was not walking with RNAs. The DON stated RNAs should have reported to the licensed nurses and PT about Resident 47 was not walking. B. During a review of Resident 3's admission Record indicated Resident 3 originally was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cellulitis (infection of the skin) of left lower limb and right lower limb, acute respiratory failure (any condition that affects breathing function and result in lungs not functioning properly) with hypoxia (low oxygen level in tissues), and muscle weakness. During a review of Resident 3's MDS dated [DATE] indicated Resident 3 had the ability to express ideas and wants and had the ability to understand others. The MDS also indicated Resident 3 had no functional limitations in range of motion in both upper extremities and had impairments on both sides of the lower extremities. The MDS indicated Resident 3 was dependent on staff for position from sit to lying, lying to sitting on side of a bed, and chair to bed transfers. The MDS indicated Resident 3 required substantial/maximal assistance from staff with eating, oral hygiene, and upper body dressing. During a review of Resident 3's Joint Mobility Assessment (JMA) dated 1/7/24 indicated Resident 3 was within functional limits (variance due to normal aging) for BUE and both ankle flexion (bend). The JMA indicated Resident 3 had minimal limitations (75 percent [%] to 100%) in both hip flexion and both knee flexion. During a review of Resident 3's Physician's Order Summary Report dated 2/14/24 indicated an order dated 7/26/23 for RNA to perform AROM exercises to BUE once a day five (5) times a week for four (4) weeks (5x/wk for 4 wks) as tolerated and an order dated 7/26/23 for RNA to perform BLE AROM (5x/wk for 4 wks) once a day as tolerated. During a review of Resident 3's care plan titled Alteration in Physical Functioning dated 3/10/23, the care plan indicated Resident 3 was at risk for decline in joint mobility and ADL decline. During a review of Resident 3's the February 2024 RNA Task Documentation Survey Report, the Survey Report indicated RNA provided to Resident 3 AROM exercises to BUE and BLE daily on 2/8/24, 2/9/24, 2/10/24, 2/11/24, 2/12/24, 2/13/24. During a concurrent observation and interview on 2/13/24 at 3:59 p.m., in Resident 3's room, observed Resident 3 was lying in bed on her back and wearing a hospital gown. Resident 3 stated she had not started doing any exercises with facility staff due to having an infection. Resident 3 was 055070 Page 23 of 40 055070 02/16/2024 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0688 observed able to move both arms with minimal limitations and able to move a little both lower extremities underneath the blankets. Level of Harm - Actual harm Residents Affected - Few During a concurrent observation and interview on 2/14/24 at 3:16 p.m., in Resident 3's room, Resident 3 was observed lying in bed with eyes closed and arousable to verbal cues. Resident 3 stated no staff came on 2/14/24 to do any exercises with her. During a concurrent interview and record review on 2/15/24 at 11:30 a.m., of Resident 3's February 2024 RNA Documentation Survey Report for RNA tasks, RNA 1 stated she did not provided ROM exercises to Resident 3. RNA 1 stated she has helped a Certified Nursing Assistants (CNA) to complete Resident 3's activity of daily living care and counted those encounters as RNA's treatment. RNA 1 stated the RNAs documented that Resident 3 completed RNA treatment when performed ADL care and not specific RNA ROM exercises to BUE and BLE. RNA 1 stated she should not have counted ADL care as RNA treatment because ROM exercises were different and that during ADL care provided to Resident 3, the resident did not move her arms and legs through a full range of motion. During an interview on 2/15/24 at 11:59 a.m., PT 1 stated joint mobility helps with function such as rolling, dressing, walking, transfers. PT 1 stated it was important to maintain Resident 3's joint mobility. During a concurrent interview and record review on 2/15/24 at 1:16 p.m., the DSD stated she was the RNA supervisor. DSD stated RNA orders for treatments were different than CNA or ADL care. DSD stated RNA orders for ROM was more intentional, more purposeful than just ADL care. DSD stated ADL care was not considered an RNA treatment. During an interview on 2/15/24 at 11:24 a.m., the DON stated an RNA program was a restorative program to maintain or improve a resident's ROM ability because residents could have ROM decline without the RNA program. The DON stated the facility should provide the RNA program to resident so that the residents maintained their function and quality of life. The DON stated RNA was different than CNA, because RNA was a special program that provides exercises to residents as recommended by PT and ordered by a resident physician. During a review of the facility's policies and procedures (P&P) revised 7/2017 titled, Resident Mobility and Range of Motion, indicated residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility. The policy indicated, documentation of the resident's progress toward the goals and objectives will include attempts to address any changes or decline in the resident's condition or needs. During a review of the facility's P&P revised 7/2017 titled, Restorative Nursing Services, indicated restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services. During a review of the facility's P&P revised 10/2020 titled, Range of Motion Exercises, indicated, the purpose of this procedure is to exercise the resident's joints and muscles .move each joint through its range of motion three (3) times unless otherwise instructed. Cross