Health inspection·November 17, 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 51) right to refuse care was honored when two nursing staff transferred Resident 51 to the bathroom after Resident 51 refused. This failure resulted in Resident 51 crying causing distress, discomfort and resisting care. Findings: During a review of Resident 51's admission Record (Face Sheet),the Face Sheet indicated, Resident 51 was admitted to the facility on [DATE] with diagnoses of but not limited to dementia (a decline in cognitive abilities that impact a person's ability to perform everyday activities), Alzheimer's (a common and devastating form of dementia that affects memory, thinking, and behavior), anxiety 9an intense , excessive and persistent worry and fear about everyday situation), chronic kidney disease (gradual loss of kidney function that occurs over a period of months to years), and osteoporosis ( a disease that weakens the bones and makes the bones more fragile and weaker than they should be). During a review of Resident 51's History and Physical (H&P) dated 3/24/2023, the H&P indicated Resident 51 did not have the capacity to understand or make decisions. During a review of Resident 51's Minimum Data Set (MDS, a comprehensive assessment and care planning tool), dated 10/26/2023, the MDS indicated Resident 51 was dependent on staff for help with eating, oral hygiene, toileting, showering, dressing, putting on and taking off footwear, and personal hygiene. During an observation on 11/14/2023 at 11:07 am in Resident 51's room, Resident 51 was sitting in a wheelchair and Certified Nurse Assistant (CNA) 3 was wrapping a sling around Resident 51's waist to transfer Resident 51 from wheelchair to the bathroom using the stand up Hoyer lift. Resident 51 was moaning and rubbing her neck. CNA 3 placed Resident 51's hand around the Hoyer lift bar and Resident 51 told CNA 3 not to do it and snatched her hand away from the Hoyer lift bar. CNA 3 attempted to place Resident 51's hand around the bar several times and Resident 51 resisted. CNA 3 went to get CNA 5. CNA 5 was able to get Resident 51 to hold on to the Hoyer lift bar and CNA 3 began to lift Resident 51 out of the wheelchair. Resident 51 began to cry saying no, please. CNA 3 and CNA 5 wheeled Resident 51 into the bathroom while Resident 51 was crying and grimacing pleading for them to stop. CNA 3 removed Resident 51's diaper, cleaned her and put a new diaper on while Resident 51 was in the stand up Hoyer lift. Resident 51 was placed back into the wheelchair and CNA 3 Page 1 of 15 055539 055539 11/17/2023 Artesia Christian Home Inc. 11614 E. 183rd St Artesia, CA 90701

F 0550 took Resident 51 to the dining room for activities. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/16/2023 at 2:00 pm with CNA 6, CNA 6 stated if a resident is refusing or being combative while trying to place the resident in the stand-up Hoyer lift, CNA 6 will stop and let the resident calm down and ask the charge nurse what needs to be done. CNA 6 stated it is risky and it is not safe to force the resident to continue with care when the resident is refusing or combative because the resident could be at risk for fall if they are not holding on to the Hoyer stand up lift bar. Residents Affected - Few During an interview on 11/17/2023 at 3:06 pm with the Assistant Director of Nursing (ADON), the ADON stated if a resident is saying no or refusing care the CNA should go to the Charge Nurse. The ADON stated the Charge Nurse will evaluate the resident and assess for safety. The ADON stated if the resident is refusing care while using the stand-up Hoyer lift, the CNA should not continue using the lift because it is against the resident wishes and should continue care for the resident in the resident's bed. During an interview on 11/17/2023 at 4:02 pm with CNA 3, CNA 3 stated when resident refuses care she will wait for the resident to calm down and go get help or report to the charge nurse that the resident is refusing. During a review of the facility's policy and procedure (P&P) titled, Dementia Care Manual, dated 2013, the P&P indicated, To continue care when a resident with dementia is resisting, violates the resident's rights to self-determination, refusal of treatment with dignity, and reasonable accommodations of needs. If resident becomes upset or agitated or indicates verbally or physically NO or STOP: maintain a calm demeanor. Apologize for causing resident distress. Cease personal care for that time, but do not leave the resident alone if it is unsafe to do so. Offer support. If a trigger is identified, re-assess situation. Re-reattempt care after a few minutes if the resident appears calm and willing. Seek co-caregiver assistance if necessary or implement Change of face technique (another caregiver to complete care). Nursing staff should implement 72-hour Behavior Monitoring if the cause of agitation and aggression during care times has not been identified. 055539 Page 2 of 15 055539 11/17/2023 Artesia Christian Home Inc. 11614 E. 183rd St Artesia, CA 90701

