Health inspection·October 19, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of 15 sampled residents (Resident 41) were treated with dignity and respect by failing to ensure Resident 41 had a dignity bag (restores the dignity of [catheterized-a procedure used to drain the bladder and collect urine, through a flexible tube patient by concealing urinary drainage bags from public view) for his indwelling catheter ([foley catheter] plastic or rubber tube that is inserted into the bladder to drain the urine) drainage bag (collects urine). This deficient practice had the potential to affect Resident 41's self-esteem, self-worth, and feeling embarrassed. Findings: During a review of Resident 41's admission Record (Face Sheet), indicated Resident 41 was admitted to the facility on [DATE], with diagnoses including infection (occurs when a [microorganism- an organism that is so small it can only be viewed under a microscope] enters a person's body and causes harm) of the right shoulder, urinary tract infection (infection in any part of the urinary system), and neuropathic bladder (lack bladder control). During a review of Resident 41's History and Physical (H/P), dated 10/9/23, the H/P indicated, Resident 41 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set [(MDS), a standardized assessment and care screening tool], dated 6/13/23, The The MDS indicated Resident 41 required maximum assistance (helper does more than half the effort; helper lifts or holds trunk or limbs and provides less than half effort) with showering, dressing, and utilized a cane as a mobility ( ability to move or be moved) device. During an observation on 10/17/23 at 8:12 a.m., in Resident 41's room, Resident 41's foley catheter drainage bag was drainage bag was secured to the bed without a dignity bag. During an interview on 10/17/2023 at 8:15 a.m., in Resident 41's room, Resident 41 stated if his foley catheter drainage bag was uncovered other residents could see it, that make him feel embarrassed and belittled Resident 41 stated, he does not want other residents and visitors see his foley catheter filled with urine (liquid waste produced by the kidneys), as he felt embarrassed. During a concurrent observation and interview on 10/17/2023 at 8:18 a.m. with Certified Nurse Assistant (CNA 1) in Resident 41's room, CNA 1 stated Resident 41 did not have a dignity bag to cover his Page 1 of 20 055262 055262 10/19/2023 Lomita Post-Acute Care Center 1955 Lomita Blvd Lomita, CA 90717

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few foley catheter drainage bag. CNA 1 stated the foley catheter's drainage bag should have a dignity bag, be kept below the bladder, and off the floor. CNA 1 stated a dignity bag was needed for Resident 41's privacy. CNA 1 stated Resident 41 could feel ashamed and embarrassed when others see their foley catheter drainage bag. During a concurrent observation and interview on 10/17/20 at 8:27 a.m. with License Vocational Nurse (LVN 1) in Resident 41's room, LVN 1 confirmed that Resident 41 did not have a dignity bag for his f/c drainage bag. LVN 1 stated f/c drainage bags need to have a dignity bag to provide privacy for the residents. LVN 1 stated it residents f/c drainage bags are not covered it could make the residents feel ashamed or embarrass and affect their self-esteem. During an interview on 10/19/2023 at 9:37 a.m. with Registered Nurse (RN 1), RN 1 stated, foley catheter drainage bags should be off the floor for infection control purposes, and a dignity bag must be provided to promote dignity and respect for the residents. RN stated, when a residents drainage bag was exposed it could make the resident feel embarrassed and feel that their privacy was being violated. During a review of the facility's policy and procedure (P&P) titled, Catheter Care, Indwelling, dated 2019, the P&P indicated, It was the policy of this facility that each resident with an indwelling catheter will receive catheter care daily and as necessary (PRN) for soiling .cover drainage bag with privacy bag. During a review of the facility's P&P titled, Quality of Life-Dignity, dated 2009, the P&P indicated, Demeaning practices and standards of car that compromise dignity are prohibited. Staff shall promote dignity and assist resident as needed by helping the resident to keep urinary catheter bags covered. During a review of the facility's P&P titled, Residents Rights: Dignity and Privacy, dated 2021. The P&P indicated, It was the policy of this facility that all residents be treated with kindness, dignity and respect. 055262 Page 2 of 20 055262 10/19/2023 Lomita Post-Acute Care Center 1955 Lomita Blvd Lomita, CA 90717