reference F580, F842 055070 Page 24 of 40 055070 02/16/2024 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 place the nasal cannula (a device that gives you additional oxygen (supplemental oxygen or oxygen therapy) through the nose to deliver oxygen for one of one sampled resident (Resident 10). Residents Affected - Few This failure had the potential for Resident 10 to not receive necessary respiratory care and services needed. Findings: During a review of Resident 10's admission Order, the admission Order indicated Resident 10 was initially admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses including type 2 diabetes mellitus (high blood sugar), essential hypertension (high blood pressure), functional quadriplegia (a form of paralysis that affects all four limbs, plus the torso), acute and chronic respiratory failure with hypoxia (happens when you don't have enough oxygen in your blood). During a review of Resident 10's Minimum Data Sheet (MDS- a comprehensive assessment and care screening tool) dated 2/03/24 indicated Resident 10 had no cognitive impairment (ability to learn, understand, and make decisions) and requires dependent assistance for all activities of daily living (ADL'S). During a review of Resident 10's care plan dated 03/07/2018, Resident 10 was at risk for ineffective breathing patterns related to acute and chronic respiratory failure with hypoxia, shortness of breath and congestive heart failure ([CHF] is a long term condition in which your heart can't pump blood well enough to meet your body's needs) and requires oxygen at 4 liters per minute via nasal cannula to be given continuously. During an observation on 2/13/2024 at 11:03 a.m., Resident 10 did not get oxygen therapy and the nasal cannula was not place at Resident 10's nostril. During an observation on 2/13/2024 at 3:12 p.m., the nasal cannula was not placed in Resident 10's nostrils. During an interview on 2/15/2024 at 11:14 a.m., the Quality Assurance Nurse (QAN) stated that if oxygen was not given as ordered to Resident 10, it will make the resident short of breath that can lead to distress and respiratory arrest. During an interview on 2/15/2024 at 11:17 a.m., the Infection Preventionist (IP) stated that if resident does not get the oxygen needed as ordered via nasal cannula, it will make the resident blood oxygen level low and can make them short of breath. During an interview on 2/16/2024 at 3:05 p.m., the MDS Coordinator stated that if a resident will continue not to get oxygen as ordered, it can lead to respiratory distress or even death and once the staff finds out the resident is not getting the oxygen must check the resident blood oxygen level and assess the resident for respiratory distress. During a review of facility's policy and procedure titled Oxygen Administration revised 10/2010 055070 Page 25 of 40 055070 02/16/2024 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0695 Level of Harm - Minimal harm or potential for actual harm indicated verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review the resident's care plan to assess for any special needs of the resident. Assemble the equipment and supplies as needed. Place appropriate oxygen device on the resident (i.e., mask, nasal cannula and/or nasal catheter). Residents Affected - Few 055070 Page 26 of 40 055070 02/16/2024 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a documented justification for the continuation of an as needed (PRN) psychotropic medication (Ativan - an anti-anxiety medication) and clonazepam (anti-anxiety medication) beyond 14 days for one 1 out of the 15 sampled residents (Resident 45). This failure had the potential to result in Resident 45 receiving unnecessary medications and can lead to adverse side effects. Findings: During a review of Resident 45's admission Record Face Sheet, the Face Sheet indicated, Resident 45 was admitted to the facility on [DATE] with diagnoses of but not limited to anxiety (intense, excessive and persistent worry and fear about everyday situations schizophrenia(a mental disorder characterized by recurring episodes of psychosis that are corelated to a misconception of reality), dementia (a general term for loss of memory, language, problem-solving and thinking abilities that are severe enough to interfere with daily life), depression(mental state of low mood and aversion (a strong dislike) to activity During a review of Resident 45's Minimum Data Set (MDS- an assessment and care screening tool) dated 1/8/24024, the MDS indicated Resident 45 rarely had the ability to understand and to make herself understood. The MDS indicated Resident 45 had a diagnosis of anxiety and was taking an antianxiety medication. During a review of Resident 45's Medication Regiment Review Report (MRR) dated 2/6/2024, the MRR indicated Resident 45 was taking two medications that are duplicate therapy Ativan and clonazepam and to have the physician document in their progress notes the reason both medications are needed. During an interview on 2/16/2024 at 2:03 pm with Registered Nurse (RN 1), RN 1 stated the physician did not document in the progress notes a reason Ativan and Clonazepam are needed. RN 1 stated she called the physician and documented in the progress notes. RN 1 stated she forgot to get the reason from the physician why the physician disagreed with the pharmacist recommendation. During an interview on 2/16/2024 at 4:30 pm with the Director of Nursing (DON), DON stated the process for licensed staff to inform the physician of a pharmacist recommendation is to call the physician, document the new orders and document in progress notes that the physician disagrees and the reason why it is not being discontinued. During a record review of the facility's policy and procedure (P&P) titled, Consultant Pharmacist Report, dated 8/2019, the P&P indicated the Physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing. If there is potential for serious harm and the attending physician does not concur, or the attending physician refuses to document an explanation for disagreeing, the director of nursing and the consultant pharmacist contact the medical director. 