Health inspection·October 13, 2023

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 Skilled Nursing Facility (SNF) Advance Beneficiary Notice of Non-coverage form (SNFABN, a document issued by medical providers to Medicare recipients, warning that services might not be covered; formally and legally transfers liability for payment of services to the Medicare recipient instead of Medicare) was completely filled out, by having one of three residents (Residents 256), chose one of the options for billing the anticipated non-covered inpatient skilled nursing facility (an in-patient rehabilitation and medical treatment center staffed with trained medical professionals) stay. Residents Affected - Few This deficient practice had the potential to affect the skilled nursing services needed to progress and achieve the highest practicable physical, mental, and psychosocial wellbeing of the affected resident (Resident 256). Findings: During a review of the admission record indicated Resident 256 was originally admitted to the facility on [DATE] and an initial admission date of 2/26/2023 with diagnoses that included, but not limited to hypertensive heart disease (a heart condition caused by high blood pressure), heart failure (a chronic condition where the heart does not pump blood as well as it should), and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). During a review of Resident 256's SNF Advance Beneficiary Notice of Non-coverage (SNFABN, a document issued by medical providers to Medicare recipients, warning that services might not be covered; formally and legally transfers liability for payment of services to the Medicare recipient instead of Medicare) form signed on 3/31/23, the SNFABN form indicated Resident 256's inpatient skilled nursing facility (an in-patient rehabilitation and medical treatment center staffed with trained medical professionals) stay will not be covered effective 4/4/2023. The Reason Medicare may not pay was due to SNF benefits have exhausted. The three options sections (for billing the anticipated non-covered inpatient skilled nursing facility stay) for Resident 256 were left blank. During a review of the undated document titled, Notice of Medicare Provider Non-Coverage document for Resident 256, indicated the effective date of current skilled nursing services will end on 4/3/2023. It also indicated Resident 256's financial liability will begin on 4/4/2023. During a concurrent interview and record review with the Business Office Manager (BOM), on 10/11/23 at 4:02 p.m., the BOM stated the protocol for beneficiary notices are, all beneficiary forms must be given to the residents 72 hours before their coverage ends. The BOM stated the facility's business Page 1 of 10 056167 056167 10/13/2023 Centinela Skilled Nursing & Wellness Centre West 950 Flower Street Inglewood, CA 90301

F 0582 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few office was responsible for providing all residents or the residents' responsible party with the form, explaining the options to the residents and/or responsible party and have residents and/or responsible party choose 1 of 3 options listed on the form. The BOM stated one option on Resident 256's beneficiary form should have been checked but was missed. During an interview with the administrator (ADM), on 10/12/23 at 2:26 p.m., the ADM stated Notice of Medicare Non-Coverage and Advance Beneficiary Notice of Non-Coverage should be explained to residents and they should be informed of the financial liability for the services provided. 056167 Page 2 of 10 056167 10/13/2023 Centinela Skilled Nursing & Wellness Centre West 950 Flower Street Inglewood, CA 90301