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure two of 15 sampled residents (Resident 47 and Resident 20) received restorative nurse aid (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) (restorative nurse aid) services and treatment to prevent the further decrease in range of motion [ROM, full movement potential of a joint (where two bones meet)] and contractures (chronic joint stiffness associated with joint deformities and pain). This failure resulted in Resident 47 and Resident 20 not receiving the needed RNA services placing them at risk for further decline in the range of motion and at risk to acquire contractures. Findings: a. During a review of Resident 47's Face Sheet the Face Sheet indicated, Resident 47 was admitted to the facility on [DATE] with diagnoses of but limited to dementia (a decline in cognitive abilities that impact a person's ability to perform everyday activities), cerebral atrophy (a condition in which the brain or regions of the brain literally shrink), osteoarthritis (inflammation of one or more joints), abnormalities of the gait (a person's manner of walking) and mobility (the ability to move or be moved freely and easily), lack of coordination (the ability to use different parts of the body together smoothly and efficiently) and other signs and symptoms involving the musculoskeletal system (a complex network of bones, muscle, joints, and connective tissue that gives shape, support, and movement to the human body). During a review of Resident 47's Physician Order Report, dated 12/22/2022, the Physician Order Report indicated PT (physical therapy) and or OT (occupational therapy) for hands on screening and joint mobility assessment as needed per IDT (interdisciplinary team is a complex process in which different types of staff work together to share expertise, knowledge, and skills to impact on the patient's care)/MD (medical doctor) recommendations. During a review of Resident 47's History and Physical (H&P) dated 12/24/2022, the H&P indicated Resident 47 had fluctuating (changing frequently and uncertainty) capacity 9the maximum amount that something can contain) to understand and make decisions. The H&P also indicated a plan for Nursing Rehabilitation. During a review of Resident 47's Minimum Data Set (MDS, a comprehensive assessment and care planning tool), dated 10/4/2023, the MDS indicated Resident 47 had the ability to express ideas and wants and to make self understood and to understand others. The MDs indicated Resident 47 needed partial to moderate assistance with changing positions from sitting to lying and lying to sitting on the side of the bed. The MDS indicated resident 47 needed substantial to maximal assistance with transferring from the chair to the bed and eating. The MDS indicated Resident 47 was dependent on staff for oral hygiene, toileting, showering, dressing, putting on and taking off footwear, and personal hygiene. The MDS indicated Resident 47 had zero number of days of the Restorative Nursing Program. During a review of Resident 47's Care Plan, titled ADLs (daily self- care activities) Functional Status/Rehabilitation Potential dated 12/22/2022 and revised on 10/5/2023, indicated Resident 47 will be provided with rehabilitation screening or treatment as needed. 055539 Page 3 of 15 055539 11/17/2023 Artesia Christian Home Inc. 11614 E. 183rd St Artesia, CA 90701

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 47's PT-Therapist Progress & Discharge Summary, dated 1/16/2023, the PT-Therapist Progress & Discharge Summary indicated, Resident 47's Discharge Plans & Instructions were to remain at the Skilled Nursing Facility for custodial care with RNA functional maintenance program until a bed becomes available for memory care community. During a review of Resident 47's IDT meeting notes, dated 10/5/2023, the IDT notes indicated, Resident 47's physical functioning continues to decline. The IDT notes indicated, Resident 47's ADLs declined and required more staff assistance in ADLs due to physical immobility. The IDT notes indicated Resident 47 can transfer with stand up lift with two-person assistance and is up daily in a wheelchair. During