055070 Page 27 of 40 055070 02/16/2024 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: Residents Affected - Few a.Label canned foods, vegetables spring rolls, ice creams, eggs, juices, meat products, and vegetables with no dates received. b.Ensure Freeze 1 was in good working condition. c.Ensure Dietary Aid 1 (DA1) change gloves and wash his hands in between touching dirty surfaces in the kitchen and Dietary Supervisor (DS) wears a glove while carrying an open lid ice cream. These failures had the potential to not identify when food was received, and when it would expire, which could affect resident's health when serve to the residents in the facility and had the potential to cause food-borne illnesses. Findings: a.During a facility kitchen tour observation on 2/13/2024 at 8:49 a.m., observed inside the kitchen freezer some broccoli, corn, carrots, brussels sprouts, vegetables spring rolls, eggs, milk, thick and easy, grape juice, tortillas, cranberry blend, tea bags, tomato catsup, Splenda, pizza sauce, mini marshmallows, multiple 6 pounds canned fruits, granulated garlic, iodized salt, oyster sauce, Worcestershire sauce, ground pork, three loaves of ground beef, bihon noodles, [NAME] noodles, white corn grits, ten pounds package of ground chicken not labelled with no received date. b.During a concurrent facility kitchen tour observation and interview on 2/13/2024 at 09:27 a.m., observed Freezer 1 thermometer not working. Dietary Aide 1 stated that freezer thermometer must be fix right away to monitor the correct temperature. During an interview on 2/13/2024 at 9:43 a.m., [NAME] 2 stated that every kitchen delivery, staff must report to their supervisor if thermometer is broken. [NAME] 2 stated it must be reported and fix right away. c.During a tray line (a process of preparing and setting food for the residents in the facility) observation on 02/14/2024 at 12:16 p.m., the dietary supervisor touches the food plates without gloves and brought milk in the food plate. During a tray line observation on 2/14/2024 at 12:22 p.m., observed Dietary Aid(DA) 1 touches the doorknob and brought the food cart 1 outside the kitchen and return to the tray line and did not change gloves. During a tray line observation on 2/14/2024 at 12:27 p.m., observed DA 1 touches the doorknob and brought the food cart 2 outside the kitchen and return to the tray line and did not change gloves. During a tray line observation on 2/14/2024 at 12:28 p.m., the Dietary Supervisor carried ice cream without cover and without wearing gloves and place it in the food plate. 055070 Page 28 of 40 055070 02/16/2024 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 02/14/2024 at 2:35 p.m., the DA1stated that she should have changed her gloves, or someone should have assisted her to open the kitchen door and brought the food cart outside to be distributed. During an interview on 02/15/2024 at 2:01 p.m., the Dietary Supervisor (DS)admitted that it was an infection control issue for not wearing gloves when serving food during the tray line and stated that she must always wear gloves when touching unclean surfaces and get back to the tray line. During a review of Food Code 2017 indicated, 2-301.14 When to Wash. Food employees shall clean their hands and exposed portions of their arms as specified under 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: (E) After handling soiled equipment or utensils. (I) After engaging other activities that contaminate the hands. During an interview on 02/16/2024 at 12:00 p.m., the maintenance director stated that the facility has called a company to fix the digital thermometer of the kitchen freezer and refrigerator. Maintenance director stated that it is important that the thermometer of both freezer and refrigerator are in working conditions to monitor the acceptable temperature of both freezers and refrigerators to help prevent wasting supplies. During a review of the facility's policy and procedure titled Labeling and dating of foods dated 2023, indicated: All food items in the storeroom, refrigerator, and freezer need to be labeled and dated. During a review of the facility's policy and procedure titled Cold Storage Temperature Monitoring and Record Keeping dated 2023, indicated: Food & Nutrition Services staff shall review and record temperatures of all refrigerators and freezers to ensure they are at the correct temperature for food storage and handling. Food & Nutrition Services staff will check the inside temperature of refrigerators and freezers. During a review of the facility's policy and procedure titled MEAL SERVICE dated 2012, indicated: Meals will be delivered to residents/patients in a timely manner and free from the risk of cross contamination by those who are serving them. 055070 Page 29 of 40 055070 02/16/2024 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 observation, interview, and record review, the facility failed to maintain timely and accurate resident medical records for five of 15 sampled residents (Resident 47, 3,15,19 and 38) when: a. Resident 47's January and February 2024 Restorative Nursing Aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) Documentation Survey Report (record