Health inspection·August 22, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent the development of pressure injuries and provided care and services consistent with professional standards of practice for one out of three sampled residents (Resident 1) by failing to: 1. Implement interventions to prevent PI (Pressure Injury - localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) development for Resident 1 who was admitted without PI, by not repositioning according to the Care Plan (CP- a document that details an individual's health conditions, treatments, needs, and goals, serving as a blueprint for their healthcare and support services) for quadriplegia dated 6/27/25. No documentation repositioning was done. Resident bedbound.2. Provide pressure-relieving mattresses as indicated in the CP for quadriplegia dated 6/27/25.3. Accurately assess Resident 1 Risk for skin breakdown. Skin assessment done on 6/30/25 indicated friction and shear no apparent problem and the assessment scored zero (no risk for skin breakdown). Resident 1 is bed bound, who had multiple co-morbidities (incontinent, hip fracture) and was totally dependent on staff, placing him at increased risk for PI development.5. Implement recommendation of the wound care specialist for Low Air loss Mattress on 8/4/2025 upon discovery of the PI.6. The lack of assessing and measuring pressure ulcers to establish a baseline of wound conditions as well as providing care and treatment for pressure injuries resulted in the development of a DTI (Deep tissue Injury- damage to the underlying muscles and fatty tissue caused by prolonged pressure or trauma, but the skin on top remains intact).7. Ensure facility staff had the necessary competencies needed to identify, describe, care,and treat Residents 1's pressure injuries.8. Report an abnormal WBC level of 15.81 (4-11) on 8/7/2025 to the resident's physician as a sign of infection. As a result, the development of the hospital acquired pressure injury had a highly potentially led to a systemic infection (sepsis- a life-threatening organ dysfunction caused by a disorganized response to an infection), unnecessary hospitalization, organ failure, and death. On 8/11/2025, Resident 1 was unresponsive, requiring transfer to GACH (General Acute Care Hospital). Resident 1 was admitted to the hospital eventually FM decided on palliative care and expired on 8/14/2025.Findings:During a review of Resident 1's Record of Admission (undated), indicated, Resident 1 was initially admitted [DATE] and readmitted to the facility on [DATE] with diagnoses including fracture (a break in the bone) of right femur (The thigh bone), chronic atrial fibrillation (A type of long-lasting, irregular heartbeat where the heart's top chambers quiver instead of beating in a coordinated, regular way), and dysphagia (Difficulty swallowing) oropharyngeal phase (Second stage of swallowing when the food goes from the back of the mouth to into the esophagus [tube that connects the throat to the stomach]). During a review of the Resident 1's CP created 6/27/2025 with a focus on the diagnosis quadriplegia. The CP indicated interventions which included:Perform skin assessments every shift. Reposition every two hours using pressure-relieving mattresses or cushions (e.g., ROHO cushions- a soft, squishy seat made of air-filled bubbles that adjust to your body. It's used mostly by people who Residents Affected - Few Page 1 of 6 056157 056157 08/22/2025 Alvarado Care Center 1154 S.Alvarado St Los Angeles, CA 90006

F 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few can't move around much, like those in wheelchairs, to help protect their skin and keep them comfortable). Use moisture-barrier creams and keep skin clean and dry. During a review of Resident 1's admission assessment dated [DATE], the assessment indicated Resident 1 was able to move in bed and chair independently with no apparent problems with friction and shear. The same assessment indicated Resident 1's skin was good/intact with no skin breakdown. The same assessment which includes the Braden scale (a widely used, evidence-based assessment tool in healthcare used to predict a patient's risk of developing pressure injuries) score was 0 (zero score would be invalid, as the lowest possible total score is 6, score ranges between 6 and 23 where the lower the score, the higher the risk). During a review of Resident 1's CP created 7/7/2025 with a focus on the diagnosis quadriplegia. The CP indicated interventions which included:Reposition is necessary to prevent skin breakdown. Prevent 90-degree flexion (bending a part of your body to create a right angle) to prevent circulation problems. During a review of Resident 1's History and Physical (H&P, a comprehensive medical assessment that includes a patient's medical history, a physical examination, and an assessment/plan), dated 7/9/2025 indicated, Resident 1 was having memory loss and had fluctuating capacity to make decisions. The same H&P indicated advance directives, and/or goals were discussed in detail with Resident 1's (Next of kin) and designated decision maker, FM1. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 7/25/2025, indicated that Resident 1 had moderate cognitive (ability to think, understand and make daily decisions) impairment. The same MDS further indicated Resident 1 was mostly dependent on staff for his activities of daily living (ADLs-toileting, shower/bathe self, lower body dressing, and putting on/taking off footwear). The same MDS indicated Resident 1 required substantial/maximal assistance (describe the level of help a patient requires to perform a task, the resident is highly dependent and requires extensive physical support to complete the task) for rolling left and right, sitting to lying, and lying to sit on side of the bed. During a review of Resident 1's wound care specialist notes dated 8/4/2025, the notes indicated Resident 1 had pressure induced deep tissue damage of sacral (the region of the human body at the base of the spine and top of the buttocks) region measuring 15 centimeter (cm, is a unit of length measurement), 3 x 5 cm ulceration (An open sore or wound that develops on the skin), moderate sanguineous drainage (A bright, red, and fresh-bleeding discharge from a wound, indicating damage to blood vessels and occurring normally in the early stages of wound healing), 26-50% slough (a type of non-viable (dead) tissue that forms in wounds), 26-50% epithelialization (the regeneration and migration of epithelial cells across the surface of a wound). The same notes indicated, recommend low air mattress. Spoke with nurse (unidentified) who will facilitate. During a review of Resident 1's physician order dated 8/4/2025 indicated, Sacrum DTI (A DTI is damage to deeper underlying structures overlaid with either intact or non-intact skin, occurring due to prolonged pressure at the bone-muscle interface): Cleanse wound with normal saline (NS, sterile mixture of salt and water that closely matches the salt concentration of human blood), pat dry, paint with betadine (a brand of antiseptic product that contains povidone-iodine to prevent and treat infections in minor wounds like cuts, scrapes, and burns), cover with foam dressing every day shift. During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, a communication tool used by healthcare workers when there is a change of condition among the residents) dated 8/4/25 indicated, that the resident presented with a deep tissue injury (DTI) on the sacrum. Resident 1 was informed of the recommendation to initiate use of a low air loss (LAL) mattress (a specialized medical air mattress designed to promote skin integrity by providing continuous airflow to reduce moisture and heat, preventing bedsores and enhancing comfort for people with limited mobility). However, the resident, who has a designated Responsible Party (RP), 056157 Page 2 of 6 056157 08/22/2025 Alvarado Care Center 1154 S.Alvarado St Los Angeles, CA 90006

F 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few declined the use of the LAL mattress. The facility initiated the appropriate treatment protocol for the DTI, and Resident 1 to be repositioned every two hours. During a review of Resident 1's CP created 8/4/2025 with a focus, The resident has DTI pressure ulcer in sacrum or potential for pressure ulcer development r/t (related to) immobility. The CP indicated interventions which included:Assess/record/monitor wound healing, measure length, width depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the medical doctor (MD).Educated the resident/family/caregivers as to the causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulation/mobility, good nutrition and frequent repositioning. During a review of Resident 1's Laboratory Results report dated 8/7/2025 and reported at 4:14 pm, the results indicated a white blood cell count (WBC - measure the total number of white blood cells in the blood, which are a crucial part of the immune system that fight infection and disease, and may indicate infection or inflammation if level is elevated) of 15.81 cells per microliter [cells/uL, unit of measurement] (normal level range 4-11 cells/uL). The MD was not notified. During a review of Resident 1's nursing notes dated 8/11/2025 at 8:39 am, indicated, Resident (Resident 1) seen in respiratory distress at around 8 AM during breakfast time. Resident (Resident 1) is difficult to arouse, even with a sternal rub. Accessory muscle use noted with a respiratory rate of 32 breaths per minute (normal is 12-20bpm). Resident's body temperature at 98.9F (Fahrenheit, temperature scale), normal range of (97 F to 99 F) blood pressure at 132/76, heart rate (HR) at fluctuating around 110~120 per min, and oxygen saturation at 88% (percent). Paramedics were called for assistance. Resident 1 left at 8:16 am (on 8/11/25) to GACH. Medical Doctor (MD) and Family Member (FM 1) notified. During a review of Resident 1's 911 (the universal emergency telephone number in the United States and Canada that you call for immediate help from the police, fire department, or emergency medical services) run sheet (report) date 8/11/2025 at 7:59 am, indicated the chief complaint as altered level of consciousness (ALOC -a condition where a person is not as awake, alert, or responsive as they normally would be ranging from mild to complete coma). Resident found fowlers (sitting up about 90 degrees) in bed, on oxygen (O2) via non-rebreather mask (NRB - a specialized medical mask with a connected reservoir bag that provides high concentrations of oxygen to patients who can breathe on their own but need more support) at 15 liters per minute (lpm-unit of measure for oxygen delivery), and Glasgow Coma Scale (GCS - a tool that doctors and nurses use to measure how awake and responsive a person is, especially after a head injury or if someone might be in a coma) of score of three (15 as fully awake and alert , 8 or below as serious condition, possibly a coma, 3 is no response at all, deep coma). Staff (unidentified) stated that Resident 1 was found to be unresponsive while doing rounds this morning with no time specified. Last known well for Resident 1 is sometime