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to ensure call lights was within reach for two of three sampled residents (Residents 33 and 39). Residents Affected - Few This deficient practice had the potential to result in a delay and inability for Resdeint 33 and Resident 39 to obtain necessary care and services. Findings: During a record review of Resident's 39 admission Record (face sheet), the face sheet indicated Resident 39 was admitted to the facility on [DATE] with diagnoses that included hypertension ( high blood pressure) , diabetes mellitus (a condition in which the body fails to metabolize (process) glucose (sugar) correctly ), and hyperlipidemia (high levels of fat particles (lipids) in the blood). During a review of the Resident 39's Minimum Data Sheet ([MDS]- a standardized assessment and care screening tool) dated 8/7/23, indicated, Resident 39 has clear speech, sometimes able to make self-understood or sometimes able to understand others. Resident 39 has a Brief Interview for Mental Status (BIMS-a tool used to calculate/assess cognition [process of thinking], scores between 0 and 7 indicate severe cognitive impairment, scores between 8 and 12 indicate moderate impairment, and scores above 13 show little to no impairment) score of zero (00) and requires maximum assistance for bed mobility, dressing, toilet use and personal hygiene. During a review of Resident 39's care plan titled: At risk for falls related to poor safety awareness, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), needs assistance with mobility revised on 5/12/2023, interventions includes, ensure call light was within reach and encourage to use it to call for assistance as needed. During an observation on 10/16/2023 at 03:32 p.m., call light was on the floor and was not accessible to Resident 39. During a record review of Resident's 33 admission Record (face sheet), indicated Resident 33 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease( the last stage of long term kidney disease) , hyperlipidemia, and hypertension( high blood pressure). During a review of the Resident 33's MDS dated [DATE], indicated Resident 33 has clear speech, impaired vision and usually able to make self-understood or able to understand others. Resident 33 has a BIMS score of 4 and requires extensive assistance for bed mobility, dressing, toilet use, and personal hygiene. During an observation on 10/17/2023 at 9:28 a.m., call light was on the floor and was not accessible to Resident 33. During a concurrent observation and interview on 10/17/2023 at 3:45 p.m. with the Licensed Vocational Nurse (LVN 2), LVN 2 stated that if call light was on the floor and resident cannot reach it, Resident 33 cannot use it and Resident 33 cannot verbalized needs that could affect the quality of care,and Resident 33 high risk for fall. 055262 Page 3 of 20 055262 10/19/2023 Lomita Post-Acute Care Center 1955 Lomita Blvd Lomita, CA 90717

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 10/17/2023 at 3:58 p.m. with the Registered Nurse Supervisor (RNS), RNS stated that it was an issue if the call light was not always attached close to resident or within reach because Resident 33 and Resident 39 will have a hard time asking for help. During a review of facility's policy and procedure ( P&P) titled Call Light/Bell revised 05/2007 indicated, It is the policy of this facility to provide the resident a means of communication with nursing staff. Leave the resident comfortable. Place the call device within resident's reach before leaving room. If the call light/bell was defective, immediately report this information to the unit supervisor. 055262 Page 4 of 20 055262 10/19/2023 Lomita Post-Acute Care Center 1955 Lomita Blvd Lomita, CA 90717

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of 15 sampled residents (Resident 41) received right arm sling (to ease pain, support healing and to protect arm from further injury) This deficient practice had the potential to place Resident 41 at risk for further range of motion (ROM - the extent of movement of a joint) decline, contracture (a condition of shortening and hardening of muscles, leading to deformity and rigidity of joints) and dehiscence (a surgery complication where the incision (surgical wound) reopens). Findings: During a review of Resident 41's admission Record (Face Sheet), indicated Resident 41 was admitted to the facility on [DATE], with diagnoses including infection of the right shoulder, urinary tract infection (infection in any part of the urinary system), and neuropathic bladder (lack of bladder control). During a review of Resident 41's History and Physical (H/P), dated 10/9/23, the H/P indicated, Resident 41 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set [(MDS), a standardized assessment and care screening tool], dated 6/13/23, The MDS indicated Resident 41 required maximum assistance (helper does more than half the effort; helper lifts or holds trunk or limbs and provides less than half effort) with showering, dressing, and utilized a cane as a mobility (ability to move or be moved) device. During a review of Resident 41's general acute care hospital (GACH) discharge summary (DS) dated 10/9/23, indicated Resident 41 was treated for infection due to internal joint prostheses (a device designed to replace a missing part of the body). During a review of Resident 41's Order Summary Report, dated 10/8/23, indicated always apply right upper extremity (RUE) sling with abduction (away from the midline of the body) and checked for proper placement and skin integrity. During a review of Resident 41's Care Plan (CP) dated 10/23 titled, Alteration in musculoskeletal status related to reverse arthroplasty ( surgical procedure used to treat shoulder conditions ) and revision of right shoulder humerus ( long bone in the upper arm) and right shoulder infections, interventions indicated to apply RUE sling with abduction at all times and checked for proper placement (sling) and skin integrity. During an observation on 10/17/23, at 8:56 a.m., in Resident 41's room, the Resident 41 was observed sitting on the bed, with a surgical dressing (protective coverings to wounds on the skin) to his right shoulder without a sling. During an interview on 10/17/23, at 9:00 a.m., in Resident 41's room, Resident 41 stated, he underwent right shoulder surgery due to infection. Resident 41 stated, he needs to always wear a right shoulder sling and currently (10/17/2033) he was not wearing his right arm sling. 055262 Page 5 of 20 055262 10/19/2023 Lomita Post-Acute Care Center 1955 Lomita Blvd Lomita, CA 90717

