Health inspection·October 13, 2023

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a code status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop) was ordered and an Advance Directive (a written statement of a person's wishes regarding medical treatment, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) was readily available to facility staff for one of three sampled residents (Resident 2) This failure had the potential for harm to Resident 2 as staff and emergency medical personnel would perform life-sustaining measures in the event of an emergency, which did not align with the wishes expressed and documented by Resident 2 and her family. Findings: During a review of Resident 2's admission Record, the admission record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure (when the respiratory system [nose, mouth, throat, voice box, windpipe, and lungs] cannot adequately provide oxygen to the body) with hypoxia (when the body or a region of the body is deprived of adequate oxygen supply), and end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). During a review of Resident 2's History and Physical (H&P), dated [DATE], the H&P did not indicate whether Resident 2 had an Advance Directive. Further review of the document indicated the section related to Resident 2's code status was left blank. During a review of Resident 2's Interdisciplinary Team (IDT, group of different disciplines working together towards a common goal of a resident) meeting notes, dated [DATE], the IDT meeting notes indicated code statuses had been discussed with Resident 2 and Resident 2's family, and indicated Resident 2 did not want life-sustaining treatment in the event of a medical emergency. During a review of Resident 2's medical record document titled, Physician Order for Life Sustaining Treatment (POLST, a form designed to improve patient care by creating a portable and physical medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency), dated [DATE], the POLST indicated Resident 2 did not want cardiopulmonary resuscitation (CPR, an emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped) performed if Resident 2 was found without a pulse or not breathing. The POLST required a provider's signature (e.g., a physician, nurse Page 1 of 23 056014 056014 10/13/2023 Brookfield Healthcare Center 9300 Telegraph Road Downey, CA 90240

F 0561 Level of Harm - Minimal harm or potential for actual harm practitioner, physician assistant) to be considered valid, and the section where the provider would sign was left blank. During a review of Resident 2's active Physician's Orders, the physician's orders indicated there was no electronic code status ordered. Residents Affected - Few During a review of the facility document titled, Advance Directive Notification, dated [DATE], the Advance Directive Notification indicated Resident 2 had an Advance Directive and that family would provide a copy. The Advance Directive was not readily available in Resident 2's paper chart. During a concurrent interview and record review on [DATE] at 9:23 AM with the Director of Social Services (DSS), the DSS stated the purpose of the Advance Directive was to ensure the wishes of the resident were respected, which included emergency healthcare decisions. The DSS stated the POLST form was a physician order that reflected the wishes of the resident and stated Resident 2's POLST form indicated Resident 2 did not want life-sustaining measures implemented in an emergency. The DSS stated Advance Directives and POLST forms were kept in the residents' physical and electronic medical records because the electronic medical record was not always accessible due to technical difficulties. The DSS stated it was important for staff to have physical copies in the event of an emergency to ensure the residents' wishes were respected. The DSS stated the POLST was not signed by the physician, and stated there was no copy of Resident 2's Advance Directive in her physical medical record. During a concurrent interview and record review on [DATE] at 9:43 AM with the Director of Nursing (DON), the DON reviewed Resident 2's POLST form and stated it reflected Resident 2's desired code status and stated the form should have been signed by the physician. The DON then reviewed Resident 2's electronic medical record (EMR) and stated there was no electronic code status ordered by the physician. The DON also stated Resident 2's Advance Directive was also not readily available in the physical medical record. The DON stated that in an emergency, staff would be unable to ensure Resident 2's wishes were carried out because the POLST had not been signed and no code status had been ordered. During a review of the facility's policy and procedure (P&P) titled, Advance Directives and Associated Documentation dated 1/2022, the P&P indicated it is the policy of this facility that a resident's choice about advance directives will be recognized and respected. The P&P further indicated it is the policy of this facility to implement the resident decisions and directives, and that staff were supposed to obtain a copy of the Advance Directive .documents and place in the resident health record. During a review of the facility's P&P titled, Advance Directives, dated 11/2019, the P&P indicated it is the policy of this facility that a resident's choice about advance directives will be recognized and respected, and further indicated the facility will be utilizing the POLST form for residents .and legal representatives to communicate their choices .and end-of-life decisions. The P&P further indicated that if the resident has an Advance Directive, the facility will require that a copy of such directives be included in the medical record, and that the facility will also notify the attending physician of advance directives so that .appropriate orders can be documented in the resident's medical record and plan of care. 056014 Page 2 of 23 056014 10/13/2023 Brookfield Healthcare Center 9300 Telegraph Road Downey, CA 90240

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the responsible party (RP) for one of three sampled residents (Resident 11) was appropriately notified regarding changes to Resident 11's Medicare coverage through provision of the Notice of Medicare Non-Coverage (NOMNC) form and the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) form. Residents Affected - Few This deficient practice had the potential to result in Resident 11, or Resident 11's RP, not being able to exercise their right to file an appeal and to unknowingly paying for non-covered care expenses. Findings: During a review of Resident 11's admission Record, the admission record indicated Resident 11 was admitted to the facility on [DATE], with admitting diagnoses that included Alzheimer's disease (a progressive disease that involves parts of the brain that control thought, memory, and language; begins with mild memory loss, and possibly leads to loss of the ability to carry on a conversation and respond to the environment). During a review of Resident 11's Minimum Data Set (MDS, a standardized assessment and care-screening/care-planning tool), dated 8/9/2023, the MDS indicated Resident 11 had severe cognitive impairment (ability to think and reason) with disorientation to time and inability to recall information. During a review of Resident 11's assessment titled, Social History, dated 4/1/2020, the assessment indicated Resident 11's had a RP (Family Member [FM] 2). During a review of the facility document titled, Advance Beneficiary Notice of Non-Coverage (ABN), undated, the document indicated the purpose of the form was to allow the recipient to make an informed decision about [their] care. The document indicated Resident 11 wanted to continue to receive skilled services, would be responsible for payment, and would not be able to appeal the payments. Resident 11 signed the document on 8/25/2023. During a review of the facility document titled, Notice of Medicare Non-Coverage, undated, the document indicated facility staff were unable to reach FM 2 by telephone on 8/28/2023 to notify her that Resident 11's coverage was ending on 8/30/2023. Resident 11 signed the document on 8/28/2023. During an interview on 10/12/2023 at 3:09 PM with the Director of Social Services (DSS), the DSS stated she was responsible for provision of the forms titled Advance Beneficiary Notice of Non-Coverage (ABN) and Notice of Medicare Non-Coverage. The DSS stated the forms informed the resident or their RP of potential coverage discontinuation and informed them of their right to appeal. The DSS stated FM 2 was responsible for making decisions for Resident 11 because Resident 11 was confused. The DSS stated FM 2 was supposed to be the recipient of the forms, but facility staff were unable to reach FM 2 so Resident 11 was asked to sign the documents instead. The DSS stated they did not attempt to identify an alternate RP for Resident 11. During an interview on 10/12/2023 at 3:53 PM with Resident 11, Resident 11 was provided with a copy of the signed documents titled Advance Beneficiary Notice (ABN) and Notice of Medicare 056014 Page 3 of 23 056014 10/13/2023 Brookfield Healthcare Center 9300 Telegraph Road Downey, CA 90240