last night with no specific time stated by staff. Staff (unidentified) states that Resident 1 is normally alert oriented, able to effectively communicate, and GCS 15. Staff states no recent trauma, cold/flu symptoms, drug or alcohol use, or abnormalities in urine output. Resident 1 has no history of stroke (when there is blood interruption to the brain causing the cells to die) or seizure (a temporary, uncontrolled electrical disturbance in the brain that can cause changes in a person's awareness, behavior, sensations, and muscle control) according to facility paperwork. Resident 1 is tachycardic (elevated heart rate) and feels hot to the touch with normal color and dry skin. During an interview with Family Member (FM) 1, on 8/15/25 at 5:10 pm, FM 1 stated that Resident 1 was admitted to the facility in January 2024 while ambulatory and no skin abnormalities. FM 1 stated that Resident 1 suffered a right hip fracture in 6/2025 and returned to the facility 6/30/2025. FM 1 stated that Resident 1 required assistance from the facility staff after he returned to the facility which 056157 Page 3 of 6 056157 08/22/2025 Alvarado Care Center 1154 S.Alvarado St Los Angeles, CA 90006

F 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few included toileting, turning, eating etc. On 8/4/2025, FM 1 received a call from nursing on the morning of on 8/11/2025 in telling her that Resident 1 had been transferred to GACH after Resident 1 was found unresponsive. FM 1 stated that she (FM 1) was very confused and asked what could have led to the sudden change and was at that point, the faculty staff notified FM 1 that Resident 1 had a pressure injury to his (Resident 1) buttocks which had opened up on 8/4/2025. FM 1 stated that she felt frustrated and asked why the facility had not notified her about the pressure injury being that she had Durable Power of Attorney for Health care (DPOA, a legal document where a trusted person [agent or health care proxy] to make medical decisions if one become mentally incapacitated) and the responsible party. FM 1 stated that Resident 1 had a history of dementia (A decline in cognitive function-such as memory, reasoning, language, and problem-solving-that is severe enough to interfere with daily life) and Parkinson's disease (a condition that affects the brain and makes it harder for a person to move their body the way they want to) which caused him to be confused and unable to make his own decisions which was the reason why she was designated DPOA. FM 1 stated that the facility as well as other health care providers called her (FM 1) regarding every decision pertaining to Resident 1's care. On the same interview FM 1 stated that the GACH healthcare personnel (unidentified) informed her that the PI was in bad shape and appeared infected. FM 1 stated that the GACH physician informed her that Resident 1 was septic with the PI as a possible source. FM 1 stated that Resident 1 was placed on comfort care on 8/12/2025, discharged to her home on 8/13/2025 and passed away on 8/14/2025. During an interview with Certified Nursing Assistant (CNA) 3 on 8/16/2025 at 11:31 am, CNA 3 stated that Resident 1 was bedbound after his surgery (right hip replacement) and readmitted on [DATE]. Resident 1 required total assistance for activities such as repositioning, feeding even though he was able to move his arms, changing his incontinence (unable to control both bladder and bowels) briefs, bed bath, and dressing. During an interview on 8/16/2025 at 11:58am, LVN 1 stated that skin assessments must be completed weekly by nursing. If a resident is found to have a stage 2 (partial-thickness skin loss involving the epidermis and dermis) or higher PI, a LAL mattress should be provided. Interventions to prevent skin breakdown included getting residents up out of bed to relieve pressure at least after breakfast and back to bed at lunch, frequent checking of the skin, and repositioning. During an interview with LVN 2 on 8/18/2025 at 11 am, LVN 2 stated that residents that are at risk of skin breakdown such as bedbound must have a CP to prevent skin breakdown and include interventions such as repositioning while in bed, keeping the residents nice and dry. LVN 2 stated the CP helps the team know how to care for the residents. LVN 2 stated skin assessment must be documented and done often/daily especially when non-ambulatory/non-verbal. LVN 2 stated that there are signs such as redness to the skin first before it develops to pressure injury or skin breakdown. LVN stated that if she had a resident who had changes in condition such as abnormal lab values, it must promptly be reported to the physician for directions on what actions to take next such as transfer the resident to the hospital. During an interview with Infection Prevention Nurse (IPN) on 8/18/2025 at 1 pm, the IPN stated that on 8/4/2025 a Certified Nursing Assistant (CNA) informed her that Resident 1 had a skin abnormality to his sacrum. The IPN stated that a consult for the wound care specialist was placed. The IPN stated that she assisted the wound care specialist with repositioning the resident to allow a clear view of the PI site for the wound care specialist. The IPN stated that she had leaned over to see the PI while holding Resident 1 on the side facing her (IPN). Resident 1's skin had a reddish/purple color to the sacrum. IPN stated that Resident 1's skin was intact with a small scratch and no drainage. The IPN stated that Resident 1's PI was classified as a DTI and may happen when a resident is not moving or repositioning. During an interview with the Registered Nurse Supervisor (RNS) 056157 Page 4 of 6 056157 08/22/2025 Alvarado Care Center 1154 S.Alvarado St Los Angeles, CA 90006

