Health inspection·April 1, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview, and record review, the facility failed to provide resident with dignity and respect by not sitting when assisting the resident with meal and eating at eye-level for one of 28 sampled residents (Resident 22). This deficient practice had the potential for Resident 22 to feel less respected as a person, which could negatively impact the resident's sense of dignity. Findings: A review of Resident 22's admission Record indicated the facility re-admitted Resident 22 on 11/18/2021, with diagnoses including seizure disorder (burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness) and gastroesophageal reflux disease (digestive disorder that occurs when acidic stomach juices, or food and fluids back up from the stomach into the throat). A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/12/2022, indicated Resident 22's cognitive skills of daily decision making were moderately impaired but required limited assistance (resident highly involved in activity, staff provided guided assistance of limbs) with one person's physical assistance with eating. A review of the Physician's Orders, dated 3/22/2022, indicated for Resident 22 to receive a Restorative Nursing Aide (RNA, nursing aide program that helps residents to maintain their function and joint mobility) to assist with feeding during breakfast and lunch, two times a day. On 3/30/2022, at 7:38 AM, during observation in the resident's room, Resident 22 was lying in bed with the head-of-bed fully elevated. Restorative Nursing Aide 1 (RNA 1) stood on the right side of the bed when assisting Resident 22 with his breakfast. RNA 1's face was approximately two-feet above Resident 22's face. On 3/30/2022, at 8 AM, during an interview, RNA 1 stated since there was no chair in the room, she had to stand when assisting the resident with his meal during breakfast. RNA 1 further stated she should have sat on a chair when feeding the resident to maintain eye contact and maintain resident's dignity. On 3/30/2021, at 8:24 AM, during an interview, the Director of Staff Development stated RNA 1 was supposed to sit at eye-level while assisting residents with meals to show mutual respect for the resident. A review of the facility's undated policy titled, Assistance with Meals, indicated residents shall Page 1 of 28 056242 056242 04/01/2022 Westlake Convalescent Hospital 316 S Westlake Avenue Los Angeles, CA 90057

F 0550 Level of Harm - Minimal harm or potential for actual harm receive assistance with meals in a manner that meets the individual needs of each resident. The policy indicated residents will be fed with attention to safety, comfort and dignity, for example, not standing over residents while assisting them with meals. Residents Affected - Few 056242 Page 2 of 28 056242 04/01/2022 Westlake Convalescent Hospital 316 S Westlake Avenue Los Angeles, CA 90057

F 0583 Keep residents' personal and medical records private and confidential. 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 ensure the residents health information was protected by not posting a sign above each resident's bed disclosing medical information regarding their dialysis access for two of three sampled residents (Resident 18 and Resident 42). This deficient practice had the potential of exposing residents medical information to staff who were not providing care to these resident and to visitors. Residents Affected - Few Findings: a. A review of Resident 18's admission Record (Face Sheet) indicated the facility originally admitted the resident on 12/14/2021, and readmitted on [DATE], with diagnoses including chronic respiratory failure (inability to breath effectively) and end stage renal (inability of the kidney to remove waste product from the blood stream) disease. A review of Resident 18's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/20/2022, indicated Resident 18's cognitive skills of daily decision making were severely impaired and was in a persistent vegetative state (has no discernible consciousness). A review of the Physician's Order dated 1/20/2022, indicated Resident 18 was to have no IV, no blood draw, no BP, no injection on left arm due to arteriovenous (AV) shunt (an artery that is surgically sutured to a vein for use in dialysis in people with severe kidney disease). On 3/29/2022, at 10:15 AM, and at 1:04 PM, and on 3/30/2022, at 9:30 AM, a sign was observed above Resident 42's bed which indicated no blood pressure (BP), no injection on right arm due to AV shunt. b. A review of Resident 42's admission Record (Face Sheet) indicated the facility originally admitted the resident, on 11/15/2021, with diagnoses including chronic respiratory failure and end stage renal disease and encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition). A review of Resident 42's MDS dated [DATE], indicated Resident 42 had severely impaired cognition (never/rarely made decisions), was totally dependent in all activities of daily living (essential and routine activities include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet). On 3/29/2022, at 10:28 AM and 2:53 PM and on 3/31/2022, at 12:08 PM observed a sign above Resident 18's bed which indicated No IV, no blood draw, no blood pressure (BP), no injection on left arm due to presence of AV shunt. The sign is viewable from the open doorway by visitors and staff who were not assigned to both residents. On 03/31/22, at 12:44 PM, LVN 3 during an observation and interview in the resident's room with Licensed Vocational Nurse (LVN) 3 stated she could see the sign above Resident 18's bed and stated that it was visible from the doorway. LVN 3 proceeded to read the sign aloud. LVN 3 further stated the signs were there to inform the phlebotomist or any other healthcare worker (HCW) of the resident's medical needs but should have been protected. 056242 Page 3 of 28 056242 04/01/2022 Westlake Convalescent Hospital 316 S Westlake Avenue Los Angeles, CA 90057