F 0582 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Non-Coverage. Resident 11 stated, That looks like my handwriting, but I don't remember signing that. Resident 11 stated he could not recall anyone talking to him about his Medicare coverage and stated he could not explain what the forms indicated. At the time of the interview, Resident 11 could only state his first name, but could not state where he was, why he was there, or what year it was. During an interview on 10/12/2023 at 4:22 PM with the Director of Nursing (DON), the DON stated Resident 11 had a diagnosis of Alzheimer's disease and severe cognitive impairment. The DON stated it was not appropriate for staff to ask Resident 11 to sign the Advance Beneficiary Notice (ABN) and Notice of Medicare Non-Coverage forms, stating the individual signing the forms should be able to understand the information being provided. The DON stated the forms should have been provided to FM 2, or an alternate decision maker should have been identified if FM 2 was not available. During a review of the facility's policy and procedure (P&P) titled, Medicare Notice of Non-Coverage (NOMNC) Generic Form CMS-10123, dated 7/2013, the P&P indicated the NOMNC must be validly delivered, and further indicated valid delivery means that the .patient was able to understand its purpose and contents in order to sign a receipt of it. The P&P further indicated when the patient is unable to comprehend the contents of the NOMNC, it must be delivered to and signed by a patient representative. During a review of the facility's P&P titled, Advanced Beneficiary Notice of Non-Coverage (Part A), dated 3/2018, the P&P indicated the Advance Beneficiary Notice must be delivered far enough in advance that the beneficiary or representative has time to make an informed decision. The P&P further indicated the Advance Beneficiary Notice must be verbally reviewed with the beneficiary or his/her representative and any questions raised during that review must be answered before [the form] is signed. 056014 Page 4 of 23 056014 10/13/2023 Brookfield Healthcare Center 9300 Telegraph Road Downey, CA 90240

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few Based on observation, interview, and record review, the facility failed to implement interventions to prevent a fall with injury for one of three residents (Resident 19) with history of falls by failing to: 1. Ensure Resident 19 performed toilet transfers toward the left, unaffected side and did not place weight onto the right leg after toileting. 2. Provide Resident 19 with two-persons assistance for toilet transfers and toilet hygiene (toileting, includes managing undergarments, clothing, and incontinence products and performing cleansing before or after voiding or having a bowel movement). 3. Provide Resident 19 with two-persons assistance for sit to stand transfers (transfers from a seated position to a standing position) after toileting. These failures resulted in Resident 19 falling from a standing position onto the floor in the restroom on 7/30/2023. On 7/31/2023, Resident 19 complained of right shoulder pain and received an X-ray (used to create images of the inside of the human body) which indicated Resident 19 had a right humeral (shoulder bone) fracture (break in the bone). The facility transferred Resident 19 to the general acute care hospital (GACH 2) on 8/1/2023 where Resident 19 underwent right shoulder surgery on 8/3/2023. Findings: During a review of Resident 19's Discharge Summary from the general acute care hospital (GACH) 1, dated 6/28/2023, the Discharge Summary indicated Resident 19 had a history of cerebral vascular accident (CVA or stroke, brain damage due to blocked blood flow) with right sided weakness and had worsening right knee pain after a fall onto the right knee at home. The Discharge Summary indicated Resident 19 had a distal femur (thigh bone close to the knee) fracture with hardware fracture (breaking of surgically placed pins, plates, or screws to help fix a broken bone). The Discharge Summary indicated Resident 19 underwent surgery on 6/26/2023 for rodding (operative insertion of a straight metal rod) with cement augmentation (injection of bone cement into a fracture) of the right leg and should maintain non-weight bearing (NWB, inability to place any weight through the limb, including an operated limb to allow healing) on the right leg for at least six weeks. During a review of Resident 19's admission Record, the admission record indicated the facility admitted Resident 19 on 6/29/2023 with diagnoses including periprosthetic fracture around internal prosthetic right knee joint (fracture of the thigh bone occurring close to metal parts of a previous right knee surgery), encounter for other orthopedic aftercare, muscle weakness, difficulty walking, and hemiplegia and hemiparesis (weakness and paralysis [inability to move] to one side of the body) affecting the right dominant side. During a review of Resident 19's Physician's Order, dated 6/29/2023, the physician's order indicated Resident 19 was NWB on the right leg for six weeks. During a review of Resident 19's Fall Risk Evaluation, dated 6/29/2023, the fall risk evaluation indicated the facility assessed Resident 19 as a high risk for falls. 056014 Page 5 of 23 056014 10/13/2023 Brookfield Healthcare Center 9300 Telegraph Road Downey, CA 90240

F 0689 During a review of Resident 19's care plan titled, At Risk For Falls, initiated on 7/11/2023, the interventions included placing the bed in the lowest position and maintain a clear pathway free of obstacles. Level of Harm - Actual harm Residents Affected - Few During a review of Resident 19's Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation and Plan of Treatment, dated 6/29/23, the PT Evaluation indicated Resident 19's was NWB on the right leg for at least six weeks. The PT Evaluation indicated Resident 19 was dependent (required more than 75% physical assistance to perform the task) requiring the assistance of two-persons with bed mobility from lying to sitting on the side of the bed. The PT Evaluation indicated Resident 19 was unable to perform sit to stand transfers, bed-to-chair transfers, and toilet transfers due to medical conditions or safety concerns. The PT Plan of Treatment included therapeutic exercises (movement prescribed to correct impairments and restore muscle function), neuromuscular reeducation (technique used to restore movement patterns through repetitive motion to retrain the brain), gait (manner of walking) retraining therapy, therapeutic activities [tasks that improve the ability to perform activities of daily living (ADLs, tasks related to personal care including bathing, dressing, hygiene, eating, and mobility)], and wheelchair management training (training on proper positioning and ability to propel the wheelchair), five times per week for four weeks. During a review of Resident 19's Occupational Therapy (OT, profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Evaluation and Plan of Treatment, dated 6/29/2023, the OT Evaluation indicated Resident 19 was NWB on the right leg for at least six weeks. The OT Evaluation indicated Resident 19 was dependent for toileting, showering, upper body dressing, and lower body dressing. The OT Evaluation indicated toilet transfers were not attempted with Resident 19 due to medical conditions or safety concerns. The OT Plan of Treatment included therapeutic exercises, neuromuscular reeducation, therapeutic activities, and self-care management training, five times per week for four weeks. During a review of Resident 19's Minimum Data Set (MDS, a comprehensive assessment and care planning tool), dated 7/3/2023, the MDS indicated Resident 19 had clear speech, clearly understood verbal content, and had moderately impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 19 was dependent for transfers (how resident moves between surfaces included to or from the bed, chair, wheelchair, and standing position) with at least two-persons physical assistance, dependent for dressing with one-person physical assistance, dependent for toilet use with one-person physical assistance, and bathing with one-person physical assistance. During a review of Resident 19's ADL flow sheet (record of nursing assistance provided) for 7/2023, the ADL flow sheet indicated Resident 19 received assistance with toilet use with one-person assistance on 7/25/2023, 7/26/2023, 7/27/2023, 7/28/2023, and 7/29/2023. During a review of Resident 19's PT Recert [sic] (Recert, re-evaluation documenting the need for continued therapy), Progress Report, and Updated Therapy Plan, dated 7/27/2023, the PT Recert indicated Resident 19 required maximum assistance with two-persons for sit to stand transfers and dependent with two-persons for functional transfers. During a review of Resident 19's OT Recert, Progress Report, and Updated Therapy Plan, dated 7/27/2023, the OT Recert indicated Resident 19 was dependent for toilet hygiene and dependent with two-persons for toilet transfers. 056014 Page 6 of 23 056014 10/13/2023 Brookfield Healthcare Center 9300 Telegraph Road Downey, CA 90240