F 0688 Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 10/17/23 9:37 a.m., with License Vocational Nurse (LVN 1) in Resident 41's room, Resident 41 was observed not wearing a sling on his RUE. LVN 1 stated Resident 41 was not wearing a sling on his RUE. LVN 1 stated Resident 41 should always wear his sling to provide immobilization (keeps an injured arm or shoulder from moving). LVN 1 stated Resident 41 could further injure his shoulder without wearing the sling. Residents Affected - Few During an interview on 10/18/23 at 9:11 a.m., with Registered Nurse (RN 1), RN 1 stated slings are used to keep extremities immobilized to prevent reoccurrence of a fracture, to prevent dehiscence if the resident has had surgery, and prevent the residents from further injury. During a review of the facility's policy and procedure (P&P) titled, ROM and Contracture Prevention, dated 2019, the P&P indicated, it is the policy of this facility to ensure that residents receive services, care, and equipment to assure that .every resident with limited range of motion and mobility maintains or improves function unless reduce range of motion (ROM)/mobility is unavoidable based on the resident's clinical condition. During a review of the facility's P&P titled, Assistive Devices and Equipment, dated 2023, the P&P indicated, Our facility maintains and supervises the use of assistive devices and equipment for residents .certain devices and equipment that assist with resident mobility, safety and independence are provided for residents. 055262 Page 6 of 20 055262 10/19/2023 Lomita Post-Acute Care Center 1955 Lomita Blvd Lomita, CA 90717

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure it was free of not greater than 5 percent (%) or below medication error rate, as evidenced by eleven medications errors out of 42 opportunities for error, which yield a 26.19% medication error rate. Residents Affected - Few This deficient practice resulted in a 26.19 percent (%) medication error rate for Resident 6. Findings: During a review of Resident 6's admission Record (face sheet), the face sheet indicated Resident 6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including aphasia ( inability to speak ) dysphagia ( inability to swallow ) and hypertension ( high blood pressure). During a review of Resident 6's history and physical (H&P) report dated 2/2/2023, the H&P indicated Resident 6 does not have the capacity to understand and make decisions. During a review Resident 6's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/7/2023 indicated Resident 6's requires extensive assistance with bed mobility (resident involved in activity, staff provide weight bearing support), total dependence ( full staff support at all times ) with transfer , locomotion on and off unit and eating. During a review of Resident 6's Order Summary Report (doctors order), the doctors order indicated the Resident 6 were to receive the following: 1. Amlodipine Besylate tablet (medication for high blood pressure) 10 milligrams (mg-unit of measurement), give 1 tablet by enteral tube (feeding tube) . Hold if systolic blood pressure (SBP) < 110 scheduled at 9:00 a.m. ordered 10/31/2022. 2. Ascorbic Acid (vitamin) tablet 500 mg, give 1 tablet by enteral tube one time a day scheduled at 9:00 a.m. ordered 10/31/2022. 3. Aspirin (blood thinner) tablet 81 mg, give 1 tablet by enteral tube once a day scheduled at 9:00 a.m. ordered 12/1/2022. 4. Cholecalciferol (Vitamin D and used to prevent brittle bones) tablet 1000 unit, give 1 tablet by enteral tube twice a day scheduled at 9:00a.m. ordered 10/31/2022. 5. Famotidine (decreases the amount of acid the stomach produces) oral tablet 20 mg, give 1 tablet by enteral tube every 12 hours scheduled at 9:00a.m. ordered 10/31/2022. 6. Keppra (treats seizures) oral solution100 mg/ml, give 5 ml by enteral tube two times a day scheduled at 9:00 a.m. ordered 2/28/2023. 7. Lasix (reduces the amount of excess fluid in the body) tablet 20 mg, give 1 tablet by mouth once a day scheduled at 9:00 a.m. ordered 2/23/2023. 8. Lisinopril (lowers blood pressure) oral tablet 20 mg, give 1 tablet by enteral tube once a day. 055262 Page 7 of 20 055262 10/19/2023 Lomita Post-Acute Care Center 1955 Lomita Blvd Lomita, CA 90717