of nursing assistant tasks) was not accurately documented indicating Resident 47 received RNA for ambulation (walking) and ambulated when Resident 47 did not receive RNA treatment for ambulation and/or did not walk. b. Resident 47's quarterly (every three months) Joint Mobility Assessment ([JMA] assessment of joints to monitor joint range of motion {ROM, full movement potential of a joint}) dated 1/10/24 was completed on 2/14/24 (about one month later). c. Resident 3's quarterly Joint Mobility assessment dated [DATE] was completed on 11/7/23 (about one month later) and quarterly Joint Mobility assessment dated [DATE] was completed on 2/14/24 (about five weeks later). d. Resident 15's quarterly Joint Mobility assessment dated [DATE] was completed on 4/10/23 (about five weeks later), quarterly Joint Mobility assessment dated [DATE] was completed on 7/9/23 (about five weeks later), and quarterly Joint Mobility assessment dated [DATE] was completed on 2/14/24 (about one month later). e. Resident 19's quarterly Joint Mobility Assessment was completed for September 2023 and December 2023. f. Resident 38's quarterly Joint Mobility assessment dated [DATE] was completed on 2/14/2023 (about two months later). These deficient practices had the potential for inaccurate medical documentation and reporting of joint range of motion limitations for Residents 47, 3, 15, 19 and 38 and cause a delay in provision of appropriate interventions. Findings: a. During a concurrent observation and interview on 2/14/24 at 10:06 a.m., in Resident 47's room, Resident 47 was in bed. Resident 47 stated he had not walked and wanted to walk again. Resident 47 stated he was walking before but now he was not walking. Resident 47 stated he had not done any walking with RNA and performed exercises on his own in the bed. During a review of Resident 47's admission Record, the record indicated Resident 47 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (condition in which the body does not metabolize blood sugar correctly), chronic kidney disease (gradual loss of kidney function to filter waste and excess fluid from the blood), unilateral primary osteoarthritis (loss of protective cartilage that cushions the ends of your bones) right knee and left knee, difficulty in walking, and muscle weakness. 055070 Page 30 of 40 055070 02/16/2024 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During review of Resident 47's Minimum Data Set ([MDS] a standardized assessment and care-screening tool) dated 12/19/23 indicated Resident 47 had no impairment in cognitive skills (ability to think, understand, learn, and remember) for daily decision making and did not exhibit behavior of rejection of care. The MDS indicated Resident 47 did not have any functional limitations in range of motion ROM on either side of the upper or lower extremities. The MDS also indicated Resident 47 required partial or moderate assistance (helper does less than half the effort) from staff for eating, oral hygiene, upper and lower body dressing, and lying to sitting on side of the bed. The MDS indicated Resident 47 was dependent on staff assistance (helper does all the effort or the assistance of two (2) or more helpers is required for the resident to complete the activity) to walk 10 feet, walk 50 feet with two turns and walking 150 feet was not attempted. During a review of Resident 47's physician order indicated an order for RNA program for assisted ambulation using platform walker (PFW, a type of walking assistive device with forearm supports to provide extra support during walking) once a day, five times a week for four (4) weeks (5x/wk for 4 wks) or as tolerated was discontinued on 2/12/24 with entered date of 2/13/24 (no start date was indicated). During a review of Resident 47's RNA Weekly Summary dated 1/18/24, the Weekly Summary indicated Resident 47 was seen by RNA five times a week in the past week (1/11/24-1/17/24), received ambulation, AROM of BUE and BLE RNA treatment, used the assistive device front-wheeled walker ([FWW] a device to assist with walking that has a wheel on each of the front legs) and walked zero feet. The RNA Weekly Summary also indicated Resident 47 Complains of pain. Not able to walk with the RNA after medicine given. During a review of Resident 47's RNA Weekly Summary dated 1/25/24, the Weekly Summary indicated Resident 47 was seen by RNA five times a week the in past week (1/18/24-1/24/24), received ambulation, AROM of BUE and BLE RNA treatment, used FWW and walked zero feet. The RNA Weekly Summary also indicated the resident Complains of pain. Not able to walk with the RNA after medicine given. During a review of Resident 47's RNA Weekly Summary dated 2/1/24, the Weekly Summary indicated Resident 47 was seen by RNA five times a week the in past week (1/25/24-1/31/24), received ambulation, AROM of BUE and BLE RNA treatment, used FWW platform and walked zero feet. The RNA Weekly Summary also indicated the resident Complains of pain. Not able to walk with RNA. During a review of Resident 47's RNA Weekly Summary dated 2/8/24, the Weekly Summary indicated Resident 47 was seen by RNA five times a week the in past week (2/1/24-2/7/24), received ambulation, AROM of BUE and BLE RNA treatment, used the assistive device platform, and walked zero feet. The RNA Weekly Summary also indicated the resident Complains of pain. Not able to walk after standing up. During a review of Resident 47's January 2024 Documentation Survey Report (record of nursing assistant tasks) for RNA, the report indicated for RNA to ambulate Resident 47 with PFW 5x/wk for 4 weeks as tolerated. The record indicated on 1/11/24 Resident 47 ambulated 20 feet for 10 minutes with Restorative Nursing Aide (RNA 1). It also indicated on 1/15/24 Resident 47 ambulated 25 feet for 15 minutes with RNA 1. During a concurrent interview and record review on 2/15/24 at 11:01 a.m. with RNA 1, the RNA's January 2024 Task Documentation Survey Report entry on 1/11/24 and 1/15/24 were reviewed. RNA 1 stated Resident 47 did not walk with RNA 1 on 1/11/24 and 1/15/24 and that must have been a documentation error. RNA 1 stated that she documented on a lot of residents and can make a mistake. RNA 1 stated 055070 Page 31 of 40 055070 02/16/2024 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0842 Resident 47 had not walked for a while. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 47's January 2024 Documentation Survey Report for RNA the report indicated for RNA to perform ambulation with PFW 5x/wk for 4 weeks as tolerated during January 2024. The record indicated on 1/13/24 and 1/24/24 Resident 47 ambulated 50 feet for 15 minutes with Restorative Nursing Aide (RNA 2). Residents Affected - Many During a phone interview on 2/16/24 at 10:53 a.m., RNA 2 stated if the documentation indicated on 1/13/24 and 1/14/24 that Resident 47 ambulated with RNA 2, then she made an error with documentation as Resident 47 was not able to walk on 1/13/24 and 1/15/24 and if he did walk, it would not be 50 feet it will be a few steps. During a review of Resident 47's January 2024 Documentation Survey Report for RNA the report indicated for RNA to perform ambulation with PFW 5x/wk for 4 weeks as tolerated during January 2024. The record indicated on 1/16/24 Resident 47 ambulated 10 feet for 10 minutes with Certified Nursing Assistant (CNA 1). During a phone interview on 2/16/24 at 10:50 a.m., CNA 1 stated she was a registry (staff employed by an outside agency to provide work on an as needed basis) and worked at the facility on 1/16/24. CNA 1 stated she must have made a documentation error because she was not assigned as an RNA that day and did not remember doing any exercises or walking with any residents on 1/16/24. During a review of Resident 47's January 2024 Documentation Survey Report for RNA the report indicated for RNA to perform ambulation with PFW 5x/wk for 4 weeks as tolerated during January 2024. The record indicated on 1/19/24 Resident 47 ambulated 35 feet for 35 minutes with CNA 2. During a phone interview on 2/16/24 at 11:01 a.m., CNA 2 stated she did not remember which day she worked at the facility on January 2024 as registry CNA. CNA 2 stated she did not remember what she had done with her assigned residents and what had been documented. During a review of Resident 47's January 2024 Documentation Survey Report for RNA the report indicated for RNA to perform ambulation with PFW 5x/wk for 4 weeks as tolerated during January 2024. The record indicated on 1/23/24 Resident 47 ambulated 15 feet for 2 minutes with Medical Records Assistant (MRA). During a concurrent interview and record review on 2/16/24 at 10:36 a.m., MRA stated she was also a licensed CNA and sometimes assisted with RNA treatments if needed. MRA stated she remembered completing RNA ROM exercises with Resident 47 and did not walk with Resident 47. MRA stated RNA documentation made on 1/23/24 was entered in error. MRA stated that the documentation needed to be corrected because it currently did not reflect what had happened and was not a current document. During a review of Resident 47's January 2024 Documentation Survey Report for RNA the report indicated for RNA to perform ambulation with PFW 5x/wk for 4 weeks as tolerated during January 2024. The record indicated on 1/26/24 and 1/28/24 Resident 47 ambulated 115 feet for 15 minutes with Medical Records Supervisor (MRS). During a concurrent interview and record review on 2/16/24 at 10:18 a.m., reviewed Resident 47's January 2024 RNA task documentation. MRS stated only RNAs should be documenting in the RNA task documentation. MRS stated the entries completed on 1/26/24 and 1/28/24 were done in error. MRS stated she 055070 Page 32 of 40 055070 02/16/2024 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many did not walk with the resident or perform any RNA services with Resident 47. MRS stated once staff was aware of a documentation error, staff should strike out the documentation entry. MRS stated it was important to have accurate medical records to ensure the correct staff was performing their responsibilities. During a review of Resident 47's January 2024 Documentation Survey Report for RNA the report indicated for RNA to perform ambulation with PFW 5x/wk for 4 weeks as tolerated during February 2024. The record indicated on 2/10/24 Resident 47 ambulated 100 feet for 15 minutes with Infection Prevention Nurse (IPN). During a concurrent interview and record review on 2/16/24 at 10:09 a.m. with IPN, reviewed Resident 47's February RNA Task Documentation Report. IPN stated on 2/10/24 IPN did not complete any RNA ambulation with Resident 47. IPN stated he documented in error because he did not walk with the resident. IPN stated it was important to have accurate documentation because the documentation showed what the facility did with the resident. IPN stated the documentation showed he walked with the resident but did not perform the activity as documented. b. During a review of Resident 47's Joint Mobility assessment dated with effective date 1/10/24 indicated Resident 47 a signed date of 2/14/24. During a concurrent interview and record review on 2/16/24 at 9:49 a.m. with RC, reviewed Resident 47's Joint Mobility Assessment. RC stated the 1/10/24 JMA was not signed until 2/14/24. RC stated it was late. RC stated it was important to complete assessments timely