F 0689 Level of Harm - Actual harm During a review of Resident 19's Progress Note for eMAR-Medication Administration, dated 7/30/2023 at 9:57 AM, the progress note indicated Licensed Vocational Nurse (LVN) 3 administered one (1) Hydrocodone-Acetaminophen (pain medication) 5-325 milligrams (mg, unit of measurement) tablet to Resident 19 by mouth for severe pain. Residents Affected - Few During a review of Resident 19's Progress Note for Nursing, dated 7/30/2023 at 12:00 PM, the nursing progress note indicated LVN 3 noted Resident 19 had an episode of weakness during transfers from wheelchair to toilet on 7/30/23 at approximately 10:20 AM that resulted in the Certified Nursing Assistant (CNA) slowly lowering Resident 19 to the ground in a sitting position. LVN 3's Nursing Progress Note further indicated Resident 19 stated she (Resident 19) felt weak upon transfer and both legs gave out. LVN 3's Nursing Progress Note indicated Resident 19 had no apparent injury, denied hitting head, and was assisted back to bed with three staff members. LVN 3's Progress Note also indicated Resident 19's physician and family members were notified. During a review of Resident 19's care plan titled, At risk for falls, initiated 7/31/2023, the care plan indicated the staff's interventions for fall included to increase staff assistance to two-persons assist during transfers as needed. During a review of Resident 19's Progress Note for Therapy, dated 7/31/2023 at 12:00 PM, the progress note indicated Physical Therapist (PT) 1 screened Resident 19 after the assisted fall on 7/30/23. PT 1's Therapy Progress Note indicated Resident 19 complained of right shoulder pain, right knee pain, and Resident 19 refused further assessment on the right shoulder and knee. PT 1's Progress Note for Therapy indicated nursing was aware and recommended an X-ray of the right shoulder and right knee. During a review of Resident 19's Radiology Results Report, dated 7/31/2023 at 9:41 PM, the right shoulder X-ray indicated Resident 19 had a comminuted fracture (broken bone in at least two places) of the right humeral neck (part of the upper arm just below the shoulder joint). During a review of Resident 19's Progress Note for Laboratory/Radiology, dated 7/31/2023 at 11:51 PM, the progress note indicated LVN 4 reported the X-ray results from 7/31/23 to Resident 19's physician (MD 1) without any new orders. During a review of Resident 19's Progress Note for eMAR-Medication Administration, dated 8/1/2023 at 8:57 AM, the progress note indicated LVN 5 administered one (1) Hydrocodone-Acetaminophen 5-325 mg tablet to Resident 19 by mouth for severe pain in the right shoulder. During a review of Resident 19's Progress Note for Transfer Out, dated 8/1/2023 at 11:11 AM, the progress note indicated Registered Nurse (RN) 2 noted Resident 19's X-ray results were received on 8:50 AM which had a significant finding of a right comminuted humeral neck fracture. RN 2's Progress Note indicated Resident 19 had sharp pain in the right shoulder which was swollen and warm to touch. RN 2's Progress Note indicated RN 2 placed a sling (bandage used to support an injured arm) on the right shoulder to ensure the right arm was NWB. RN 2's Progress Note indicated MD 1 was notified and provided orders to transfer Resident 19 to GACH 2 for further evaluation and treatment. During a review of GACH 2's Emergency Department Note, dated 8/1/2023 at 11:14 AM, the GACH 2 Emergency Department Note indicated GACH 2 admitted Resident 19 for right shoulder pain after a fall in the restroom. 056014 Page 7 of 23 056014 10/13/2023 Brookfield Healthcare Center 9300 Telegraph Road Downey, CA 90240

F 0689 Level of Harm - Actual harm Residents Affected - Few During a review of GACH 2's X-ray Report, dated 8/1/2023 at 12:46 PM, the GACH X-ray Report indicated Resident 19's right shoulder had diffuse osteopenia (bones weaker than normal) with a displaced (bone came out of alignment) and comminuted fracture through the right humeral head (shoulder joint) and neck. During a review of GACH 2's X-ray Report, dated 8/3/2023 at 6:00 PM, the GACH X-ray Report indicated Resident 19's right shoulder underwent an open reduction internal fixation (ORIF, surgical procedure where fractured bones are realigned and then stabilized in place with screws, plates, or rods) of the right humeral fracture. During a review of GACH 2's Progress Note, dated 8/4/2023 at 7:57 AM, the GACH Progress Note indicated Resident 19 had to be transferred to the Intensive Care Unit (ICU, department of the hospital for patients who are dangerously ill requiring constant observation) due to acute hemorrhagic shock (severe blood loss which leads to inadequate oxygen delivery) and required a blood transfusion (process of transferring blood into the veins of a patient). During a review of Resident 19's Physician's Orders, dated 8/7/2023, the physician's orders indicated the facility re-admitted Resident 19 with diagnoses including displaced comminuted fracture of the right humerus and subsequent encounter for fracture with routine healing. During a concurrent observation and interview on 10/10/2023 at 10:01 AM with Resident 19, in the resident's room, Resident 19 was observed lying in bed with the head-of-bed elevated. Resident 19 appeared to understand questions but had limited ability to speak. Resident 19 stated she fell three months ago at home and broke the right leg. Resident 19 had difficulty lifting the right arm and raising the right leg. Resident 19 stated there was a problem with the right arm and the right leg but was unable to explain in further detail. During an observation on 10/10/2023 at 11:48 AM, in the Resident 19's room, Resident 19 was seated in a wheelchair and observed using the left arm to operate a touch screen tablet. During an interview on 10/11/2023 at 9:23 AM with Resident 19, in Resident 19's room, Resident 19 stated Resident 19 was assisted to the restroom with one staff member when Resident 19 fell (7/30/2023). Resident 19 was unable to explain the incident in further detail. Resident 19 stated having right arm pain after the fall and had surgery, which Resident 19 stated relieved the pain. During an observation on 10/11/2023 at 10:45 AM, in Resident 19's restroom, the small room contained a toilet on the right side and a sink on the left side, which was approximately two feet (unit of measure) immediately in front of the toilet. During a follow-up observation on 10/11/2023 at 12:51 PM, in the restroom, there was a vertical grab bar (safety devices a person can grab onto to maintain balance and hold some body weight while transferring) mounted to the wall on each side of the toilet. During an interview on 10/11/23 at 10:45 AM, in Resident 19's bathroom, LVN 3 recounted the events with Resident 19 on 7/30/2023. LVN 3 stated LVN 3 administered pain medication to Resident 19 in the morning due to right knee pain. LVN 3 stated Certified Nursing Assistant (CNA) 1 called LVN 3 through the facility's two-way radio earpiece for assistance in Resident 19's restroom. LVN 3 stated Resident 19 was already sitting on the floor with CNA 1 positioned behind Resident 19. LVN 3 stated CNA 1 reported Resident 19 stood at the sink after using the toilet. LVN 3 stated CNA 1 reported being positioned behind Resident 19 for toilet hygiene when Resident 19's knees gave out and CNA 1 056014 Page 8 of 23 056014 10/13/2023 Brookfield Healthcare Center 9300 Telegraph Road Downey, CA 90240