F 0759 Hold for (SBP) below < 110 scheduled at 9:00 a.m. ordered 10/31/2022. Level of Harm - Minimal harm or potential for actual harm 9. Multivitamin - Minerals (helps your body function properly) oral tablet, give 1 tablet a day by enteral tube scheduled at 9:00 a.m. ordered 10/31/2022. Residents Affected - Few 10. Potassium Chloride (prevent and treat low blood potassium) liquid 20 milliequivalent (meq-unit of measurement)/ 15 ml (10 %) , give 30 milliliter (ml-unit of measurement) by enteral tube in the morning scheduled at 9:00 a.m. ordered 6/15/2023. 11. Pro Stat (protein supplement) Sugar Free oral liquid, give 45 ml by enteral tube three times a day. May mix with water scheduled at 9:00a.m. ordered 6/2/2023. During a medication administration observation 10/17/2023 at 9:00 am with Licensed Vocational Nurse 2 (LVN), LVN 2 was observed crushing medications as follows: 1.Amlodipine Besylate tablet (high blood pressure) 10 milligrams (mg) 1 tablet. 2.Ascorbic Acid (vitamin that protects cells and keep them healthy) tablet 500 mg 1 tablet. 3.Aspirin (blood thinner) tablet 81 mg 1 tablet. 4.Cholecalciferol (vitamin D) tablet 1000-unit 1 tablet. 5.Famotidine 20 mg 1 tablet. 6.Lasix 20 mg 1 tablet. 7.Lisinopril 20 mg 1 tablet. 8.Multivitamin - Minerals 1 tablet. During a subsequent medication administration observation on 10/17/2023 at 9:00 a.m. with LVN 2, LVN 2 was observed combining in a cup (cup one) crushed Lasix 20 mg 1 tablet, Famotidine 20 mg 1 tablet, and Amlodipine 10 mg 1 tablet with 30cc of water. LVN 2 was observed combining in a separate cup (cup two) crushed Lisinopril 20 mg 1 tablet, Aspirin 81 mg 1 tablet, Pro- stat liquid 45 ml, Potassium liquid 30 ml, and Keppra liquid 5ml with 30 cc of water. LVN 2 was observed combining in a cup (cup three) crushed Multivitamin 1 tablet, Cholecalciferol tablet 1000-unit, Ascorbic acid 1 tablet with 30 cc of water. During an interview on 10/17/2023 at 1:28 p.m. with LVN 2, LVN 2 stated crushed medications should not be mixed all together in the three different cups. The LVN stated the correct way was to administer each medication into Resident 6's with 30 cc of water into the enteral tube let it flow in by gravity and continue with the next medication. LVN 2 stated there can be a drug interaction when mixing medications. During an interview on 10/17/2023 at 1:50 p.m. with Registered Nurse Supervisor (RNS), the RNS stated when passing multiple medications by enteral tube it must be given one at a time, after each medication licensed staff must flush with 30 cc of water. RNS stated when you mix certain medications this can be dangerous, some medication can become less effective, or some can become more potent 055262 Page 8 of 20 055262 10/19/2023 Lomita Post-Acute Care Center 1955 Lomita Blvd Lomita, CA 90717

F 0759 (strong effect). RNS stated it was safer to call pharmacy to see if the medications were compatible. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/17/2023 at 2:15 p.m. with the Director of Nursing (DON), the DON stated the process of passing multiple medication by enteral tube was to administer one medication at a time and flush enteral tube with 30 cc of water after each medication. DON stated there are some medications that should never be mixed together. Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled General Guidelines for Administering Medications Via Enteral Tubes updated 11/2021, the P&P indicated interactions between medications and feeding formulas (example- phenytoin [seizure medication]), and interactions of multiple medications, are considered before administering through the enteral tube. If necessary, information is obtained from pharmacy provider or consultant pharmacist. 1.Prior to crushing tablets for administration through the enteral tube, the nurse must consult the medication crushing guidelines to determine if the tablet can be crushed. Medications on the Do not crush med list may only be crushed upon a physician's order. 2.Crushed medications are not mixed. The powder from each medication is mixed with water (sterile water for irrigation is preferred2·3) before administration. The souffle cup is rinsed with water to get all the medication. 3. Each medication is administered separately to avoid interaction and clumping. The enteral tubing is flushed with at least 10-15 ml of water between each medication to avoid physical interaction of the medications. (Alternatively, crushed medications may be mixed, mixed together, diluted with sufficient water, and administered together so long as no incompatibilities exist. The enteral tube is still flushed with at least 10-15 ml of water before and after administering the group of medications. 055262 Page 9 of 20 055262 10/19/2023 Lomita Post-Acute Care Center 1955 Lomita Blvd Lomita, CA 90717