a concurrent observation in Resident 47's room and interview on 11/14/2023 at 2:51 pm with Resident 47, Resident 47s legs were observed to be contracted. Resident 47 stated she was not receiving any therapy for the legs. During a concurrent interview and record review on 11/16/2023 at 1:18 pm with LVN 1, LVN 1 stated Resident 1 had no RNA orders. During an interview on 11/16/2023 at 3:46 pm with the Physical Therapist (PT) 1, the PT 1 stated she is not familiar with Resident 47 and does not know why she is not receiving any services from physical therapy. During an interview on 11/16/2023 at 4:41 pm with the Director of Nursing (DON), the DON stated Resident 47 had physical therapy for 2 weeks and the physical therapy was discontinued on 1/24/2023. The DON stated if physical therapy is discontinued or exhausted then RNA services should be ordered. The [NAME] stated if RNA services are recommended it would be beneficial to Resident 47. b. During a review of Resident 20's Face Sheet the Face Sheet indicated, Resident 20 was admitted to the facility on [DATE] with diagnoses of but limited to dementia, transient cerebral ischemic attack (a minor stroke that causes a temporary blockage of blood flow to the brain and usually dissolves or gets dislodged within a hour) , Hx of falling, difficulty in walking, and generalized (affecting much of or all of the body) muscle weakness. During a review of Resident 20's Physician Order Report, dated 10/17/2023, the Physician Order Report indicated PT and or OT for hands on screening and joint mobility assessment as needed per Interdisciplinary Team(IDT-group of people help in the care)/MD recommendations. During a review of Resident 20's Care Plan, titled ADLs Functional Status/Rehabilitation Potential dated 10/16/2023, indicated Resident 20 will be provided with rehabilitation screening or treatment as needed. During a review of Resident 20's Rehabilitation Screening, dated 10/17/2023, the Rehabilitation Screening report indicated, Resident 20 was appropriate (suitable) for RNA for PROM to the bilateral upper extremities and bilateral lower extremities and part B PT and OT when approved. During a review of Resident 20's History and Physical (H&P) dated 10/22/2023, the H&P indicated Resident 20 did not have the capacity to understand and make decisions. During a review of Resident 20's MDS dated [DATE], the MDS indicated, Resident 20 is rarely or 055539 Page 4 of 15 055539 11/17/2023 Artesia Christian Home Inc. 11614 E. 183rd St Artesia, CA 90701

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some never understood. The MDS indicated, Resident 20 was dependent on staff for eating, oral hygiene, showering, toileting dressing, putting on and taking off footwear, personal hygiene, changing positions from sitting to lying, lying to sitting, sitting to standing, and transferring from the chair to the bed. During a concurrent interview and record review on 11/16/2023 at 12:42 pm with LVN 1, Resident 20's Rehabilitation Screening notes, dated 10/17/2023 was reviewed. LVN 1 stated Resident 20 was admitted to the facility with limited range of motion and was not receiving RNA services. LVN 1 stated Resident 20 had a contracture in the left leg. LVN 1 stated Resident 20 had a recommendation from PT 2 for RNA for range of motion. During a concurrent interview and record review on 11/16/2023 at 4:31 pm with the DON, Resident 20's Rehabilitation Screening notes, dated 10/17/2023 was reviewed. The DON agreed the PT 1 notes indicated Resident 20 had a recommendation for RNA services. The DON stated PT 1 did not communicate to the staff about Resident 20 needed RNA services and PT did not right any orders for RNA services. The DON stated PT 1 can write an RNA order but did not. The DON stated any resident could run the risk of contractures if they are not receiving the recommended RNA services. During an interview on 11/17/2023 at 4:38 pm with PT 2, PT 2 stated the process for a resident admitted to the facility and needs physical therapy or is admitted with contractures needs to be assessed or screened by rehabilitation department and if RNA is appropriate will order an RNA program . PT 2 stated, if the resident does not receive RNA services after receiving physical therapy the resident can decline and all the PT services the resident received would not have benefitted the resident. During a review of the facility's policy and procedure (P&P) titled, Dementia Care Manual, dated 2013, the P&P indicated, The facility's Restorative Nurses Aid (RNA) exercise program will be offered to qualified Residents to provide maintenance exercises a minimum of 5 times a week as ordered. This program will be maintained and monitored by the Rehabilitation Department Director and or the DON. Private pay Physical therapy group and individual sessions will be available for appropriate residents to provide increased exercise. Rehab screens will be provided yearly, every six months for high-risk residents, and as needed by Rehabilitation staff to monitor for contractures and functional and or physical decline. 055539 Page 5 of 15 055539 11/17/2023 Artesia Christian Home Inc. 11614 E. 183rd St Artesia, CA 90701