F 0689 Level of Harm - Actual harm reportedly lowered Resident 19 to the ground. LVN 3 stated Resident 19 denied any pain while seated on the floor during the assessment. LVN 3 stated CNA 1 and CNA 2 lifted Resident 19 back into the wheelchair, and all three staff members assisted Resident 19 from the wheelchair to the bed. LVN 3 stated Resident 19 did not complain of any pain throughout LVN 3's work shift. Residents Affected - Few During a concurrent interview and record review with Physical Therapy Assistant (PTA) 2 on 10/11/2023 at 12:12 PM, PTA 2 reviewed Resident 19's PT Recert, dated 7/27/2023. PTA 2 stated Resident 19 was NWB on the right leg, required maximum assistance with two-persons for sit to stand transfers, and dependent with two-persons assistance for transfers. PTA 2 stated Resident 19 required the assistance of two-persons for safety and to maintain the NWB precautions on the right leg. During an interview on 10/11/2023 at 12:51 PM with CNA 1, in Resident 19's restroom, CNA 1 stated Resident 19 was sitting up in a wheelchair and requested to use the restroom on 7/30/2023. CNA 1 wheeled Resident 19 to the restroom, close to the toilet, and transferred Resident 19 from the wheelchair to the toilet toward the right side. CNA 1 stated Resident 19 used the grab bar on the right side of the toilet to assist with the transfer. CNA 1 stated CNA 1 assisted Resident 19 from sitting on the toilet to standing while CNA 1 stood on Resident 19's left side. CNA 1 stated Resident 19 took a step forward to hold onto the sink directly in front of the toilet. CNA 1 stated Resident 19 stood on both legs at the sink while CNA 1 was behind Resident 19 to clean and fasten Resident 19's incontinence brief. CNA 1 stated CNA 1 noticed Resident 19's right leg was getting weak and bent more. CNA 1 then grabbed the waist of Resident 19's pants to lower Resident 19 to the ground. CNA 1 stated CNA 1 called LVN 3 for assistance over the two-way radio, saw CNA 2 walk by Resident 19's room, and asked CNA 2 for assistance with Resident 19. During a concurrent interview and record review on 10/11/2023 at 1:35 PM with Occupational Therapist (OT) 1, OT 1 reviewed Resident 19's OT Recert, dated 7/27/2023. OT 1 stated Resident 19 was dependent with the assistance of two-persons for toilet transfers due to Resident 19's prior history of stroke affecting the right side and the NWB status on the right leg. OT 1 stated the transfer required two-persons since one person had to lift or support Resident 19's right leg during the transfer to ensure Resident 19 maintained NWB on the right leg. OT 1 stated a resident's level of assistance (in general) for transfers were communicated verbally to the nurses. OT 1 stated it would be unsafe for Resident 19 to transfer into the restroom's toilet toward right side due to Resident 19's NWB status on the right leg and weakness on the right side from the previous stroke. OT 1 stated Resident 19 was not allowed to place any weight on the right leg including standing on both legs. OT 1 stated placing any weight on Resident 19's right leg could result in pain, re-injury of the right leg, buckling (bending) of the right leg, or a fall. During an interview on 10/11/2023 at 2:05 PM with CNA 2, CNA 2 recounted the events with Resident 19 on 7/30/2023. CNA 2 stated CNA 2 looked into Resident 19's room and saw CNA 1 in the restroom asking for assistance. CNA 2 stated CNA 1 was behind Resident 19, who was already on the floor in a seated position, both legs were in front of Resident 19's body, and Resident 19's back was leaning against CNA 1. LVN 3 came into the restroom and assessed Resident 19. CNA 2 stated Resident 19 was anxious due to the fall but did not have any pain. CNA 2 stated LVN 3 was behind the wheelchair, holding it into place, while CNA 2 was positioned on the left side and CNA 1 was on the right side of Resident 19. CNA 2 demonstrated how CNA 1 and CNA 2 lifted Resident 19 from the floor and into the wheelchair. CNA 2 hooked CNA 2's elbow underneath the arm pit and stated using the other arm to grab behind Resident 19's waist pants to lift Resident 19 up into the wheelchair. During a concurrent interview and record review on 10/12/2023 at 10:30 AM with PT 1, PT 1 reviewed 056014 Page 9 of 23 056014 10/13/2023 Brookfield Healthcare Center 9300 Telegraph Road Downey, CA 90240

F 0689 Level of Harm - Actual harm Residents Affected - Few Resident 19's PT Evaluation dated 6/29/2023, PT Recert dated 7/27/2023, and Resident 19's Progress Note for Therapy dated 7/31/2023. PT 1 stated Resident 19 had NWB precautions on the right leg since the initial PT Evaluation on 6/29/2023. PT 1 reviewed the PT Recert, dated 7/27/2023, and stated Resident 19 required maximum assistance of two-persons for sit to stand transfers due to Resident 19's limited ability to perform the activity. PT 1 stated Resident 19 required two-persons assistance to ensure to not place any weight onto the right leg for safety since Resident 19 was placing all body weight onto the left leg. PT 1 stated Resident 19 did not stand on both legs during therapy sessions due to the NWB status on the right leg. PT 1 stated Resident 19's NWB status, need for two-persons during transfers, and need to transfer towards the left, strong side was verbally communicated to nursing staff (in general). Pt 1 stated nursing staff also observed Resident 19 perform two-person transfers with the therapists. PT 1 stated PT 1 performed the post-fall assessment on 7/31/2023. PT 1 stated Resident 19 usually had right knee pain after the surgery but complained of new right shoulder pain, which was a significant change. PT 1 stated Resident 19 did now allow PT 1 to assess the right shoulder because of the pain. PT 1 reported this finding to nursing and recommended an X-ray of the right shoulder and right knee. During a concurrent interview and record review on 10/12/2023 at 10:51 AM with Certified Occupational Therapy Assistant (COTA) 1, COTA 1 stated Resident 19 performed toilet transfers and toileting during OT treatment on 7/26/2023. COTA 1 stated Resident 19 was dependent with two-persons assistance for safety due to Resident 19's history of stroke and NWB precautions on the right leg. COTA 1 stated Resident 19 never stood on both legs during treatment since Resident 19's right leg was NWB. COTA 1 stated the therapy staff (in general) were in constant verbal communication with nursing staff regarding Resident 19's need for two-person assistance during toileting. During a telephone interview on 10/12/2023 at 12:24 PM with Resident 19's Family Member (FM) 1, FM1 stated the facility notified FM 1 immediately after Resident 19 fell on 7/30/2023. FM 1 stated Resident 19 understood everything but had difficulty speaking. FM 1 stated Resident 19 explained the fall to FM 1 as best as possible. FM 1 stated Resident 19 went to the bathroom toilet with CNA 1. FM 1 stated Resident 19 stood at the sink after using the toilet when Resident 19's right, surgical knee buckled. FM 1 stated Resident 19 had some pain on the right shoulder, and FM 1 asked for an ice pack for the right shoulder which relieved some pain. During a concurrent interview and record review on 10/12/2023 at 2:00 PM with the Director of Nursing (DON), the DON reviewed Resident 19's clinical record. The DON stated the facility admitted Resident 19 on 6/29/2023 after a fall at home, requiring surgery for the right distal femur fracture and was NWB on the right leg. The DON stated Resident 19 scored a 13 on the initial fall assessment, which indicated Resident 19 was a high risk for fall. The DON stated Resident 19's care plan for a high risk for fall included interventions to anticipate and meet needs, ensure the call light was in reach, encourage resident to use call light for assistance, and maintain a clear pathway free of obstacles. The DON stated Resident 19's LVN (in general) knew Resident 19's NWB status on the right leg since it was a physician's order. The DON stated the LVN should verbally communicate Resident 19's NWB status to the CNAs (in general) before each shift. The DON reviewed the PT Recert, dated 7/27/2023, and stated Resident 19 required maximum assistance with two-persons for sit to stand and functional transfers. The DON reviewed the OT Recert, dated 7/27/2023, and stated Resident 19 was dependent for toileting and dependent with two-persons assistance for toilet transfers. The DON stated the PT's and OT's assessments of Resident 19 requiring two-persons assistance with transfers were verbally communicated to the direct care CNA staff. The DON reviewed Resident 19's ADL Flow Sheet for 7/2023 and stated multiple CNAs, including CNA 1, had transferred Resident 19 onto the toilet and performed toileting successfully with 056014 Page 10 of 23 056014 10/13/2023 Brookfield Healthcare Center 9300 Telegraph Road Downey, CA 90240