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Cross Reference F759 Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 6) was free from significant medication errors by failing to ensure crushed medications were not mixed before medication administration according to facility's policy and procedure. This deficient practice had the potential to affect medication efficacy, compatibility and can have drug interactions for Resident 6. Findings: During a review of Resident 6's admission Record (face sheet), the face sheet indicated Resident 6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including aphasia ( inability to speak ) dysphagia ( inability to swallow ) and hypertension ( high blood pressure). During a review of Resident 6's history and physical (H&P) report dated 2/2/2023, the H&P indicated Resident 6 does not have the capacity to understand and make decisions. During a review Resident 6's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/7/2023 indicated Resident 6's requires extensive assistance with bed mobility (resident involved in activity, staff provide weight bearing support), total dependence ( full staff support at all times ) with transfer , locomotion on and off unit and eating. During a review of Resident 6's Order Summary Report (doctors order), the doctors order indicated the Resident 6 were to receive the following: 1. Amlodipine Besylate tablet (medication for high blood pressure) 10 milligrams (mg-unit of measurement), give 1 tablet by enteral tube (feeding tube) . Hold if systolic blood pressure (SBP) < 110 scheduled at 9:00 a.m. ordered 10/31/2022. 2. Ascorbic Acid (vitamin) tablet 500 mg, give 1 tablet by enteral tube one time a day scheduled at 9:00 a.m. ordered 10/31/2022. 3. Aspirin (blood thinner) tablet 81 mg, give 1 tablet by enteral tube once a day scheduled at 9:00 a.m. ordered 12/1/2022. 4. Cholecalciferol (Vitamin D and used to prevent brittle bones) tablet 1000 unit, give 1 tablet by enteral tube twice a day scheduled at 9:00a.m. ordered 10/31/2022. 5. Famotidine (decreases the amount of acid the stomach produces) oral tablet 20 mg, give 1 tablet by enteral tube every 12 hours scheduled at 9:00a.m. ordered 10/31/2022. 6. Keppra (treats seizures) oral solution100 mg/ml, give 5 ml by enteral tube two times a day scheduled at 9:00 a.m. ordered 2/28/2023. 055262 Page 10 of 20 055262 10/19/2023 Lomita Post-Acute Care Center 1955 Lomita Blvd Lomita, CA 90717

F 0760 Level of Harm - Minimal harm or potential for actual harm 7. Lasix (reduces the amount of excess fluid in the body) tablet 20 mg, give 1 tablet by mouth once a day scheduled at 9:00 a.m. ordered 2/23/2023. 8. Lisinopril (lowers blood pressure) oral tablet 20 mg, give 1 tablet by enteral tube once a day. Hold for (SBP) below < 110 scheduled at 9:00 a.m. ordered 10/31/2022. Residents Affected - Few 9. Multivitamin - Minerals (helps your body function properly) oral tablet, give 1 tablet a day by enteral tube scheduled at 9:00 a.m. ordered 10/31/2022. 10. Potassium Chloride (prevent and treat low blood potassium) liquid 20 milliequivalent (meq-unit of measurement)/ 15 ml (10 %) , give 30 milliliter (ml-unit of measurement) by enteral tube in the morning scheduled at 9:00 a.m. ordered 6/15/2023. 11. Pro Stat (protein supplement) Sugar Free oral liquid, give 45 ml by enteral tube three times a day. May mix with water scheduled at 9:00a.m. ordered 6/2/2023. During a medication administration observation 10/17/2023 at 9:00 am with Licensed Vocational Nurse 2 (LVN), LVN 2 was observed crushing medications as follows: 1.Amlodipine Besylate tablet (high blood pressure) 10 milligrams (mg) 1 tablet. 2.Ascorbic Acid (vitamin that protects cells and keep them healthy) tablet 500 mg 1 tablet. 3.Aspirin (blood thinner) tablet 81 mg 1 tablet. 4.Cholecalciferol (vitamin D) tablet 1000-unit 1 tablet. 5.Famotidine 20 mg 1 tablet. 6.Lasix 20 mg 1 tablet. 7.Lisinopril 20 mg 1 tablet. 8.Multivitamin - Minerals 1 tablet. During a subsequent medication administration observation on 10/17/2023 at 9:00 a.m. with LVN 2, LVN 2 was observed combining in a cup (cup one) crushed Lasix 20 mg 1 tablet, Famotidine 20 mg 1 tablet, and Amlodipine 10 mg 1 tablet with 30cc of water. LVN 2 was observed combining in a separate cup (cup two) crushed Lisinopril 20 mg 1 tablet, Aspirin 81 mg 1 tablet, Pro- stat liquid 45 ml, Potassium liquid 30 ml, and Keppra liquid 5ml with 30 cc of water. LVN 2 was observed combining in a cup (cup three) crushed Multivitamin 1 tablet, Cholecalciferol tablet 1000-unit, Ascorbic acid 1 tablet with 30 cc of water. During an interview on 10/17/2023 at 1:28 p.m. with LVN 2, LVN 2 stated crushed medications should not be mixed all together in the three different cups. The LVN stated the correct way was to administer each medication into Resident 6's with 30 cc of water into the enteral tube let it flow in by gravity and continue with the next medication. LVN 2 stated there can be a drug interaction when mixing medications. 055262 Page 11 of 20 055262 10/19/2023 Lomita Post-Acute Care Center 1955 Lomita Blvd Lomita, CA 90717