F 0583 Level of Harm - Minimal harm or potential for actual harm A review of Resident 42's Physician's Order dated 11/15/2021, indicated there was to be no IV, no blood draw, no BP, no injection on right arm due to AV shunt. On 3/31/2022, at 12:51 PM, during an interview, LVN 3 stated it was the facility's responsibility to safeguard a resident/s health information and to make sure it remained private. Residents Affected - Few On 3/31/2022, at 2:19 PM, during an interview, the Director of Nurses (DON) stated she was not aware of the signs above the beds regarding no BP, etc. and that it was just an extra reminder. The same information was documented in the progress notes and on the medication administration record (MAR). When asked was the family asked before the sign was posted, she stated that she was not sure. The DON then stated we should remove the signs because they are a Health Insurance Portability and Accountability Act of 1996 (HIPAA - a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge) violation. A review of the facility's policy and procedure titled, Confidentiality of Information, undated, indicated, the facility will safeguard all resident records, whether medical, financial, or social in nature to protect the confidentiality of the information. A review of the facility's policy and procedure titled, Resident Rights, undated, indicated that the unauthorized disclosure of resident information was prohibited. 056242 Page 4 of 28 056242 04/01/2022 Westlake Convalescent Hospital 316 S Westlake Avenue Los Angeles, CA 90057

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a homelike environment with adequate lighting for two of 28 sampled residents (Resident 22 and 32). This deficient practice had the potential to place Resident 22 and 32 at risk for choking hazards while being assisted with meals and decreased the residents' alertness to adequately eat, which increases their potential for weight loss. Findings: a. A review of Resident 32's admission Record indicated the facility re-admitted Resident 32 on 4/24/2019. Resident 32's diagnoses included but was not limited to gastroesophageal reflux disease [digestive disorder that occurs when acidic stomach juices, or food and fluids back up from the stomach into the throat), acute embolism and thrombosis (types of blood vessel blockage) of deep veins in the lower extremity (leg), and dependence on wheelchair. A review of Resident 32's Minimum Data Set (MDS, a standardized assessment and care -screening took), dated 1/30/2022, indicated Resident 32's cognitive skills of daily decision making were moderately. The MDS also indicated Resident 32 required extensive assistance (resident involved in activity while staff provided weight-bearing support) with one person's physical assistance for bed mobility, dressing, and eating. On 3/29/2022, at 12:33 PM, during an observation in the resident's room, Resident 32 was lying in bed with the head-of-bed (HOB) fully elevated. Certified Nursing Assistant 3 (CNA 3) sat in a chair on the right side of the bed while feeding Resident 32 lunch. The lights were not on in the room or around Resident 32's bed. During another lunch time observation on 3/30/2022, at 12:27 PM, CNA 3 assisted Resident 32 with feeding again without any lights around Resident 32's bed or in the room. On 3/31/2022, at 12:14 PM, during an observation and interview in the resident's room, Resident 32 was lying asleep in bed. CNA 3 fully elevated Resident 32's HOB in preparation for lunch. The lights were turned off around Resident 32's bed. CNA 3 attempted to wake Resident 32, who appeared drowsy with eyes closed. CNA 3 continued to feed Resident 32 lunch without any lights in the room or around Resident 32's bed. CNA 3 responded, I don't know, when asked the reason for keeping the lights off during mealtimes. On 3/31/2022, at 12:24 PM, during an observation and interview with Director of Nursing (DON) observed Resident 32's room and requested for CNA 3 to turn on the lights around Resident 32's bed. The DON stated the lights needed to be turned on while eating to create a homelike environment since it was not typical to eat without adequate lighting. The DON also stated having the lights on was important for safety to ensure the resident received the correct diet and to remove any hazardous items in the food, like bones. A review of the facility's undated policy titled, Quality of Life - Homelike Environment, indicated the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include .Comfortable (minimum glare) yet adequate (suitable to task) lighting. b. A review of Resident 22's admission Record indicated the facility re-admitted Resident 22 on 056242 Page 5 of 28 056242 04/01/2022 Westlake Convalescent Hospital 316 S Westlake Avenue Los Angeles, CA 90057