F 0641 Ensure each resident receives an accurate assessment. 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 an accurate Minimum Data Set (MDS) assessment, a comprehensive assessment and care planning tool, regarding the pneumococcal vaccination (vaccine to prevent pneumococcal disease), was conducted for one of two sampled residents (Resident 3). Residents Affected - Few This deficient practice had the potential for a poor care planning which can affect the health and safety of the affected resident (Resident 3). Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnosis that included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), dysphagia (difficulty of swallowing), aphasia (loss of ability to understand or express speech, caused by brain damage) and dementia (the loss of thinking, remembering, and reasoning). During a review of Resident 3's Minimum Data Set (MDS), a comprehensive assessment and care planning tool) dated 8/10/2023, the MDS indicated Resident 3's cognitive skills for daily decision making was severely impaired. The MDS, indicated Resident 3 required extensive assistance from staff with one-person physical assist in bed mobility, transfer, dressing, personal hygiene, and bathing. The MDS also indicated, Resident 3's Pneumococcal Vaccine (vaccine to prevent pneumococcal disease) was coded as 1 (up to date). During a review of Resident 3's Pneumococcal Vaccination, the Consent or Refusal (PVCR) form dated 11/8/2021 indicated Resident 3's responsible party refused for Resident 3 to receive the Pneumococcal Vaccine. During an interview on 10/13/2023 at 8:55 a.m. with the MDS nurse (a nurse that collects and assess information for the health and well-being of residents in Medicare or Medicaid certified nursing homes), the MDS nurse stated the MDS are completed upon admission, quarterly and yearly. The MDS nurse also stated if there was a significant change of resident's status, the facility should transmit a new MDS. When asked if the MDS assessment dated [DATE] under section 00300 Pneumococcal vaccine was completed accurately, the MDS nurse stated it was a wrong assessment. It should have been coded 2 (as offered and declined), not 1, since Resident 3 refused to receive the Pneumococcal Vaccine. The MDS nurse stated if the facility did not put the correct assessment in the MDS, there would be a problem in billing and with the care of the resident. During a review of the facility's policy and procedure (P&P), titled RAI process, revised October 4, 2016, indicated the facility will utilize the Resident Assessment Instrument (RAI) process as the basis for the accurate assessment of each resident's functional capacity and health status, as outlined in the CMS RAI MDS 3.0 Manual. 056167 Page 3 of 10 056167 10/13/2023 Centinela Skilled Nursing & Wellness Centre West 950 Flower Street Inglewood, CA 90301

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 follow its policy and procedure by ensuring one of one sampled resident (Resident 42), had a titration order (order to adjust flow of oxygen to achieve target oxygen level range in the system) for oxygen use, and ensuring the oxygen tubing was changed and labeled every seven days per policy. Residents Affected - Few The deficient practice had the potential to cause respiratory complications and had the potential for facility acquired respiratory infections associated with oxygen therapy. Findings: During an observation on 10/10/2023 at 10:10 a.m., Resident 42 was receiving oxygen at two (2) liters per minute (LPM) via nasal cannula (a small flexible tube that has two open prongs that sit inside the nostrils used to deliver oxygen). The oxygen regulator (regulator that controls the flow of oxygen) was set at 2 LPM. During an observation on 10/12/2023 at 7:57 a.m. at Resident 42's room, Resident 42 was receiving oxygen at three (3) LPM via nasal cannula. Resident 42's oxygen tubing had no label and date. During an interview on 10/12/2023 at 8:10 a.m. with the Director of Nursing (DON), the DON confirmed that Resident 42's oxygen tubing was not dated and labeled. The DON stated our practice is to put the date on the plastic bag and on the oxygen tubing. The DON can't verify when the oxygen tubing was last changed because it was not labeled and dated. During an interview on 10/12/2023 at 9:40 a.m. with the Licensed Vocational Nurse 1 (LVN) and DON, LVN 1 stated Resident 42's physician orders for oxygen was 2-3 liters per minute as needed for shortness of breath. LVN 1 stated Resident 42 sometimes increased his oxygen flow to 4 liters per minute by herself. The DON stated that Resident 42's physician's order for oxygen was not clear and was confusing for the nursing staff. The DON stated the physician order should have included titration order and parameters. The DON stated I will have LVN 1 call the doctor and clarify the oxygen order of Resident 42. During a review of Resident 42's admission Record, the admission Record indicated Resident 42 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (a lung disease characterized by long term poor airflow), encephalopathy (damage or disease that affects the brain), and congestive heart failure (a chronic condition in which the heart doesn't pump blood as well it should). During a review of Resident 42's History and Physical (H&P), dated 8/7/2023, the H&P, indicated Resident 42 has the capacity to understand and make decisions. During a review of Resident 42's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 7/14/2023, the MDS indicated Resident 42 required extensive assistance in dressing, toilet use, and personal hygiene. The MDS indicated Resident 42 was on oxygen therapy. During a review of Resident 42's Physician Order dated 7/8/2023, the physician order indicated, May use oxygen at 2-3 liters per minute via nasal cannula for shortness of breath as needed and to 056167 Page 4 of 10 056167 10/13/2023 Centinela Skilled Nursing & Wellness Centre West 950 Flower Street Inglewood, CA 90301