F 0689 Level of Harm - Actual harm Residents Affected - Few one-person assistance. The DON stated Resident 19 did not have the assistance of two-persons during the fall on 7/30/2023. The DON stated Resident 19 had severe osteoporosis (medical condition in which bones become brittle and fragile) and believed Resident 19 fractured the right arm during the transfer from the floor into the wheelchair since CNA 1 and CNA 2 had an elbow under each of Resident 19's arm pits. The DON did not answer when asked whether Resident 19's fall was avoidable but stated Resident 19's right shoulder fracture was related to the fall. During a review of the facility's policy and procedure (P&P) titled, Fall Management System, revised on 1/2022, the P&P indicated the facility provided each resident an appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. 056014 Page 11 of 23 056014 10/13/2023 Brookfield Healthcare Center 9300 Telegraph Road Downey, CA 90240

F 0697 Provide safe, appropriate pain management for a resident who requires such services. 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 effectively manage a resident's pain for one of five sampled residents (Resident 21). Residents Affected - Few This failure caused Resident 21 to endure pain for almost three (3) hours before being treated with pain medication. Findings: During a review of Resident 21's admission Record, the admission Record indicated Resident 21 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 21 had diagnoses of displaced (out of alignment) fracture of the right femur (broken thigh bone), periprosthetic fracture (a broken bone that occurs around the implants of a hip replacement) around internal prosthetic right hip joint and reduced mobility (ability to move). During a review of Resident 21's Minimum Data Set (MDS- a comprehensive assessment), dated 8/5/2023, the MDS indicated Resident 21's cognition (ability to think and reason) was moderately impaired. The MDS indicated Resident 21 required extensive assistance with bed mobility, when transferred from bed to chair and when she performed personal hygiene. During an interview, on 10/10/2023, at 10:00 AM, with Resident 21, Resident 21 stated, They are slow. I wait for more than 30 minutes sometimes. I ring for a pain pill, and it takes a long time. Resident 21 stated she notified the Certified Nursing Assistant (CNA) she was in pain at 8 AM. During a concurrent interview and record review, on 10/10/2023, at 2:45 PM, with Licensed Vocational Nurse (LVN) 1, the Medication Administration Record (MAR), for the month of October 2023, was reviewed. The MAR indicated Resident 21 received Norco (a brand name for hydrocodone-acetaminophen, a combination medication used to treat pain) Oral Tablet 10-325 milligram (mg - a unit of measurement) at 10:47 AM on 10/10/2023 and Resident 21's pain was documented as an eight out of 10. The reassessment of Resident 21's pain was performed and documented as a zero out of 10 at 1:37 PM. LVN 1 stated she performed and documented Resident 21's pain reassessment late and it should have been documented at 11:47 AM, or an hour after the pain medication administration. LVN 1 stated it was important to document the reassessment of pain timely to verify with the resident if the pain was managed with the medication. During an interview, on 10/10/2023, at 3:36 PM, with LVN 1, LVN 1 stated she had knowledge Resident 21 was in pain at 9 AM on 10/10/2023. LVN 1 stated an acceptable time frame to administer pain medication was within five to ten minutes. LVN 1 stated Resident 21 had pain due to her femur fracture and for this kind of diagnosis, a resident should be treated right away so the resident did not have to be uncomfortable for an extended amount of time. During an interview, on 10/11/2023, at 12:15 PM, with Registered Nurse Supervisor (RN 1), RN 1 stated, At least 30 minutes is an acceptable time frame to administer pain meds when a resident is in pain. During an interview, on 10/11/2023, at 1:10 PM, with the Director of Nursing (DON), the DON stated, Pain should be addressed as soon as possible. It depends on the severity of the pain, but waiting 056014 Page 12 of 23 056014 10/13/2023 Brookfield Healthcare Center 9300 Telegraph Road Downey, CA 90240

F 0697 for a medication for an hour is acceptable, not over an hour. Level of Harm - Minimal harm or potential for actual harm During an interview, on 10/12/2023, at 9:23 AM, with LVN 2, LVN 2 stated it was not acceptable to allow a resident to wait an hour before receiving pain medicine. LVN 2 stated, Pain medicine should be administered right away because we do not want the resident to be uncomfortable unnecessarily. Residents Affected - Few During a review of Resident 21's Physician's Orders, dated 10/11/2023, the Physician's Orders indicated Norco Oral Tablet 10-325mg was ordered to be given every eight hours as needed for moderate pain. During a review of Resident 21's care plan, titled, Has potential for acute pain/ discomfort related to right femur fracture status post open reduction internal fixation (surgery that requires putting pieces of bone into place), recent mechanical trip and fall at home 7/23/2023, initiated 8/2/2023, the care plan indicated the facility was to anticipate Resident 21's need for pain relief and respond immediately to any complaint of pain. During a review of the facility's policy and procedure (P&P) titled, Pain Management, dated 2/1/2020, the P&P indicated the facility was to assist each resident with pain to maintain or achieve the highest practicable of well-being and functioning . by using pharmacologic and/or non-pharmacologic interventions to manage the pain consistent with the resident's goals. The P&P also indicated, Resident pain is assessed and managed by an interdisciplinary team who work together to achieve the highest practicable outcome. 056014 Page 13 of 23 056014 10/13/2023 Brookfield Healthcare Center 9300 Telegraph Road Downey, CA 90240

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to administer Folic Acid (a medication used as a supplement for heart health) 1 mg tablet as ordered by the physician for one of four sampled residents during medication administration (Resident 28) and failed to administer Norco (a brand name for hydrocodone-acetaminophen, a combination medication used to treat pain) on time for one of five sampled residents (Resident 21.) As a result, Residents 21 and 28 did not receive medication in accordance with the physician's orders and standards of practice and had the potential to experience adverse effects (unwanted effects from a medication) and negative impact to their health and well-being. Findings: a. During a review of Resident 21's admission Record, the admission Record indicated Resident 21 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 21 had diagnoses of displaced (out of alignment) fracture of the right femur (broken thigh bone), periprosthetic fracture (a broken bone that occurs around the implants of a hip replacement) around internal prosthetic right hip joint and reduced mobility (ability to move). During a review of Resident 21's Minimum Data Set (MDS- a comprehensive assessment), dated 8/5/2023, the MDS indicated Resident 21's cognition (ability to think and reason) was moderately impaired and Resident 21 required extensive assistance with bed mobility, when transferred from bed to chair and when she performed personal hygiene. During a review of Resident 21's Physician Orders, dated 10/11/2023, the Physician Orders indicated Norco 10-325 milligrams (mg, unit of measurement) oral tablet was ordered to be given every eight hours as needed for moderate pain. During a review of Resident 21's care plan titled, Has potential for acute pain/ discomfort related to right femur fracture status post (after) open reduction internal fixation (a surgery that requires putting pieces of bone into place), recent mechanical trip and fall at home on 7/23/2023, initiated 8/2/2023, the care plan indicated the facility was to anticipate need for pain relief and respond immediately to any complaint of pain. During an interview, on 10/10/2023, at 10:00 AM, with Resident 21, Resident 21 stated, They are slow. I wait for more than 30 minutes sometimes. I ring for a pain pill, and it takes a long time. Resident 21 stated Resident 21 notified the certified nursing assistant (CNA) Resident 21 was in pain on 10/10/2023 at 8 AM. During a concurrent interview and record review, on 10/10/2023, at 2:45 PM, with Licensed Vocational Nurse (LVN) 1, the Medication Administration Record ([MAR] - a document of the medications administered to a resident that is part of the resident's permanent medical record], dated October 2023, was reviewed. The MAR indicated Resident 21 received Norco oral tablet 10-325 mg at 10:47 AM on 10/10/2023. Resident 21's pain was documented as eight out of 10. The reassessment of pain was performed and documented as zero out of 10 at 1:37 PM on 10/10/2023. LVN 1 stated LVN 1 performed and documented the pain reassessment late and it should have been at 11:47 AM, or an hour after administration of 056014 Page 14 of 23 056014 10/13/2023 Brookfield Healthcare Center 9300 Telegraph Road Downey, CA 90240