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 observations, interview and record review, the facility failed to: Residents Affected - Many a.Ensure an open box of red bean ice bar was labeled with open date and use by date in the freezer. b.Ensure an open bag of fresh peeled garlic was labeled with open date and expiry date in the refrigerator. c.Ensure a bag of Panko Breadcrumbs was not laying directly on the floor of the dry storage area. This failure had the potential to put residents at risk for food borne illness (any illness resulting from ingestion of food contaminated with bacteria, viruses or parasites). Findings: a.During a concurrent observation and interview on 11/14/2023, at 8:30 a.m. with the Director of Dining Services (DDS), observed an open box of red bean ice bar was not labeled with open date and use by date. The DDS stated the red bean ice bar belonged to a resident in the assisted living area and it should be labeled with the resident's name, open date and use by date. DDS asked one of the dietary staff members to label the open box of red bean ice bar. b.During a concurrent observation and interview on 11/14/2023, at 8:40 a.m. with the DDS, an open bag of fresh peeled garlic was not labeled with open date and use by date in the walk-in refrigerator. The DDS stated they label open food items in the freezer and refrigerator with open date and by use date. c.During a concurrent observation and interview with the DDS, a bag of Panko Breadcrumbs was laying directly on the floor in between the storage rack for canned goods and storage bin. DDS stated the bag of Panko Breadcrumbs was delivered last Thursday (11/9/2023). The DDS stated the bag of Panko Breadcrumbs should not be on the floor because it might get wet. During an interview on 11/17/2023, at 4:23 p.m. with [NAME] (CK 1), CK 1 stated they have to label open food items by putting the name of the product, date it was open and date of expiration to ensure the products will be good and will not be used beyond the expiration date. CK 1 stated residents could get sick with food borne illness if served with expired food. CK 1 stated the bag of Panko Breadcrumbs should be on the cart and should be six inches above to floor because of possible water damage and pest infestation. During an interview on 11/16/2023, at 2;59 P.M. with the Registered Dietician (RD), the RD stated it was important to label food items that are open so the staff members would know when to throw it out for food safety. The RD stated anything in the fridge has to be dated and label for food storage. RD stated dry food like bag of Panko Breadcrumbs had to be six inches off the floor and should not be left laying on the floor. During a review of facility's policy and procedure (P/P) titled Food and Supply Storage' revised 1/2021, the P/P indicated to cover, label and date unused portions and open packages and complete all 055539 Page 6 of 15 055539 11/17/2023 Artesia Christian Home Inc. 11614 E. 183rd St Artesia, CA 90701

F 0812 Level of Harm - Minimal harm or potential for actual harm sections on a [NAME] orange label or use the Medvantage/ Freshdate or other approved labeling system. The P/P indicated food in packages and working containers maybe stored less than 6 inches above the floor and all food and nonfood items used in food preparation will be stored in such a manner to prevent contamination and maintain the safety and wholesomeness of food for human consumption. Residents Affected - Many 055539 Page 7 of 15 055539 11/17/2023 Artesia Christian Home Inc. 11614 E. 183rd St Artesia, CA 90701