F 0695 change the oxygen tubing weekly on Sunday and as needed. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, Oxygen Therapy, revised November 2017, the P&P indicated, oxygen titration orders will have parameters specified by the physician (example: 02 @ 2-4 L/min to maintain 02 @ saturations at or above 92%) and the humidifier and tubing should be changed no more than every 7 days and labeled with the date of change. Residents Affected - Few 056167 Page 5 of 10 056167 10/13/2023 Centinela Skilled Nursing & Wellness Centre West 950 Flower Street Inglewood, CA 90301

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two insulin pens (a type of medication used to treat high blood sugar) requiring refrigeration were stored according to the manufacturer's requirements affecting Residents 10 and 21, in one of two inspected medication carts (West Back Medication Cart 1.) The deficient practices of failing to store medications per the manufacturers' requirements increased the risk that Residents 10 and 21 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization. Findings: During a concurrent observation and interview on [DATE] at 2:10 p.m. of the [NAME] Back Medication Cart 1 with the Licensed Vocational Nurse 1 ( LVN), the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date, as required by their respective manufacturer's specifications: 1. One unopened insulin lispro (a type of insulin used to treat high blood sugar) pen for Resident 21 was found stored at room temperature. According to the manufacturer's product labeling, unopened insulin lispro pens must be stored in the refrigerator. 2. One unopened insulin aspart (a type of insulin used to treat high blood sugar) pen for Resident 10 was found stored at room temperature. According to the manufacturer's product labeling, unopened insulin aspart pens should be stored in the refrigerator. LVN 1 stated the insulin for Residents 10 and 21 were not stored properly according to the manufacturer's requirements. LVN 1 stated when an insulin is unopened, it must remain in the refrigerator. LVN 1 stated she does not know why the insulin for Residents 10 and 21 are stored in the medication cart. LVN 1 stated if the insulin is stored at room temperature, the expiration date is shortened significantly and needs to be discarded much sooner. LVN 1 stated when insulin is stored improperly at room temperature, there is a risk of administering it to the resident once it has expired. LVN 1 stated administering expired insulin to residents could result in poor blood sugar control which could cause medical complications possibly leading to hospitalization. A review of the facility's policy titled, Medication Storage in the Facility, dated [DATE], indicated Medications and biologicals are stored safely, securely, and properly, following the manufacturer's recommendations . medications requiring 'refrigeration' . are kept in a refrigerator with a thermometer to allow temperature monitoring . 056167 Page 6 of 10 056167 10/13/2023 Centinela Skilled Nursing & Wellness Centre West 950 Flower Street Inglewood, CA 90301