F 0760 Level of Harm - Minimal harm or potential for actual harm During an interview on 10/17/2023 at 1:50 p.m. with Registered Nurse Supervisor (RNS), the RNS stated when passing multiple medications by enteral tube it must be given one at a time, after each medication licensed staff must flush with 30 cc of water. RNS stated when you mix certain medications this can be dangerous, some medication can become less effective, or some can become more potent (strong effect). RNS stated it was safer to call pharmacy to see if the medications were compatible. Residents Affected - Few During an interview on 10/17/2023 at 2:15 p.m. with the Director of Nursing (DON), the DON stated the process of passing multiple medication by enteral tube was to administer one medication at a time and flush enteral tube with 30 cc of water after each medication. DON stated there are some medications that should never be mixed together. During a review of the facility's policy and procedure (P&P) titled General Guidelines for Administering Medications Via Enteral Tubes updated 11/2021, the P&P indicated interactions between medications and feeding formulas (example- phenytoin [seizure medication]), and interactions of multiple medications, are considered before administering through the enteral tube. If necessary, information is obtained from pharmacy provider or consultant pharmacist. 1.Prior to crushing tablets for administration through the enteral tube, the nurse must consult the medication crushing guidelines to determine if the tablet can be crushed. Medications on the Do not crush med list may only be crushed upon a physician's order. 2.Crushed medications are not mixed. The powder from each medication is mixed with water (sterile water for irrigation is preferred2·3) before administration. The souffle cup is rinsed with water to get all the medication. 3. Each medication is administered separately to avoid interaction and clumping. The enteral tubing is flushed with at least 10-15 ml of water between each medication to avoid physical interaction of the medications. (Alternatively, crushed medications may be mixed, mixed together, diluted with sufficient water, and administered together so long as no incompatibilities exist. The enteral tube is still flushed with at least 10-15 ml of water before and after administering the group of medications. 055262 Page 12 of 20 055262 10/19/2023 Lomita Post-Acute Care Center 1955 Lomita Blvd Lomita, CA 90717

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure medication cart and treatment cart were locked when unattended by Licensed Vocational Nurse (LVN 3). This deficient practice had the potential for unauthorized access to medications and medical supplies by residents, staff, and visitors. Findings: During a concurrent observation and interview on 10/16/2023 at 12:18 pm with Licensed Vocational Nurse (LVN) 3, observed medication cart C-D was left unlocked. LVN 3 stated medication cart should be locked when left unattended to prevent potential unauthorized access by resident, staff, and visitors. During an observation on 10/16/2023 at 12:23 pm, observed treatment cart (storage for medical supplies used to treat wounds) was left unlocked in the hallway next to the nursing station. During an interview on 10/18/2023 at 9:11 am with LVN 4, stated residents can steal medical supplies that can be harmful to residents when ingested. During an interview on 10/18/2023 at 10:08 am with Registered Nurse (RN) 1, stated anyone can access the medication cart when left unattended and resident can potentially steal or tamper with medications. RN 1 stated, this can lead to medication errors, drug diversion (act that removes a prescription medication from its intended use), or even harm to residents. RN 1 stated residents with behavior problem can steal a scissors in the treatment cart and possible use to harm themselves. During a review of facility's policy and procedure titled Medication Storage in the Facility updated on 08/2019 indicated: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer. medications. 055262 Page 13 of 20 055262 10/19/2023 Lomita Post-Acute Care Center 1955 Lomita Blvd Lomita, CA 90717