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview the facility failed to ensure handwashing or hand hygiene was performed before and after contact with a resident, before using gloves and after removing gloves during medication administration for 4 of 15 sampled residents, (Resident 16, Resident 43, Resident 4, and Resident 35.) Residents Affected - Some This failure had the potential to result in the transmission of and exposure to infectious microorganisms, contaminants and increased the risk of the spread of infection to the residents. Findings: During an observation on 11/16/2023 at 8:33 am with Licensed Vocational Nurse (LVN 1) on the South Covenant, during medication pass, LVN 1, placed medication in a medicine cup then went to get a blood pressure machine, put on a pair of gloves, removed one of the gloves and placed it in the trash can and then grabbed another pair of gloves and while holding the pair of gloves in his hand, grabbed another blood pressure machine because the first blood pressure machine was not working put on the second pair of gloves and closed the curtains, took Resident 16's blood pressure and removed the gloves and administered the medication to the Resident 16. During an observation on 11/16/2023 at 8:53 am with LVN 1 on the South Covenant, during medication pass, LVN 1 went to get Resident 43 from the dining room, checked the medication orders, removed medication from the medication cart, placed the medication in a medicine cup, put gloves on, administered medication to the resident orally and administered a nasal spray, removed the gloves and threw the gloves in the trash, and wheeled Resident 43 back to the dining room. During an observation on 11/16/2023 at 9:11 am with LVN 1 on the North Covenant, during medication pass, LVN 1, knocked on Resident 4's door, checked the medication orders, grabbed a medicine cup, took the medicine cart key from his pocket, got medications from the medication cart, and placed them in a medicine cup, then administered the medication to Resident 4. During an observation on 11/16/2023 at 9:32 am with LVN 1 on the North Covenant, during medication pass, LVN 1 got Resident 35 from the dining room, reviewed the doctor's order, took medication from the medication cart, got a pair of gloves and a glove dropped on the floor, LVN1 picked the glove up off the floor and threw the glove away in the trash, grabbed Resident 35's medication and crushed the medication and put the medication in a medicine cup and mixed it with applesauce, then left the gloves on the medicine cart and administered the medication to Resident 35 and then took Resident 35 back to the dining room. During an interview on 11/16/23 at 9:46 am with LVN 1, LVN 1 stated he should perform hand hygine or santize hands, after patient contact and before patient contact. LVN 1 stated the hands are washed or sanitized when preparing medications, and agreed the hands should be washed or sanitized before and after putting on gloves. LVN 1 stated if staff are not washing and sanitizing hands between residents and before and after using gloves there is a risk of infection to staff and residents. During an interview on 11/16/2023 at 4:24 pm with the Director of Staff Development (DSD), the DSD stated hand hygiene is done before patient care, after the hands are visibly soiled, and before using gloves due to the risk of infection. 055539 Page 8 of 15 055539 11/17/2023 Artesia Christian Home Inc. 11614 E. 183rd St Artesia, CA 90701

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 11/17/2023 at 3:45 pm with the Infection Preventionist Nurse (IPN) the IPN stated, hand hygiene is performed before and after a task, and before and after using gloves due to contamination and infection the gloves could still be dirty or soiled. During a review of the facility's policy and procedure titled, Handwashing/Hand Hygiene, revised 8/2015, the P&P indicated, Use an alcohol-based hand rub containing at least 62% alcohol; alternatively, soap (antimicrobial or non-microbial) and water for the following situations: before and after contact with residents, before preparing or handling medications; before donning sterile gloves; after removing gloves; and before applying non-sterile gloves. 055539 Page 9 of 15 055539 11/17/2023 Artesia Christian Home Inc. 11614 E. 183rd St Artesia, CA 90701