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to prepare food by methods that conserved flavor, texture, and appearance for one of one puree food test-tray. The texture of the pureed diet was sticky and gummy with glossy and shiny appearance. When tasted the food was sticky to palate and gums and difficult to swallow and the flavor was bland. This deficient practice had the potential to result in meal dissatisfaction, decreased intake and placed Four resident on the puree diet at risk for unplanned weight loss. Residents Affected - Few Findings: During initial facility tour on 10/10/2023 at 9:00 a.m., complaints about the temperature and flavor of the food were identified. During an observation and interview in the kitchen on 10/10/2023 at 10:00 a.m., Cook1 was preparing the lunch menu. Cook1 said the lunch includes chicken, creamy pasta, and spinach. Cook1 was cooking the chicken in the oven, she had prepared the creamy sauce for the pasta and was steaming the spinach on the stove. Cook1 stated, once food is cooked will take a portion and will blend for the residents on the pureed diet. Cook1 said that she blends with the juices of the chicken or adds broth then adds thickener until the consistency is thick and is not runny. During an observation of the tray line service for lunch at 11:45 a.m., the pureed spinach was thick and had sticky consistency, it was sticking to the serving scoop. The pureed spinach looked shiny and glossy. During the test tray on 10/10/2023 at 12:34 p.m., the pureed spinach was thick, clinging or sticking to the mouth and palate and difficult to clear the mouth and swallow like a peanut butter consistency. The taste was bland and didn't taste that it had cheese per recipe. The pureed pasta was bland and had no creamy pasta taste like the regular unblended pasta. During a concurrent interview with the Dieatry Supervisor (DS) and Registered Dietitian (RD1), the DS said the pureed food could use a little more seasoning. RD1 stated the puree should have an apple sauce like consistency and not thick like this spinach. RD1 agreed that the balance of the thickness is off in the spinach and will discuss with the cooks. During an interview with Cook1 on 10/10/34 at 1:30 p.m., Cook1 said she adds a portion of the cooked food in the blender and sometimes adds broth. Once blended, she adds enough thickener that will make the consistency thick and not runny. Cook1 said she does not measure how much thickener she uses. A review of facility menu titled recipe: pureed vegetables indicated, complete regular recipe, measure out the total number of potions needed for puree diets, puree on low speed, puree should reach the consistency of applesauce. 056167 Page 7 of 10 056167 10/13/2023 Centinela Skilled Nursing & Wellness Centre West 950 Flower Street Inglewood, CA 90301

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen were followed when: 1. Three bags of breaded potato hash browns were stored in the reach-in freezer with no date label. One large container of apple sauce was store in the reach-in refrigerator with no date. 2. Personal water bottles were stored in the facility two door reach-in refrigerator. 3. Nutritional supplement labeled store frozen, with manufactures instruction to use within 14 days of thawing, were not monitored for the date they were thawed to ensure expired shakes were discarded after this time frame. 30 strawberry flavored nutrition supplements were stored in the reach in refrigerator with no thaw date. This deficient practice had the potential to result in food borne illness (food poisoning caused by consuming contaminated food, beverages, or water) in 9 residents who are on nutrition supplements at the facility. 4. Juice machine tubing connectors were sticky and had drops of dried sticky residue, two gnats were flying around the sticky tubing connectors. One juice tubing connector was not attached to juice box and was hanging close to the floor and touching other juice boxes. Coffee making machine glass gauge pipe was stained with dark brown color residue. 5. Resident food brought from outside, including leftovers, were stored in the resident refrigerator with no label and date. Resident (1) had three containers of leftover cooked beans stored in the refrigerator with no date. This deficient practice had the potential to result in food borne illness in one resident who had food stored in the resident refrigerator with no date. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 49 out of 52 residents who received food from the kitchen and Resident 1 who stored and consumed personal foods from the resident refrigerator. Findings: 1. During an observation in the kitchen on 10/10/2023 at 9:00 a.m., there were three large bags of breaded triangle shaped food items stored in the reach-in freezer with no label or date. During a concurrent interview with Dietary Aide (DA1), DA1 stated they are fish but was not sure and will have to check. During an observation in the kitchen on 10/10/23 at 9:10 a.m., there was a large container of apple sauce stored in the reach-in refrigerator with no date. During a concurrent interview with Dietary supervisor (DS), DS stated that everything in the refrigerator must be labeled and dated. DS said the apple sauce will be discarded since there is no date. A review of facility policy titled Food Storage policy No.DS-52 (revised7/25/2019) indicated, All 056167 Page 8 of 10 056167 10/13/2023 Centinela Skilled Nursing & Wellness Centre West 950 Flower Street Inglewood, CA 90301

