Health inspection·October 6, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide the necessary care and services for one of four sampled residents (Resident 1) by: Residents Affected - Few a. Failing to notify the responsible party of Resident 1 that an intruder entered Resident 1's room through the sliding door. This deficient practice potentially affected the delivery of care and services for Resident 1. b. Failing to assess Resident 1 for any physical or psychological problems after the intruder was observed in Resident 1's room. This deficient practice potentially placed Resident 1 at risk for unidentified harm that the intruder might have caused. Findings: During a review of Resident 2's Face sheet, the face sheet indicated, Resident 2 was admitted to the facility on [DATE] with the diagnosis chronic obstructive pulmonary disease (lung disease that causes restricted airflow and breathing problems), major depressive disorder, insomnia (inability of sleep), and anxiety. During a review of Resident 2's H&P, the H&P indicated that Resident 2 has the capacity to understand and make decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 cognitive skills for daily decision making was intact. During a review of Resident 1's Face sheet (admission record), the face sheet indicated Resident 1 was admitted to the facility on [DATE] with the diagnosis of stroke (when blood flow to the brain is blocked or there is sudden bleeding in the brain) affecting the left side, major depressive disorder ( mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily life) , and anxiety (persistent worry or fear that can interfere with life). During a review of Resident 1's History and Physical (H&P), the H&P indicated that Resident 1 does not have 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 8/7/2023, the MDS indicated Resident 1's cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 1 required total dependence with eating, bed mobility, transfer, and walking. Page 1 of 4 055457 055457 10/06/2023 Intercommunity Healthcare & Rehabilitation Center 12627 Studebaker Road Norwalk, CA 90650

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1's Change of condition (COC) reports and nurse progress notes, the notes and reports indicated there was no documentation of an assessment conducted and family notification of the event after the intruder was noted in the facility on 8/20/2023. During a review of Resident 2's change of condition (COC), dated 8/21/2023 at 1:41 p.m. the COC indicated an on 8/20/2023 at 10:10 p.m. an intruder tried to enter the facility. 911 was called immediately and at 10:15 p.m. the intruder was found in the Resident 2's room after Resident 2 alerted the nurse. During a review of the document titled County of Los Angeles Sheriff ' s Department Incident Report dated 8/20/2023, the document indicated that the intruder (IND) was found on the facility's premises and was taken away to a local general acute care hospital emergency room and was place on a 5150 hold (allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72- hour psychiatric hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disabled). During an interview with Responsible Party (RP) 1 on 10/3/2023 at 2:00 p.m., RP 1 stated, on 9/28/2023, Resident 2 informed her ( RP 1) about an intruder in Resident 1's room. RP 1 stated the facility did not inform RP 1 about the trespassing incident. During an interview with Resident 2 on 10/4/2023 at 11:58 a.m., Resident 2 stated, on 8/20/2023, she (Resident 2) first saw the intruder in the patio and observed staff telling the intruder to leave. Resident 2 stated a few minutes later, the same intruder was observed in Resident 1's room so she (Resident 2) went to get certified nurse assistant (CNA) 4. Resident 2 stated she saw the intruder run into room [ROOM NUMBER] (Resident 2's room) and the intruder tried going out through the sliding door; CNA 4 went into room [ROOM NUMBER] apprehended the intruder and few minutes later the police came to take the intruder away. During an interview with LVN 1 on 10/4/2023 at 7:35 p.m., LVN 1 stated on 8/20/2023, an intruder tried to enter the facility, 911 was called immediately, and at 10:15 p.m. the intruder was found in the Resident 2's room after Resident 2 alerted the nurse, Resident 2's room is by Resident 1's room. LVN 1 stated the sheriffs took the intruder away. LVN 1 stated Resident 1 was not assessed after the incident. During an interview with LVN 2 on 10/4/2023 at 8:04 p.m., LVN 2 stated it was important to assess the resident after an incident of any type occurs. LVN 2 stated residents could have been injured by the intruder so it was important to assess the resident. During an interview with the Director of Nursing (DON) on 10/6/2023 at 11:20 a.m., the DON stated that responsible parties were not notified. During a review of the facility policy and procedure (P/P) titled Change in a Resident's Condition or Status revised February 2021, the P/P indicated that the 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. 055457 Page 2 of 4 055457 10/06/2023 Intercommunity Healthcare & Rehabilitation Center 12627 Studebaker Road Norwalk, CA 90650