F 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few on 8/18/2025 at 12:02 pm, the RNS stated that residents who are admitted with surgical wounds must have ongoing assessments with documentation describing the condition of the wound including size (measurements) and drainage upon admission and throughout admission until completely healed. RNS stated that there was no specific protocol for DTI, but that interventions such as repositioning every two hours, wound care specialist consults and daily skin assessments should be done. RNS stated that the facility refers to the PI policy. During a concurrent interview and record review of Resident 1's wound care specialist notes dated 8/4/2025 with the MDS nurse (also as treatment Nurse) on 8/18/2025 at 2:02 pm, the MDS nurse stated that when he completed Resident 1's dressing changes on 8/8/2025, the skin to Resident 1's sacrum had some reddish/ purple color but that the skin was intact with no drainage noted. The MDS nurse confirmed that he had not received specific training as a treatment nurse (a licensed nurse who specializes in providing direct care and expert assessments for wounds, skin conditions, and other therapeutic needs, including medication administration and treatment plan development, all under physician orders and facility guidelines) cause his main job is doing MDS. During an interview with the wound care specialist on 8/18/2025 at 2:10 pm, the wound care specialist stated that pressure ulcers usually have signs such as redness before breakdown and develop over time. He stated that Resident 1 had a DTI with an area of ulceration upon his assessment on 8/4/2025. Wound care specialist stated that an elevated WBC must be reported to either himself or the primary medical provider because it may indicate an infection process. The wound care specialist confirmed that he had not received any call from the facility regarding the elevated WBCs. The specialist stated that had he received a call about the elevated WBC, he would have ordered for a wound culture to be collected to rule out wound infection. The specialist stated that wound infection may lead to sepsis. During an interview with the DON on 8/19/2025 at 12:43 pm, the DON confirmed that the facility did not have a full-time treatment nurse. The DON stated that one of the requirements for treatment nurses was to complete a special treatment nurse training online. The DON confirmed that the facility staff (IPN, MDS, ADSD- assistant Director of staff Development) that were covering as a treatment nurse had not completed the training. During an interview with the DON on 8/19/2025 at 2 pm, the DON stated that Resident 1 had a care plan for quadriplegia based on documentation received upon the resident's readmission from the General Acute Care Hospital (GACH) on 6/30/2025. The DON further stated that the pressure injury risk assessment for Resident 1 was done inaccurately. The DON confirmed that there was no documented evidence that the interventions outlined in Resident 1's care plan, initiated on 6/27/2025 and 8/4/2025, were implemented. Specifically, there was no documentation of skin assessments being performed every shift, nor of repositioning every two hours using pressure-relieving mattresses or cushions. DON further stated these interventions, if consistently applied, may have prevented the development of pressure injury. During a review of a policy and procedures (P&P) titled, Pressure Ulcer Prevention, reviewed 5/19/2025, indicated to identify residents at risk for skin breakdown, implement measures to prevent and/or manage pressure ulcers and minimize complications. The same P&P indicated the following procedure:Risk Identification and Assessment:The Licensed Nurse will complete a Braden Scale Assessment upon admission and quarterly to identify residents at risk for skin breakdown. The Licensed Nurse will conduct a skin assessment for a resident upon admission, readmission, weekly, and as needed. Results of the weekly skin assessment will be documented in the medical record. (Results may be documented using the Weekly Skin Inspection form. Weekly Skin Inspection) .If the resident is identified as having a wound, refer to policy for Wound Management.If the resident is identified as having a wound upon admission, findings will be documented on the Resident admission Assessment. Each identified wound will be documented in the resident's clinical chart. 056157 Page 5 of 6 056157 08/22/2025 Alvarado Care Center 1154 S.Alvarado St Los Angeles, CA 90006

F 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few During a review of a P&P titled, Change of Condition Notification, reviewed 5/19/2025, the P&P indicated, To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner. The same P&P defined an acute change in condition (ACOC) as, is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. Clinically important means a deviation that, without intervention, may result in complications or death). The P&P's further indicated the following:The Licensed Nurse will notify the residents' Attending Physician when there is an:A significant change in the resident's physical, mental or psychosocial status, e.g., deterioration in health, mental or psychosocial status, life-threatening conditions or clinical complications.A need to alter treatment significantly (e.g. based on lab/x-ray results, a need to discontinue an existing form of treatment due to change of condition). 056157 Page 6 of 6