F 0812 items will be correctly labeled and dated. Level of Harm - Minimal harm or potential for actual harm A review of the 2022 U.S. Food and Drug Administration Food Code titled Ready to Eat, Time/Temperature control for safety food, Date Marking Code#3-501.17, indicated, Ready to eat, time temperature control for safety food prepared and packaged by food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed, sold, or discarded. Residents Affected - Some 2. During a concurrent observation and interview with DS on 10/10/23 at 9:15 a.m., there were 2 plastic water bottles stored in the kitchen refrigerator next to food preparation area. DS stated these belong to staff and staff should not store their water bottles inside the refrigerators due to possible cross contamination with facility food for residents. 3. During an observation in the kitchen on 10/10/23 at 9:20 a.m.,there were 30 single serve cartons of strawberry nutrition supplement stored inside the dairy refrigerator with no date. During a concurrent interview with DS, DS stated the single serve carton of nutrition supplements are frozen and are stored in the refrigerator. DS said once thawed they are good for 14 days. DS agreed there should be a date on the supplements to monitor date of thaw. DS was not sure when the Strawberry flavored nutrition supplements were thawed. 4. During an observation in the kitchen on 10/10/23 at 9:30 a.m., juice machine tubing connectors were sticky to the touch, there were dark sticky spots on the tubing and there were two gnats flying around the sticky tubing and connectors. One of the tubing connectors was disconnected from the juice box and was hanging close to the floor and touching other juice boxes and tubing. During a concurrent observation and interview with the DS, the DS stated the juice machine in-serviced by the juice machine company. DS stated that kitchen staff are responsible to wipe down and clean the tubing and connectors. DS agreed that juice spills and dry sticky juices on tubing can attract pests such as gnats. During an observation in the kitchen on 10/10/23 at 9:40 a.m., observed the coffee maker machine had glass gauge pipe in front of the machine. The pipes were half filled with coffee and there was dark brown stains inside the pipes. During a concurrent interview with DA1, DA1 stated that the pipes are cleaned every week with a special thin pipe brush. DA1 acknowledged that the glass pipe is dirty and said that it has not been cleaned. DA1 said that stained and dirty coffee maker can contaminate the coffee and change the quality. During an interview with DS on 10/11/23 at 1:30 p.m., DS stated that we will begin a new cleaning schedule log which will include the cleaning the juice box machine and connectors and the coffee machine. A review of facility policy titled Bag-in Box juice Dispenser cleaning and sanitizing instructions not dated indicated, wipe down all connecting hoses and product rack, with a soft cloth and a mild soap and water solution. A review of facility daily cleaning schedule log indicated to clean the juice machine, nozzle, holder, and tray so no build up. Clean machine area no sticky counters. The cleaning schedule also includes to clean the coffee maker on daily basis. 056167 Page 9 of 10 056167 10/13/2023 Centinela Skilled Nursing & Wellness Centre West 950 Flower Street Inglewood, CA 90301

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 5. During a review of Resident 1's admission Record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses of hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), affecting right and left dominant side, polyarthritis (joint pain and stiffness) and right hand contracture (fixed tightening of muscle, tendons, ligaments, or skin). During a review of Resident 1's History and Physical (H&P), dated 5/1/2023, the H&P, indicated Resident 1 has the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool dated 7/25/2023, the MDS indicated Resident 1 required extensive assistance in bed mobility, transfer, toilet use, and personal hygiene. During an observation of Resident 1's food refrigerator in his room on 10/10/2023 at 1:25 p.m., it was observed one unopened carton of milk with used by date 10/18/2023, one unopened Arizona tea, and three containers of leftover cooked beans with no label and date. During an interview on 10/10/2023 at 1:35 p.m., with Certified Nursing Assistant 1 (CNA 1) at Resident 1's room, CNA 1 verified the three containers of left-over cooked beans with no label of date opened or when was it stored or kept in the refrigerator. CNA 1 stated she does not know who brought Resident 1's outside food. During an interview on 10/12/2023 at 8:45 a.m., with Director of Nursing (DON), the DON stated food brought from outside of the facility needs to be labeled and dated prior to keeping in Resident 1's food refrigerator. The DON stated it important to label and date outside food especially the perishable food because of the risk of food borne illness. During a review of the facility's policy and procedure (P&P), titled Food Brought in by Visitors, revised June 2018, the P&P indicated When food is brought into a nursing home prepared by others, the nursing home is responsible for ensuring that the food container is clearly labeled with the resident's name and date received and stored in a refrigerator designated for this purpose. 056167 Page 10 of 10