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the Norco. LVN 1 stated it was important to document the reassessment timely to verify with the resident if the pain was managed with the medication. During an interview, on 10/10/2023, at 3:36 PM, with LVN 1, LVN 1 stated LVN 1 had knowledge Resident 21 was in pain at 9 AM (on 10/10/2023). LVN 1 stated an acceptable time frame to administer pain medication was within 5 to 10 minutes. LVN 1 stated Resident 21 had pain due to her femur (thigh bone) fracture (partial or complete break in the bone) and for this kind of diagnosis, a resident should be treated right away so the resident did not have to be uncomfortable for an extended amount of time. During an interview, on 10/11/2023, at 12:15 PM, with the Registered Nurse Supervisor (RN 1), RN 1 stated, At least 30 minutes is an acceptable time frame to administer pain meds when a resident is in pain. During an interview, on 10/11/2023, at 1:10 PM, with the Director of Nursing (DON), the DON stated pain should be addressed as soon as possible. The DON stated, It depends on the severity of the pain, but waiting for a medication for an hour was acceptable, not over an hour. During an interview, on 10/12/2023, at 9:23 AM, LVN 2 stated it was not acceptable to allow a resident to wait an hour before receiving pain medicine. LVN 2 stated pain medicine should be administered right away because the facility did not want the resident to be uncomfortable unnecessarily. b. During a review of Resident 28's admission Record, dated 10/12/2023, the admission Record indicated Resident 28 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including atrial fibrillation (irregular, fast heart rate caused by poor blood flow) and presence of cardiac pacemaker (small device placed under the skin to prevent irregular heartbeats.) During a review of Resident 28's Order Summary Report (a report listing the physician order for the resident), dated 10/8/2023, the order summary report indicated Resident 28 was prescribed Folic Acid 1 mg tablet by mouth one time a day starting 4/19/2023. During a review of Resident 28's MAR, for the month of October 2023, the MAR indicated Resident 28's dose of Folic Acid 1 mg was due every day at 9 AM. There was no documentation for the Folic Acid 1 mg administration on 10/12/2023. Review of the Pharmacy document History Manifests, indicated the facility's contracted Pharmacy faxed the authorization request form for Folic Acid 1 mg for Resident 28 to the facility on [DATE] at 6:24 AM. During a concurrent observation and interview on 10/12/2023 at 9:29 AM, with LVN 6, LVN 6 was observed not administering Folic Acid 1 mg tablet by mouth to Resident 28. LVN 6 stated LVN 6 did not administer the Folic Acid 1 mg to Resident 28 because it was not available in the medication cart or in the facility. LVN 6 stated the Pharmacy was notified to refill the folic acid 3 days prior and the refill requests were faxed on 10/8/2023 and 10/9/2023. LVN 6 stated the folic acid was not available to administer at the scheduled time on 10/12/2023. LVN 6 stated LVN 6 would follow up with the Pharmacy to expedite the refill of the folic acid and call the physician to inform the physician the morning dose on 10/12/2023 was not administered and obtain an order to administer once it arrived. LVN 6 stated medications should be ordered from the Pharmacy when there were 3 days of doses left, and followed up as needed, to ensure timely availability of medications. 056014 Page 15 of 23 056014 10/13/2023 Brookfield Healthcare Center 9300 Telegraph Road Downey, CA 90240

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 10/12/2023 at 11:01 AM with LVN 6, LVN 6 stated LVN 6 spoke with the Pharmacy that day (10/12/2023) and the Pharmacy was unable to refill the Folic Acid 1 mg since the medication was already filled at a pharmacy chain store. LVN 6 stated LVN 6 also called the physician on 10/12/2023 and the physician changed the order to administer the Folic Acid 1 mg once it arrived at 5 pm. During an interview on 10/12/2023 at 12:38 PM, with the Pharmacist in Charge (PIC) and Pharmacist, the PIC stated the facility should request refills at least 3 days prior to the last dose of a medication to ensure timely delivery of medications to the facility. The Pharmacist stated the Pharmacy submitted the refill authorization form for Resident 28's Folic Acid 1 mg to the facility on [DATE] requesting an approval for the refill. The Pharmacist stated the Pharmacy records indicated no approval was submitted back by the facility for the refill of Resident 28's Folic Acid 1 mg. During an interview on 10/12/23 at 12:55 PM, with LVN 6, LVN 6 stated the faxed refill authorization forms from the Pharmacy were usually forwarded to the DON to sign off and submit back to the Pharmacy for medications to be refilled. During an interview on 10/12/2023 at 12:57 PM, with the DON, the DON stated that refills should be ordered from the Pharmacy about 3 to 5 days before the last dose to prevent medications from not being available to the residents at their scheduled times. The DON stated LVN 6 called Resident 28's physician to inform the physician Resident 28's Folic Acid 1 mg tablet was not available, and the dose was missed. The DON stated the physician changed the order to administer the Folic Acid 1 mg tablet to Resident 28 at 5 pm once the medication arrived. The DON stated the DON did not see the Pharmacy faxed refill authorization form for Resident 28's Folic Acid 1 mg on 10/4/2023 and did not recall signing or submitting the form back to the Pharmacy. The DON stated the DON would sign the Pharmacy authorization request form immediately to have the Pharmacy begin the refill process. The DON stated the current process for medication refills and proper follow-up and documentation needed to be revisited and addressed with the nursing staff and the Pharmacy to ensure medications were readily available to residents. During an interview on 10/12/2023 at 3:54 PM, with the DON, the DON stated while the LVNs were administering medications the LVNs were expected to follow-up on medication refills to ensure medications were available to residents. The DON stated the licensed nurses should have followed up after the fax requests on 10/8/2023 and 10/9/2023 for the refill of Folic Acid 1 mg for Resident 28, to prevent the unavailability and interruption in the medication therapy. The DON stated there needed to be a more proactive approach and better communication to prevent the failure in the future. Review of the facility's policy and procedures (P&P), titled Medication Administration - General Guidelines, dated November 2021, the P&P indicated that the facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. The P&P indicated medications are administered in accordance with written orders of the attending physician. The P&P indicated medications are administered within (60 minutes) of scheduled time. During a review of the facility's P&P, titled Ordering and Receiving Non-Controlled Medications from the Dispensing Pharmacy, dated August 2020, the P&P indicated that medications and related products are received from the dispensing pharmacy on a timely basis. During a review of the facility's P&P titled, Pain Management, dated 2/1/2020, the P&P indicated the facility was to assist each resident with pain to maintain or achieve the highest practicable of 056014 Page 16 of 23 056014 10/13/2023 Brookfield Healthcare Center 9300 Telegraph Road Downey, CA 90240