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, distributed, and served in a sanitary manner to prevent foodborne illness (also called food poisoning caused by eating contaminated food or eating food not kept at appropriate temperatures) by failing to: 1) Label canned foods, corn bread powder, butter, meat products, and vegetables with opened date and received date. 2) Ensure damp cloth used by [NAME] 1 did not repeatedly touched the food inside the plate. 3) Ensure [NAME] 2 who handed utensils back and forth to [NAME] 1 wore gloves. 4) Ensure [NAME] 3 wore gloves while reaching inside the food cart and touches the plate inside the food cart. These deficient practices had the potential to result in foodborne illnesses and can lead to other serious medical complications and hospitalization for residents residing in the facility. Findings: During a facility kitchen tour observation on 10/16/2023 at 8:06 am. found soup base beef style with no open date, corn bread powder with no open date, creamy wheat with no open date, butter with no open date, carrots with no date received, sausages with no date received, chopped spinach with no received date and broccoli with no received date. During a tray line (a process of preparing and setting food for the residents in the facility) observation on 10/17/2023 at 12:02 p.m., [NAME] 1 used a damp cloth to wipe the sides of the plate and touched the food inside the plate. During a tray line observation on 10/17/2023 at 12:05 p.m., [NAME] 2 was observed to removed utensils inside the utensil bin and handed it to [NAME] 1 without wearing gloves. During a tray line observation on 10/17/2023 at 12:15 p.m., observed [NAME] 3 touched the plates inside the food cart without wearing gloves. During an interview on 10/17/2023 at 2:51 p.m., with [NAME] 1 stated that the damp cloth used to wipe down the kitchen area, touched the food inside the plate. [NAME] 1 stated [NAME] 2 should have worn gloves when helping with the tray line process when [NAME] 2 handed utensils to her. [NAME] 1 further stated [NAME] 3 should have worn gloves when putting food plates inside the food cart. [NAME] 1 stated it was an infection control issue. During an interview on 10/17/2023 at 3:12 p.m., with [NAME] 2 stated he did not wear gloves when handling utensils to [NAME] 1. [NAME] 1 stated it was an infection control issue. During an interview on 10/17/2023 at 3:27 p.m., with the Dietary Supervisor (DS), DS stated that all foods received must be labeled with date received and date opened. 055262 Page 14 of 20 055262 10/19/2023 Lomita Post-Acute Care Center 1955 Lomita Blvd Lomita, CA 90717

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a review of the facility's policy and procedure (P&P) titled Labeling and dating of foods dated 2018, indicated, All food items in the storeroom, refrigerator, and freezer need to be labeled and dated based on established procedures for either food safety or product rotation (FIFO - First In - First Out). Food delivered to facility needs to be marked with a delivery or received date. Note that many distributors include a delivery sticker which is dated and can serve as the delivery date for the product. The individual opening or preparing a food shall be responsible for date marking at the time of processing and/or storage. 055262 Page 15 of 20 055262 10/19/2023 Lomita Post-Acute Care Center 1955 Lomita Blvd Lomita, CA 90717

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure heparin lock (heplock- locking device on an intravenous catheter [ placed in a vein ] to administer medication) was covered. Residents Affected - Few This deficient practice has the potential to contaminate the intravenous catheter, and risk of infection. Findings: During a record review of Resident 102's admission Record (Face sheet), the Face sheet indicated Resident 102 was initially admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure), atrial fibrillation (an irregular and often very rapid heart rhythm), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), pneumonia (an infection that affects one or both lungs). During a record review of Resident 102's Minimum Data Set (MDS), a standardize assessment and care-screening tool, dated 9/01/2023, the MDS indicated, Resident 102's needs total assistance on dressing and toilet use and needs extensive assistance on bed mobility and personal hygiene. During a record review of the Physician's order dated 10/13/2023 indicated to administer ceftrixone sodium solution (intravenous antibiotic) every 24 hours for treatment of pneumonia. During an observation 10/17/2023 at 3:55 p.m. in Resident 102's room, observed Resident 102's hep-lock was not covered. During a concurrent observation and interview on 10/17/2023 at 4:05 p.m. with Registered Nurse (RN) 2, RN2 stated hep-lock opening must be covered to prevent contamination of the intravenous catheter. During an interview on 10/18/2023 at 2:33 p.m. with the Infection Preventionist Nurse (IPN), IPN stated infection control needs to be followed during intravenous administration of medications. IPN stated hep lock should be covered to prevent contamination of the intravenous catheter. During a record review of the facility's policy and procedure (P&P) titled Infusion Guidelines & Procedures (undated) , indicated, To safely administer medications via intravenous push when no other route of administration was available, or in emergency situations when the immediate effect of the medication was necessary. Clamp the tubing just above the lowest injection port. Attach the syringe with the ordered medication to the injection cap attached to the extension tubing set. 055262 Page 16 of 20 055262 10/19/2023 Lomita Post-Acute Care Center 1955 Lomita Blvd Lomita, CA 90717