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 observation, interview, and record review the facility failed to monitor and address the use of antibiotics (a drug to treat infection) on one of two sampled residents (Resident 53) by prescribing an antibiotic that did not meet the clinical criteria (relevant signs and symptoms of the disease) of urinary tract infection( [UTI] infection in any part of the urinary system). Residents Affected - Few This failure had the potential to result in Resident 53 developing multi-drug resistance (antibiotic will not be effective to treat infection) from unnecessary or inappropriate use of antibiotic. Findings: During a review of resident 53's admission Record, the admission record indicated Resident 53 was admitted on [DATE] with diagnoses that included dementia ( a group of symptoms affecting memory, thinking and social abilities that can interfere with daily life) with other behavioral disturbance, dysphagia (difficulty in swallowing), difficulty in walking and atrial fibrillation (quivering or irregular heartbeat). During a review of Resident 53's History and Physical Examination (H and P) dated 5/17/2023, the H and P indicated Resident 53 did not have the capacity to understand or make decisions because of dementia. During a review of Resident 53's Minimum Data Set ([MDS] a standardized screening and care tool) dated 8/25/2023, the MDS indicated the resident had severely impaired cognition (thought process) and required one person assist with bed mobility, dressing, eating, toileting, and personal hygiene. During a review of Resident 53 's Event Report (a document that indicates a change of condition) dated 10/6/2023, the event report indicated the certified nursing assistant reported the resident was manifesting increased confusion, combative, hitting, and resisting to care during the 11:00 p.m. to 7:00 a.m. shift The event report indicated a urinalysis ([UA] a test that examines the visual, chemical and microscopic aspects of urine) and urine culture and sensitivity (urine test that can identify bacteria or yeast causing UTI and can identify an antibiotic most likely to kill the particular bacteria) were ordered by the physician. The Event Report did not indicate symptoms related to an infection like fever, any discomfort, painful urination, and resident's vital signs ([vs] measurements of the body's most basic functions) were normal. During a review of Resident 53's Event Report dated 10/14/2023, the event report indicated the resident was on antibiotic therapy for a UTI for 3 days related to confusion, combativeness, hitting and resisting to care. The Event Report indicated a urine culture and sensitivity (urine test that can identify bacteria or yeast causing UTI and can identify an antibiotic most likely to kill the particular bacteria) test results relayed to the physician and Bactrim DS ( antibiotic used to treat UTI) was ordered by the physician. During a review of Resident 53's urine culture and sensitivity test collected on 10/11/2023 and resulted on 10/14/2023, the updated result indicated the presence of Escherichia coli ([E coli] type of bacteria commonly found in the digestive system and can cause serious infection in the bladder and urinary system) with a colony count of 20,000 to 49,000 ( colony count- number of bacteria present in the urine sample). 055539 Page 10 of 15 055539 11/17/2023 Artesia Christian Home Inc. 11614 E. 183rd St Artesia, CA 90701

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 53's Physician Order dated 10/14/2023, the record indicated an order of Bactrim DS 800-160 milligrams([mg] unit of measurement) one tablet by mouth every 12 hours for UTI for three days related to increased confusion and behavior. During a review of Resident 53's Medication Administration Record (MAR) dated 10/14/2023 to 10/17/2023, the MAR indicated resident completed the dose of the prescribed antibiotic (Bactrim DS). During a review of facility's Individual Infection Report (Surveillance Report) dated 10/14/2023, the Individual Infection Report indicated acute change in mental status as the only criterion for UTI and resident was manifesting fluctuating behavior of confusion during assessment. The Individual Infection Report indicated Infection Preventionist Nurse (IPN) documented the antibiotic prescribed, urine culture result and symptoms did not meet the criteria for UTI treatment, and physician ordered the antibiotic to prevent sepsis (severe infection that can cause organ failure) and for empiric (directed against a likely but not confirmed infection) use. During an interview on 11/17/2023, at 3:12 p.m. with the Infection Prevention Nurse (IPN,) the IPN stated the facility used McGeer Criteria for Surveillance of Infection (a guide for initiating antibiotic use on the residents) . IPN stated she notified the prescribing physician about the use of Bactrim on Resident 53 because Resident 53 did not meet the McGeer Criteria and was only showing confusion and the urine culture indicated only 20,000 to 49,000 of Escherichia Coli in the urine but the physician wanted to start antibiotic for empiric use. The IPN stated presence of E. coli in the urine had to be greater than 100,000 colonies as one of the criteria and the resident needed 3 clinical criteria