F 0755 Level of Harm - Minimal harm or potential for actual harm well-being and functioning . by using pharmacologic and/or non-pharmacologic interventions to manage the pain consistent with the resident's goals. The P&P also indicated, Resident pain is assessed and managed by an interdisciplinary team who work together to achieve the highest practicable outcome. Residents Affected - Some 056014 Page 17 of 23 056014 10/13/2023 Brookfield Healthcare Center 9300 Telegraph Road Downey, CA 90240

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. Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: Residents Affected - Some a. Margarine was observed at 74 Degrees (º) Fahrenheit (F). b. The ice machine baffle (slanted component used to keep ice from falling out of the bin when the door is opened) was observed with black and pink residues. c. The storage areas for the pots and pans were observed with dust and dirt residue. d. The mixer attachments were found with oil residue. e. Seven (7) resident's food trays were observed chipped and cracked. f. The refrigerator shelves were observed chipped with black and orange metal discoloration exposed. g.The trayline area was observed with black, reddish dirt and grease build up. h. One expired resident yogurt in the resident's refrigerator. These failures had the potential to result in harmful bacteria growth and cross contamination that could lead to foodborne illness in sixty (60) of sixty-one (61) medically compromised residents who received food and ice from the kitchen. Findings: a. During a concurrent observation of the margarine on top of the stove in the kitchen and interview with [NAME] 1 and the Dietary Services Supervisor (DSS) on 10/10/2023 at 8:52 AM, the margarine temperature read 74°F. [NAME] 1 stated the margarine had been out since 6:00 AM (on 10/10/2023). The DSS stated the manufacturer's guidelines for margarine was to be refrigerated for best use but the margarine did not have to be refrigerated if staff used it for four (4) hours. The DSS stated she wanted the product to be at its best quality and that margarine was not a self-stable product (a product that can stand in room temperature without spoiling) compromising food safety of the residents. During a review of the facility's policy and procedure (P&P) titled, Meal Service, dated 2023, the P&P indicated cold food items would be placed on the trays as close to the serving time as possible to assure the temperature was below 41°F. The P&P indicated to accomplish that, all cold foods would be pre-poured and kept in the refrigerator or freezer and pulled out on small quantities at a time. During a review of Food Code 2017, the Food Code 2017 indicated stored frozen foods shall be maintained frozen. The Food Code 2017 indicated Time/Temperature Control for safety Food, Hot and Cold Holding (A) Except during preparation, cooking or cooling, or when times is used as a public health control as specified under §3-501.19 and except under (B) and in (C) of this section, 056014 Page 18 of 23 056014 10/13/2023 Brookfield Healthcare Center 9300 Telegraph Road Downey, CA 90240

F 0812 time/temperature control for safety food shall be maintained: (2) at 5°F (41°F) or less. Level of Harm - Minimal harm or potential for actual harm b. During an observation of the ice machine on 10/10/2023 at 10:18 AM, the ice machine baffle had black and pink residues upon wiping it with a paper towel. Residents Affected - Some During a concurrent observation of the ice machine and interview with the DSS on 10/10/2023 at 10:26 AM, the ice machine baffle had black and pink dirt particles after wiping it with a paper towel. The DSS stated the last time the ice machine had a detailed cleaning was on 9/21/2023 by the maintenance department. The DSS stated the ice machine should be free from any residue to prevent possible cross contamination (transfer of bacteria from one thing to another). The DSS stated nursing staff would get ice from the kitchen for resident consumption and having cross contamination of ice was not a good food safety practice. During a review of the facility's P&P titled, Ice Machine Cleaning Procedures Mixer-Operation and Cleaning, dated 2023, the P&P indicated the ice machine needs to be cleaned and sanitized monthly. The P&P indicated the internal components were cleaned monthly or per manufacturer's recommendation, and the date recorded when cleaned. During a review of the document titled, Food Code 2017, Food Code 2017 indicated 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be clean to sight and touch. 4-701.10 Food Contact Surfaces and Utensils shall be sanitized. 4-702.11 Before use After cleaning. Utensils and Food-Contact Surfaces of Equipment shall be sanitized before use after cleaning. c. During an observation of the clean area for pots and pans storage on 10/10/2023 at 10:42 AM, the storage area where pots and pans were stored had visible dust. During an interview with the DSS on 10/10/2023 at 10:55 AM, the DSS stated the storage area for pots and pans was in the clean area of the kitchen. The DSS stated the area was wiped clean and cleaned once a week as needed. The DSS stated there was dirt residue in the storage area and it was not okay for it to be dusty. The DSS stated the possible harm for residents was cross contamination. During a review of the facility's P&P titled, Sanitation, dated 2023, the P&P indicated all utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracked and chipped areas. During a review of Food Code 2017, the Food Code 2017 indicated 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be clean to sight and touch. (B) NonFood-Contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris. d. During an observation of the mixer on 10/10/2023 at 10:46 AM, the mixer attachment was observed with yellow oil debris. During an interview with the DSS on 10/10/2023 at 10:55 AM, the DSS stated mixer was used only once a week and it was cleaned after each use. The DSS stated the mixer attachments were oily to touch and had a grease residue. The DSS stated the mixer should be always clean to prevent possible cross contamination. During a review of the facility's P&P titled, Electrical Food Machines, dated 2023, the P&P indicated to keep and maintain all food machines in good operating, sanitary condition, including the 056014 Page 19 of 23 056014 10/13/2023 Brookfield Healthcare Center 9300 Telegraph Road Downey, CA 90240

F 0812 mixer, grinders, and toasters. Level of Harm - Minimal harm or potential for actual harm During a review of Food Code 2017, Food Code 2017 indicated the food contact surfaces of cooking and baking equipment shall be cleaned at least every 24 hours. Residents Affected - Some e. During a concurrent observation of randomly selected resident's food trays located on the clean cart and interview with the DSS on 10/10/2023 at 11:01 AM, seven (7) resident's trays were observed to be cracked and pending use for lunch service. The DSS stated cracked trays should not be used due to safety. The DSS stated cracked trays could attract bacteria and could cause possible cross contamination. During a review of the facility's P&P titled, Sanitation, dated 2023, the P&P indicated all utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracked and chipped areas. The P&P indicated plastic ware, china, and glassware that becomes unsightly, unsanitary, or hazardous because of chips, cracks, or loss of glaze shall be discarded. During a review of Food Code 2017, Food Code 2017 indicated multiuse food-contact surfaces shall be (1) smooth and (2) free of breaks, open seams, cracks, chips, inclusions, pits and similar imperfections. f. During an initial kitchen tour observation of the refrigerator shelves near the trayline on 10/10/2023 at 8:32 AM, the refrigerator shelves were observed chipped with metal exposing. During an interview with the DSS on 10/10/2023 at 11:01 AM, the DSS stated the refrigerator shelves were old and needed replacing as it had black and orange debris. The DSS stated the refrigerator shelves were chipped and metal was exposed. The DSS stated the shelves needed to be cleaned to prevent possible contamination. During a review of the facility's P&P titled, Refrigerator and Freezer, dated 2023, the P&P indicted Maintaining a clean refrigerator and freezer can improve the safety and quality of your foods. For the best cleaning results, always refer to your owner's manual. How to keep your refrigerator and freezer working efficiently (9) Periodically inspect shelves and replace if coating is chipped away exposing meal shelves. During a review of Food Code 2017, Food Code 2017 indicated nonfood-contact surfaces of equipment that are exposed to spillage, or other food spoiling or that require frequent cleaning shall be constructed of a corrosion-resistant, nonabsorbent, and smooth material. g. During an observation of the trayline area on 10/10/2023 at 11:11 AM, the trayline metal roof was observed with black, reddish buildup. During a concurrent observation and interview with the DSS on 10/11/2023 at 8:27 AM, the DSS stated the trayline area had detailed cleaning every Sunday and the area was wiped daily. The DSS was observed wiping the trayline roof with a paper towel. The DSS stated the trayline roof had grease build up. The DSS stated the buildup had been there for over a night. The DSS stated it was not okay as the dirt build up could fall into the resident's food. The DSS stated the trayline should be free from debris, grease, dust, food particles, corrosion or rust to prevent cross contamination. 056014 Page 20 of 23 056014 10/13/2023 Brookfield Healthcare Center 9300 Telegraph Road Downey, CA 90240