because if it was not completed timely, then staff would not be able to monitor any joint mobility changes and it would affect the type of interventions provided. c. During a review of Resident 3's admission Record indicated Resident 3 originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cellulitis (infection of the skin) of left lower limb and right lower limb and acute respiratory failure (any condition that affects breathing function and result in lungs not functioning properly) with hypoxia (low oxygen level in tissues), and muscle weakness. During a review of Resident 3's MDS, dated [DATE] indicated Resident 3 had the ability to express ideas and wants and had the ability to understand others. The MDS also indicated Resident 3 had no functional limitations in range of motion in both upper extremities and had impairments on both sides of the lower extremities. The MDS indicated Resident 3 required dependent assistance (helper does all the effort) for sit to lying, lying to sitting on side of bed, and chair to bed transfers. The MDS indicated Resident 3 required substantial/maximal assistance (helper does more than half the effort) with eating, oral hygiene, and upper body dressing. During a review of Resident 3's JMA dated with effective date 10/7/23 indicated a signed date of 11/7/23. During a review of Resident 3's JMA dated with effective date 1/7/24 indicated a signed date of 2/14/24. During a concurrent interview and record review on 2/15/24 at 10:21 a.m., reviewed Resident 15's JMA. RC stated the JMA dated 10/7/23 was not signed until 11/7/23 and was late. RC stated the JMA dated 1/7/24 was not signed until 2/14/24 and was late. 055070 Page 33 of 40 055070 02/16/2024 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview on 2/16/24 at 9:49 a.m., RC stated it was important to complete assessments timely because if it was not completed timely, then staff would not be able to monitor any joint mobility changes and it would affect the type of interventions provided to the residents. d. During a review of Resident 15's admission Record indicated Resident 15 admitted to the facility on [DATE] with diagnoses including but not limited to, contracture (loss of motion of a joint) right knee, contracture left knee, and type 2 diabetes mellitus (condition in which the body does not metabolize blood sugar correctly). During a review of Resident 15's MDS dated [DATE] indicated had severe cognitive (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving) impairment and required substantial/maximum assistance (helper does more than half the effort) with rolling left to right, sit to lying, oral hygiene. The MDS also indicated Resident 15 required dependent assistance (helper does all the effort) with bed to chair transfers. The MDS indicated Resident 15 had no functional limitations in range of motion of both upper extremities (BUE, shoulder, elbow, wrist, hand) and impairment on both sides of lower extremities (BLE, hip, knee, ankle, feet). During a review of Resident 15's JMA dated with effective date 3/1/23 indicated a signed date of 4/16/23. During a review of Resident 15's JMA dated with effective date 6/1/23 indicated a signed date of 7/9/23. During a review of Resident 15's JMA dated with effective date 1/14/24 indicated a signed date of 2/14/24. During a concurrent interview and record review on 2/16/24 at 9:49 a.m., reviewed Resident 15's JMA. RC stated the JMA dated 3/1/23 was not signed until 4/16/23 and was late. RC stated the JMA dated 6/1/23 was not signed until 7/9/23 and was late. RC stated the JMA dated 1/14/24 was not signed until 2/14/24 and was late. RC stated it was important to complete assessments timely because if it was not completed timely, staff would not be able to monitor any joint mobility changes and it would affect the type of interventions provided to the residents. e. During a review Resident 19's admission Record, indicated Resident 19 was admitted to the facility on [DATE], with diagnoses including Parkinson (a brain condition that causes slowed movements, stiffness, and tremors [shaking]). During a review of Resident 19 MDS dated [DATE], indicated Resident 19 was dependent in toileting, showering, bathing, personal hygiene, dressing their lower body. During a review of Resident 19 care plan dated titled Diagnosis of Parkinson dated 11/17/2023, the care plan interventions including staff needed to monitor Resident 19 for stiffness of the arms, legs, and trunk (torso), slowness of movement, and poor balance and coordination. During an interview on 2/14/2024 at 9:42 a.m. with the Rehab Coordinator (RC), stated the Joint Mobility Assessment was done upon admission, quarterly, and annually. During an interview on 2/16/2024 at 8:56 a.m. with the Quality Assurance nurse (QAN), stated that a 055070 Page 34 of 40 055070 02/16/2024 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many JMA was done quarterly. If the staff does not do a JMA upon admission, quarterly and yearly the resident may have a decline in their ROM, develop contractures that the facility staff do not know about, and the physical therapist and occupational therapists will not be able to intervene appropriately. During an interview on 2/16/2024 at 9:53 a.m. with RC stated that if JMA was not done the rehab department will not be able to properly monitor the resident. The RC stated that if there are any changes in the resident regarding mobility, it will affect the interventions they provide. During a concurrent interview and record on 2/16/2024, at 11:22am, with QAN, Resident 19's electronic medical record (an electronic version of a patient's medical history) was reviewed. The QAN