for UTI to start antibiotic therapy based on McGeer Criteria. The IPN stated the resident did not have other symptoms related to infection aside from confusion and combativeness. The IPN stated Resident 53 could develop resistance to Bactrim because the antibiotic was not indicated based on the result of urine culture and symptoms, but was still administered. During an interview on 11/17/2023, at 4:49 p.m. with Certified Nursing Assistant (CNA1), CNA1 stated residents who are experiencing a UTI looked different, confused , would complain of pain below the stomach and would have a very strong smell of urine. CNA1 stated it should be reported right away to the charge nurse when residents are observed having these symptoms. During an interview on 11/17/2023, at 4:33 p.m. with Licensed Vocational Nurse (LVN1), LVN 1 stated Resident 53 was hitting and kicking staff during care and this was reported to the physician who had prescribed Bactrim. LVN 1 stated Resident 53 had confusion but no fever, bladder pain or any pain at that time and no abnormal change in vital signs. LVN 1 stated she relayed the result of the urine culture and did not question why an antibiotic was ordered for a urine culture that had a 20,000 - 49,000 colony count of bacteria because the Bactrim was used for prevention. LVN 1 stated the facility was using McGeer Criteria as a guide for usage of antibiotic and per clinical criteria for a UTI, Resident 53's urine culture should have a colony count of bacteria greater than 100,000 to be considered as one of the criteria to start the antibiotic. LVN 1 stated Resident 53 would develop resistance to the antibiotic without proper indication and would not be susceptible or responsive to the prescribed antibiotic next time it will be used on the resident. During a review of Centers for Disease Control and Prevention ([CDC] the national public health agency of the United States) online article dated 8/2021 titled Core Elements of Antibiotic Stewardship for Nursing Homes | Antibiotic Use | CDC, the online article indicated antibiotics are most frequently prescribed medications in nursing homes, with up to 70 % of residents in nursing home receiving one or more courses of systemic antibiotics. Harms from antibiotic overuse are significant for the 055539 Page 11 of 15 055539 11/17/2023 Artesia Christian Home Inc. 11614 E. 183rd St Artesia, CA 90701

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few frail and older adults receiving care which can include serious diarrheal infections, increased adverse drug events , colonization and infection with antibiotic-resistant organisms. During a review of facility's policy(P/P) and procedure titled Antibiotic Stewardship-Orders for Antibiotics revised 12/2016, the P/P indicated appropriate indications for use of antibiotics include criteria met for clinical definition of active infection or suspected sepsis(life threatening medical emergency in response to an extensive inflammation throughout your body that can lead to tissue damage or death) and or pathogen( disease causing agent) susceptibility based on culture and sensitivity to antimicrobial drug. 055539 Page 12 of 15 055539 11/17/2023 Artesia Christian Home Inc. 11614 E. 183rd St Artesia, CA 90701

F 0912 Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Level of Harm - Potential for minimal harm During an interview with the Administrator (ADMIN) on 11/17/2023 at 1040 AM, the ADM Residents Affected - Some stated the residents in the affected rooms were not negatively impacted. The ADM stated there is sufficient room for the provision of nursing services for these group of residents. the rooms were approved during OSHPD inspection. During a review of the letter provided by the ADMIN dated 1/12/2023 , the ADMIN requested a room waiver for the residents' room sizes less than 80 sq ft per resident for six of 18 rooms. The following resident rooms measured as followed: Room Number of beds Square Footage 34 4 305.5 35 4 305.5 36 2 151 37 2 152 38 2 152 39 2 151 During observations in these rooms throughout the survey period 11/14/2023 through 11/17/2023, there were no issues observed with the residents having access in and out of the rooms, the space for their furniture, and no problems with staff being able to administer or assist with care. 055539 Page 13 of 15 055539 11/17/2023 Artesia Christian Home Inc. 11614 E. 183rd St Artesia, CA 90701