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 12 of 34 resident rooms (Rooms # 1, 2, 3, 4, 5, 6, 7, 9, 12, 14, 15, and 17) met the requirements of 80 square feet (sq. ft.) for each resident. This deficient practice had the potential to result in an inadequate provision of safe nursing care, and privacy for the residents. Findings: During a record review on 10/16/23 at 9:44 a.m., the Administrator (ADM) provided a copy of the facilities 2023 annual request for waiver letter. A review of the letter indicated there are 12 resident room with less than the required 80 sq. ft. per resident, and the rooms are monitored to ensure that furnishing and equipment in the room does not hamper provision of needed care and there is sufficient space to meet the needs of both residents. ADM stated the facility would be requesting a room waiver for 2024. According to the Client Accommodations Analysis form, dated 10/16/23, the facility had 12 rooms that measured less than 80 sq. ft. per resident. The resident rooms were as follow: room [ROOM NUMBER] (2 beds) 150.00 sq. ft. room [ROOM NUMBER] (2 beds) 149.50 sq. ft. room [ROOM NUMBER] (2 beds) 149.50 sq. ft. room [ROOM NUMBER] (2 beds) 149.50 sq. ft. room [ROOM NUMBER] (2 beds) 161.00 sq. ft. room [ROOM NUMBER] (2 beds) 149.50 sq. ft. room [ROOM NUMBER] (2 beds) 149.50 sq. ft. room [ROOM NUMBER] (2 beds) 143.00 sq. ft. room [ROOM NUMBER] (2 beds) 155.25 sq. ft. room [ROOM NUMBER] (2 beds) 143.00 sq. ft. room [ROOM NUMBER] (2 beds) 137.50 sq. ft. room [ROOM NUMBER] (2 beds) 155.25 sq. ft. During observations, from 10/16/23 - 10/19/23, the residents residing in these rooms had enough space to move freely inside the rooms. Each resident in the above rooms had beds and side tables with drawers. There was adequate room for the operation and use of wheelchairs, walkers, or canes. Room 055262 Page 17 of 20 055262 10/19/2023 Lomita Post-Acute Care Center 1955 Lomita Blvd Lomita, CA 90717

F 0912 size did not affect the nursing care or privacy provided to the residents. Level of Harm - Potential for minimal harm Residents Affected - Some 055262 Page 18 of 20 055262 10/19/2023 Lomita Post-Acute Care Center 1955 Lomita Blvd Lomita, CA 90717

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the call system was functional including the audible sounds to alert the staff for one of two sampled Residents (Resident 11). Residents Affected - Few This deficient practice had a potential in a delay in meeting care or services for Resident's 11. Findings: During a review of Resident 11's admission record (face sheet), the face sheet indicated Resident 11 was admitted to the facility on [DATE] with diagnosis of chronic obstructive pulmonary disease (a lung disease that block air flow and make it difficult to breathe), unspecified osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time), muscle weakness (decreased strength in the muscle). During a review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 7/29/2023, indicated Resident 11cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 11 required extensive assistance with (bed mobility) , dressing and total dependence with transferring . During an interview on 10/16/2023 at 9:55 a.m., in Resident 11's room, Resident 11 stated it usually takes the nurse over 30 minutes to answer the call light. Resident 11 stated most of the time she used the call to ask for assistance for moving in bed and changing her incontinence pad (diaper) During an observation on 10/16/2023 at 10:00 a.m. Resident 11's call light was pressed and the light outside the Resident 11's room did not light to alert the facility staff. During an interview on 10/16/2023 at 10:13 am with Certified Nursing Assistant 3 (CNA), CNA3 stated the call light of Resident 11 was not working. CNA 3 stated it was important to make sure Residents 11's call light was in working condition to ensure Resident 11's needs were attended. During an interview on 10/17/2023 at 2:20 pm with Maintenance (MN), MN stated Resident 11 has a mechanical nurse call pad system (used for resident's who have difficulty using standard call cords ). MN stated should make rounds at the beginning of the shift to make sure call lights were working. If the call light was not working facility staff should write the issues in the maintenance log. MN stated there was no entry of non-working call light for Resident 11 in the log. During an interview on 10/17/2023 at 1:57 p.m.with Department of Staff Development (DSD), the DSD stated at the beginning of the shift the residents are assessed for functioning call lights and if it within residents reach. During an interview on 10/10/2023 at 2:27 p.m. with Activities Director (AD), the AD stated it was everyone's responsibility to check residents call light to make sure it was in working condition. AD stated if a call light was not working the Resident 11 could try to get out of bed and could fall. During a review of the facility's policy and procedure (P&P ) titled Call Light/ Bell revised 05/2007, the P&P indicated It was the policy of this facility to provide the resident a means of communication with nursing staff. Leave the resident comfortable. Place the call light device within 055262 Page 19 of 20 055262 10/19/2023 Lomita Post-Acute Care Center 1955 Lomita Blvd Lomita, CA 90717

F 0919 Level of Harm - Minimal harm or potential for actual harm resident's reach before leaving room . If the call light/bell was defective, immediately report this information to the unit supervisor. , Residents Affected - Few 055262 Page 20 of 20