stated Resident 19 JMA entry for September 2023 and December 2023 were missing. f. During a review of Resident 38's admission Record, indicated Resident 38 was admitted to the facility on [DATE], with diagnoses including spinal stenosis (the spaces in the spine narrow from injury, aging or a medical condition), right artificial knee joint, osteoporosis(a systemic skeletal disorder characterized by low bone mass), and contusion (a type of bleeding under the skin that can affect bones, muscles, cartilage, and organs) of the left knee. During a review of Resident 38's MDS dated , 12/28/2023, the MDS Joint Mobility Assessment indicated it was completed quarterly for Resident 38. The MDS indicated Resident 38 had impairment on both sides of the lower extremities. The MDS indicated Resident 38 used a wheelchair and did not attempt to walk 10 feet. During an interview on 2/14/2024 at 2:50 p.m. with Restorative Nurse Aide (RNA) 1, RNA 1 stated Resident 38 received RNA 1 services for mobility and strength. RNA 1 stated Resident 38's legs were contracted and if she was not getting the RNA 1 services as ordered by Resident 38's physician, her contractures will worsen. During a concurrent interview and record review on 2/16/2024 at 10:57 a.m. with Licensed Vocational Nurse (LVN) 3, reviewed Resident 38's Joint Mobility Assessment dated 12/23/2023. The Joint Mobility assessment indicated it was initiated on 12/23/2023 and was not completed until 2/14/2023. LVN 3 stated Resident 38 needs extensive assistance with mobility. LVN 3 stated the Joint Mobility Assessment needs to be done quarterly and should be completed the same day it was initiated and not two months later. During an interview on 2/16/24 at 11:24 a.m., with the Director of Nursing (DON) stated the purpose of documentation to have a record of what staff did as they cannot remember everything and trust their memory. DON stated it was a paper trail that showed what happened. DON stated it was important for documentation to be timely, honest, and accurate. DON stated documentation allowed other team members to review what happened and gave a history and helped with planning what to do. DON stated if the documentation was not accurate it could affect resident plan of care. During an interview on 2/16/24 at 11:52 a.m. with Registered Nurse (RN) 1, stated the last Joint Mobility Assessment was initiated on 12/23/2023 and was completed on 2/14/2024. RN 1 stated the Joint Mobility Assessment are done to ensure no decline with ROM and mobility. RN 1 stated if there was two months delay in completing the Joint Mobility Assessment, facility staff will not be able assess resident ROM and mobility if there was improvement or decline. 055070 Page 35 of 40 055070 02/16/2024 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a concurrent interview and record review on 2/16/2024 at 3:50 pm with Rehabilitation Coordinator (RC), Resident 38's Joint Mobility assessment dated [DATE] was reviewed. The Joint Mobility Assessment indicated it was started on 12/23/28 and completed on 2/14/2023. RC stated Joint Mobility Assessments are done quarterly, as needed, and every three months. RC stated the Joint Mobility Assessment was late. During a review of the facility's policy and procedure (P&P) titled, Resident Mobility and Range of Motion, revised 7/2017., the P&P indicated, Residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. Part of the resident's comprehensive assessment, the nurse will identify the resident's current range of motion of his or her joints, current mobility status, and their limitations in movement or mobility. During a review of the facility's P&P revised 7/2017, titled, Charting and Documentation, indicated all services provided to the resident .shall be documented in the resident's medical record. The P&P also indicated documentation in the medical record will be objective, complete, and accurate. The P&P also indicated documentation of procedures and treatments will include care-specific details including .the date and time the procedure/treatment was provided. 055070 Page 36 of 40 055070 02/16/2024 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure laundry aide (LA) perform hand hygiene (hand washing using soap and water, and cleaning hands with waterless or alcohol-based hand sanitizers) after removing dirty gloves and proceeded to handling clean linens. Residents Affected - Few This failure had the potential to cause contamination of clean linens and place residents of the facility at risk for infection. Findings: During an observation on 2/15/2024 at 2:38 p.m. in the facility's laundry room, the LA loaded dirty linens into the washing machine, removed his gloves and gown, put on clean gloves and gown, and went to unload clean laundry without performing hand hygiene. During an interview on 2/15/2024 at 2:50 p.m., the LA stated hand hygiene should have been performed in between handling dirty to clean laundry and when removing dirty gown and gloves. LA stated failure to perform hand hygiene may result in infections among the facility residents. During a record review of the facility's policy and procedure ( P&P) revised 12/2007, titled Handwashing/Hand Hygiene, indicated hand hygiene needs to be done immediately after glove removal and after handling items potentially contaminated with blood, body fluids, or secretions. 