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 maintain a functional call light for one of five sampled residents (Resident 21). Residents Affected - Few This failure had the potential to result in a delay in meeting Resident 21's needs for assistance and could lead to falls and accidents. Findings: During a review of Resident 21's admission Record(Face Sheet), the Face Sheet indicated the resident was admitted on [DATE] to the facility with diagnoses that included dementia( loss of cognitive functioning like remembering, thinking and reasoning that can interfere with daily life), congestive heart failure (heart capacity to pump blood cannot keep up with the body's needs), difficulty in walking, muscle weakness and encounter for palliative care ( specialized medical care for people living with serious illness, such as cancer or heart failure). During a review of Resident 21's Minimum Data Set ([MDS] standardized screening tool) dated 10/10/20223, the MDS indicated Resident 21 had moderately impaired cognition ( person's ability to think, learn, remember, and make decisions) and required moderate assistance( helper lifts, holds, or supports trunk or limbs with less than half the effort)with toileting and bed mobility. The MDS indicated the resident was frequently incontinent of urine ( having no sufficient voluntary control over urination). During a concurrent observation and interview on 11/14/2023, at 3:02 p.m. with Resident 21, Resident 21 stated his call light was not working and had told an unnamed staff member about it today. Observed Resident 21 pressing the call light and no audible alarm or light were present on the call light indicator in the room or outside of Resident 21's room. Resident 21 stated he felt frustrated and angry when he could not call someone for help with his needs because the call light has been working on and off. During a concurrent observation and interview on 11/14/2023, at 3:16 p.m. with Licensed Vocational Nurse(LVN1), LVN 1 confirmed Resident 21's call light was not working after pressing it. LVN 1 disconnected call light cable and reconnected it back which made the call light worked again. LVN 1 stated call light should be functional to ensure residents would be assisted and provided care when they call for the staff members. During a concurrent observation and interview on 11/14/2023, at 3:23 p.m. with Disaster Coordinator (DC), DC stated Facility Maintenance (FM) had switched the cable of Resident 21's call light today at around 11:00 a.m. after receiving a call from an unnamed staff member. DC stated all call lights of residents were wireless and call lights can be viewed and monitored in the Nursing Station. Observed a monitor screen where all room numbers of residents were present and were in green including Resident 21's room whose call light was intermittently working. DC pressed call light at resident's room across the station and the color of the room turned red in the screen. DC stated nursing staff should be able to monitor the screen when they are not around. During an interview on 11/16/2023, at 9:17 a.m. with Family Member (FM1), FM 1 stated the facility had a Maintenance Logbook where staff members would write the order request so it would be followed 055539 Page 14 of 15 055539 11/17/2023 Artesia Christian Home Inc. 11614 E. 183rd St Artesia, CA 90701

F 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few up. FM1 stated the monitor screen in the nursing station where the room numbers were displayed would turn yellow from normal color of green when a call light's batteries were low, or wire was loose, and a red light meant a resident was calling. FM stated the nurses or certified nursing assistants should see and check the monitor when he is not around. FM stated a functional call light to call for help or assistance. During an interview on 11/17/2023, at 10:30 a.m. with Certified Nursing Assistant (CNA2), CNA 2 stated call light had to be within reach and working because the residents need it for safety and in case of emergencies.CNA2 stated if a call light is defective, it will be reported to the charge nurse immediately and the charge nurse will log it in the book and report the issue to the Maintenance Department. During a review of facility's policy and procedure(P/P) titled Work Orders, Maintenance undated, the P/P indicated in order to establish a priority of maintenance service, work orders must be written, and facilities staff would check the book daily for any issues needing repair or looked at. During a review of facility's P/P titled Answering Call Light undated, the P/P indicated to report all defective call lights to the nurse supervisor promptly and ensure frequent checks are performed for residents that may not be able to use their call light. 055539 Page 15 of 15