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the sliding door for one (Resident 1) of four sampled resident's rooms were secured and locked after certified nurse assistant (CNA) 1 and licensed vocational nurse (LVN) 1 identified an intruder in the patio on 8/20/2023 at 10:10 p.m. This deficient practice resulted in the intruder entering the facility through Resident 1's sliding door and ending up in Resident 2's room on 8/20/2023 at 10:15 p.m., risking the health and safety of the residents and staff of the facility. Findings: During a review of Resident 1' s Face sheet (admission record), the face sheet indicated Resident 1 was admitted to the facility on [DATE] with the diagnosis of stroke (when blood flow to the brain is blocked or there is sudden bleeding in the brain) affecting the left side, major depressive disorder ( mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily life), and anxiety (persistent worry or fear that can interfere with life). During a review of Resident 1's History and Physical (H&P), the H&P indicated that Resident 1 does not have 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 8/7/2023, the MDS indicated Resident 1's cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 1 required total dependence with eating, bed mobility, transfer, and walking. During a review of Resident 2's Face sheet, the face sheet indicated Resident 2 was admitted to the facility on [DATE] with the diagnosis chronic obstructive pulmonary disease (lung disease that causes restricted airflow and breathing problems), major depressive disorder, insomnia (inability of sleep), and anxiety. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 cognitive skills for daily decision making was intact. The MDS indicated Resident 2 required supervision with eating, bed mobility, transfer, and walking. During a review of Resident 2's change of condition (COC), dated 8/21/2023 at 1:41 p.m., the COC indicated on 8/20/2023 at 10:10 p.m. an intruder tried to enter the facility, 911 was called immediately, and at 10:15 p.m. the intruder was found in the Resident 2's room after Resident 2 alerted the nurse. During a review of the document titled County of Los Angeles Sheriff ' s Department Incident Report dated 8/20/2023, the document indicated that the intruder was found on the facility ' s premises and was taken away to a local general acute care hospital emergency room and was place on a 5150 hold (allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72- hour psychiatric hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disabled). 055457 Page 3 of 4 055457 10/06/2023 Intercommunity Healthcare & Rehabilitation Center 12627 Studebaker Road Norwalk, CA 90650

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with Resident 2 on 10/4/2023 at 11:58 a.m., Resident 2 stated, on 8/20/2023, she (Resident 2) first saw the intruder in the patio and observed staff telling the intruder to leave. Resident 2 stated a few minutes later, the same intruder was observed in room [ROOM NUMBER] (Resident 1's room) so she (Resident 2) went to get CNA 4. Resident 2 stated the intruder ran to room [ROOM NUMBER] (Resident 2's room) and the intruder tried going out through the sliding door; CNA 4 went into room [ROOM NUMBER] apprehended the intruder and few minutes later the police came to take the intruder away. During an interview with CNA 1 on 10/4/2023 at 7:20 p.m., CNA 1 stated, on 8/20/2023, she remembers seeing the intruder in the patio and staff telling him to leave. Then a couple minutes later, the intruder was found in Resident 2's room and then staff held down the intruder until cops arrived. CNA 1 stated that it was a scary situation because you never know what can happen. During an interview with LVN 1 on 10/4/2023 at 7:35 p.m., LVN 1 stated on 8/20/2023, the intruder was standing outside the patio and was informed by staff to leave. LVN 1 stated she called 911; and about 20 minutes or later, she heard an unknown staff member scream, and everybody ran to the screaming. LVN 1 stated the intruder was found in Resident 2's room; and within a few minutes, the sheriffs took the intruder away. LVN 1 also stated the safety of all residents was the responsibility of all staff members. During an interview with the Administrator (ADM) on 10/5/2023 at 2:12 p.m., the ADM stated that the facility was the residents' home; and the facility was responsible for the safety of the residents. During a review of the facility policy and procedure (P/P) titled Safety and Supervision of Resident, revised July 2017, the P/P indicated that the facility strives to make the environment as free from accident hazards as possible. Resident safety, supervision and assistance to prevent accidents were facility-wide priorities. 055457 Page 4 of 4