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of the facility's P&P titled, Sanitation, dated 2023, the P&P indicated, The FNS Director is responsible for instructing Food and Nutrition Services personnel I the use of equipment. Each employee shall know how to operate and clean all equipment in his specific work area. During a review of Food Code 2017, the Food Code 2017 indicated 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be clean to sight and touch. 4-701.10 Food Contact Surfaces and Utensils shall be sanitized. 4-702.11 Before use After cleaning. Utensils and Food-Contact Surfaces of Equipment shall be sanitized before use after cleaning. h. During a concurrent observation of the resident's refrigerator located near the nursing unit and interview with Licensed Vocational Nurse 3 (LVN 3) on 10/11/2023 at 11:05 AM, a yogurt for Resident 7 had an expiration date of 10/5/2023. There were 3 unopened yogurts observed with no resident name. LVN 3 stated the yogurt should have been discarded as residents could get sick from consuming expired food. During a review of the facility's P&P titled, Sanitation and Infection Control Subject: Foods Brought by Family or Visitor, revised 11/2021 indicated, the P&P indicated food/fluid(s) brought to a resident by family/visitors must be accepted by the resident, inspected before facility storage, and stored and served in accordance with food safety professional standards. The P&P indicated perishable manufactured foods/fluids stored in the manufacturer packaging will be discarded as per the best by or use by date. The P&P indicated perishable prepared foods/fluids or perishable foods/fluids without date will be discarded after 3 days of storage. 056014 Page 21 of 23 056014 10/13/2023 Brookfield Healthcare Center 9300 Telegraph Road Downey, CA 90240

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain equipment in safe operating condition in the kitchen and the rehabilitation room by failing to: Residents Affected - Some a. Maintain the kitchen refrigerator by the preparation area in a safe operating condition. b. Annually calibrate (process of setting a measure device to conform with a reference standard) three of three physical agent modalities (treatments to produce a response in soft tissue through the use of light, water, temperature, sound, or electricity) in accordance with the facility's policy, including one diathermy (use of electric currents to generate heat in layers of the skin below the surface) unit and two combination ultrasound (use of sound waves to penetrate soft tissues which increases blood flow) and electrical stimulation (use of mild electrical pulses through the skin to help stimulate injured muscles or manipulate nerves to reduce pain) units. These deficient practices had the potential to result in food stored in the danger zone temperatures (a temperature range in which disease-causing bacteria grow best) that could lead to foodborne illness in sixty (60) of sixty-one (61) medically compromised residents who received food from the kitchen and had the potential to prevent effective use on residents requiring these modalities. Findings: a. During an initial kitchen observation of the refrigerator, located by the hand washing sink near the trayline (an area used for assembling food of the residents) on 10/10/2023 at 8:32 AM, the tuna salad was observed to be 56 degrees (°) Fahrenheit (F, unit of measurement). During a concurrent observation of the refrigerator, located by the hand washing sink near the trayline, and interview with [NAME] 1 on 10/10/2023 at 8:39 AM, the refrigerator temperatures were observed to be 46°F on the outside gauge and 50°F on the internal thermometer. The refrigerator was observed full of food and food boxes and there was no proper air circulation. The tuna salad temperature was observed to be 53°F and the cottage cheese temperature was observed to be 44°F. [NAME] 1 stated the temperature for tuna and cottage cheese were not acceptable because it needed to be at 41°F and below. [NAME] 1 stated the tuna salad was from the other single refrigerator by the preparation area and it needed to be transferred as the temperature of the single refrigerator was 52°F that morning (10/10/2023). [NAME] 1 stated residents could get sick if they ate foods that were not on the acceptable temperatures. During a concurrent observation of the right-side refrigerator, located by the preparation area, and interview with [NAME] 1 on 10/10/2023 at 8:42 AM, the refrigerator temperatures were observed to be 34°F on the outside gauge and 60°F on the internal thermometer. Foods inside the refrigerator were observed 53°F for ham, 55°F for turkey and 64°F for ground meat. [NAME] 1 stated the refrigerator was not working that morning (10/10/2023) since 8:00 AM. [NAME] 1 stated he did not have time to transfer the food in a different refrigerator due to the lunch meal preparation. During a concurrent observation of the left-side refrigerator, located by the preparation area, and interview with the Dietary Service Supervisor (DSS) on 10/10/2023 at 8:50 AM, the sliced cheese temperature was observed 47°F. The DSS stated the refrigerator was not working and food needed to be thrown away. 056014 Page 22 of 23 056014 10/13/2023 Brookfield Healthcare Center 9300 Telegraph Road Downey, CA 90240

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of the facility's policy and procedure (P&P) titled, Procedure for Refrigerated Storage, dated 2023, the P&P indicated (1) Refrigerator: 41°F. To keep food at a specific temperature, the air temperature in the refrigerator usually must be about 2°F lower. For example, to hold chicken at 41°F, the air temperature must be 39°F. (5) Food should be covered and stored loosely to permit circulation of air. Do not overload the refrigerator. Overloading may prevent airflow and make the unit work harder to stay cold. b. During an observation on 10/10/2023 at 8:24 AM, in the rehabilitation gym, there were two combination units for ultrasound and electrical stimulation. No calibration label (label indicating the date of the last calibration and the due date for the next calibration) was located on either combination units. One diathermy unit was observed in the rehabilitation gym but did not have a calibration label. During a concurrent observation and interview on 10/11/2023 at 9:30 AM, with the Director of Rehabilitation (DOR), in the rehabilitation gym, the DOR was unable to locate the calibration label and did not know when the diathermy unit and two combination units for ultrasound and electrical stimulation were last calibrated. The DOR stated calibration was important to ensure the rehabilitation equipment worked properly. During an interview on 10/11/2023 at 10:11 AM, with the Maintenance Supervisor (MS), the MS stated the rehabilitation equipment was checked monthly but did not keep a log of the monthly inspections. The MS did not know whether the rehabilitation equipment required calibration. During an observation on 10/11/2023 at 3:13 PM, with the DOR, in the rehabilitation gym, the diathermy unit had a touch screen which indicated system information. The diathermy's system information indicated the last calibration was on 8/17/2021. During a concurrent interview and record review on 10/12/2023 at 10:13 AM with the DOR, the facility's rehabilitation calibration records, titled, Certificate of Conformance, were reviewed. The diathermy unit was last calibrated on 8/17/2021 and was due for inspection on 8/17/2023. The two to combination units for ultrasound and electrical stimulation were last calibrated on 6/30/2022 and were due for inspection on 6/30/2023. The DOR stated a representative would be coming that day (10/12/2023) to calibrate all therapy equipment. During a review of the facility's undated P&P titled, Rehab Equipment Maintenance, the P&P indicated all equipment involving the modalities of water, heat, light, electricity and sound will be inspected yearly by the Therapy Director and the Maintenance Director. The P&P also indicated Inspection will include general condition of equipment and calibration if necessary and a log will be kept for each piece of equipment to be inspected. 056014 Page 23 of 23