055070 Page 37 of 40 055070 02/16/2024 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship for two of two sampled residents (Resident 46 and 47) by failing to: Residents Affected - Some a.Resident 46 was prescribed antibiotic drug without meeting the criteria, before being screen for urinary tract infection ([UTI]an infection in any part of the urinary system). b.Resident 47 was prescribed antibiotic drug without meeting the criteria, before being screen for upper respiratory tract infection. These failures had the potential for resident to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use. Findings: a. During a record review of Resident 46's admission Order (Face Sheet) indicated Resident 46 was admitted on [DATE] with diagnoses including Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), type 2 diabetes mellitus (high blood sugar), severe chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should). During a record review of Resident 46's Minimum Data Sheet (MDS- a comprehensive assessment and care planning tool) dated 01/19/24 indicated Resident 46 had severe cognitive impairment (ability to learn, understand, and make decisions) and requires dependent assistance for all activities of daily living (ADL'S). During a record review of physician's order dated 1/12/2024 for antibiotic order-Bactrim DS oral tablet 800-160 mg (unit of measurement) (Sulfamethoxazole-Trimethoprim). Give one tablet by mouth two times a day for UTI for fourteen days. During a record review of the Infection Report Surveillance form indicated that Resident 46 was not screened for UTI and urine analysis (U/A) was not done. During a record review with the Director of Nursing (DON) on 2/14/2024 at 3:27 p.m., it indicated there was an antibiotic ordered for urinary tract infection (UTI) IN January of 2024 but there was no laboratory works done and there was no order for urinalysis, culture, and sensitivity. b. During a record review of Resident 47's admission Order (Face Sheet), the Face Sheet indicated Resident 47 was admitted on [DATE] with diagnoses including diabetes mellitus, lobar pneumonia (a type of pneumonia characterized by the infection and inflammation of one or more lobes of the lung and is typically caused by bacteria), and acute pulmonary edema (a buildup of fluid in your lungs). During a record review of Resident 47's MDS dated [DATE] indicated Resident 47 had no cognitive impairment and requires moderate assistance for all activities of daily living. During a review of the Infection Report Surveillance form indicated that Resident 47 was not screened for URTI (upper respiratory tract infection) and laboratory works was not done for cellulitis. 055070 Page 38 of 40 055070 02/16/2024 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 2/15/2024 at 9:13 a.m., the Infection Preventionist (IP) stated that he should have recommended the assigned physician for laboratory works and urinalysis, culture, and sensitivity for confirmation that it is really a UTI. IP stated that the possibility of using antibiotic makes the resident resistant. During an interview on 2/15/2024 at 9:15 a.m., the DON stated that the IP should have questioned the antibiotic order for both Resident 46 and 47 and should have recommended laboratory works first and urinalysis with culture and sensitivity must be done first to prevent unnecessary use of antibiotic. During a concurrent interview and record review on 2/15/2024 at 11:01 a.m. of the laboratory test , both quality assurance nurse (QAN) and IP stated that there was no laboratory works done for both Resident 46 and Resident 47 done to confirm as a determining factor that antibiotics are needed and must be prescribed. During a record review of the facility's policy and procedure titled, Antibiotic Stewardship revised 12/2016 indicated: Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents. When a culture and sensitivity (C&S) is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. 055070 Page 39 of 40 055070 02/16/2024 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 8 of 17 residents rooms met the 80 square feet (sq. ft.) per residents in multiple resident rooms. Rooms 20, 21, 22, 23, 25, 26, 27, and 32 housed four residents per room and room [ROOM NUMBER] and 34 housed five residents per room. Findings: During the initial tour on 2/13 /2024 at 9:10 a.m.to the facility, Rooms 20, 21, 22, 23, 25, 26, 27, and 32 rooms did not meet the requirement of 80 sq. ft. per residents and rooms [ROOM NUMBERS] housed five residents per room. During a record review of Client Accommodations Analysis form, provided by the facility Maintenance Supervisor (MS) Rooms 20, 21, 22, 23, 25, 26, 27, and 32 occupied by four residents each, ranged in total square feet measurement between 73.8 square feet to 76.5 square feet per resident and rooms [ROOM NUMBERS] occupied by five residents ranged in total square feet measurement between 500.73 square feet for rooms [ROOM NUMBERS].42 square feet for Rooms 34. During a review of Room Waiver letter dated 2/16/2024 provided by the ADM, indicated, all residents and caregivers have ample space in mobility with walkers and wheelchairs. Residents can get in and out of their rooms with ease and facility staffs are able to give care of administrator treatment or medications to the residents inside the room. The floor size of room [ROOM NUMBER] was 500.73 sq. ft (100.14 sq. ft per bed), and room [ROOM NUMBER] was 534.42 sq. ft (106.88 sq. ft per bed. This exceeds the required 80 sq. ft per bed requirement. During the survey observations from 2/13/2024 to 2/16/2024, the other resident's room were observed with sufficient space to move around freely within the room, and the nursing staff had enough space to provide care. There was space for the beds, side tables, dressers, and resident care equipment. There were no adverse effects noted to the residents' privacy, health, and safety, which could have been compromised by the size of the rooms. 055070 Page 40 of 40