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 11/18/2021 with diagnoses including seizures (burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness) and gastroesophageal reflux disease (digestive disorder that occurs when acidic stomach juices, or food and fluids back up from the stomach into the throat). A review of Resident 22's MDS dated [DATE], indicated Resident 22 required limited assistance (resident highly involved in activity, staff provide guided assistance of limbs) with one person's physical assistance for eating. On 3/31/2022, at 12:14 PM, during an observation in the resident's room, Resident 22 was lying in the bed with the head-of-bed (HOB) fully elevated. The Restorative Nursing Aide 1 (RNA 1) assisted Resident 22 with eating lunch and the lights were turned off in the room and around Resident 22's bed. On 3/31/2022, at 12:24 PM, during an observation and interview the Director of Nursing (DON) observed Resident 22's room and requested for RNA 1 to turn on the lights around Resident 22's bed. The DON stated the lights needed to be turned on while eating to create a homelike environment since it was not typical to eat without adequate lighting. The DON also stated having the lights on was important for safety to ensure the resident received the correct diet and to remove any hazardous items in the food, like bones. A review of the facility's undated policy and procedures titled, Quality of Life - Homelike Environment, indicated the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include .Comfortable (minimum glare) yet adequate (suitable to task) lighting. 056242 Page 6 of 28 056242 04/01/2022 Westlake Convalescent Hospital 316 S Westlake Avenue Los Angeles, CA 90057

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide one of 28 sampled residents (Resident 32) with care and services to maintain the ability to perform activities of daily living (ADLs, tasks related to personal care) by failing to: Residents Affected - Few -dress Resident 32 in appropriate clothes and assist Resident 32 out-of-bed daily in accordance with the care plan and the facility's policy, and -provide Resident 32 with a Restorative Nursing Aide (RNA, nursing aide program that helps residents to maintain their function and joint mobility) feeding program in accordance with the physician's order. These deficient practices had the potential for Resident 32 to experience a decline in overall function, endurance, strength, and mental health, which affects the resident's quality of life. Cross reference F805 Findings: A review of Resident 32's admission Record indicated the facility re-admitted Resident 32 on 4/24/2019 with diagnoses including gastroesophageal reflux disease (digestive disorder that occurs when acidic stomach juices, or food and fluids back up from the stomach into the throat), acute embolism and thrombosis (types of blood vessel blockage) of deep veins in the lower extremity (leg), and dependence on wheelchair. a. A review of Resident 32's care plan for ADL Maintenance, initiated on 4/24/2019, indicated to dress the resident daily, encourage increased participation with ADLs and assist as needed, and assist to the wheelchair or gerichair (reclining chair that allows a person to get out of bed and sit comfortably in different positions while fully supported) daily as tolerated. A review of Resident 32's Minimum Data Set (MDS, a comprehensive assessment used as a care planning took), dated 1/30/2022, indicated Resident 32 was moderately impaired for daily decision making (unable to make decisions) and required extensive assistance (resident involved in activity while staff provided weight-bearing support) with two person's physical assistance for transfers between surfaces. The MDS also indicated Resident 32 required extensive assistance with one person's physical assistance for bed mobility, dressing, and eating. During an observation on 3/29/2022, at 12:33 PM, in the resident's room, Resident 32 wore a hospital gown while lying in bed with the head-of-bed (HOB) fully elevated to eat lunch. On 3/29/2022, at 2:30 PM, Resident 32 continued to lay in bed wearing a hospital gown. During an observation on 3/30/2022, at 7:38 AM, in the resident's room, Resident 32 wore a hospital gown while lying with the HOB fully elevated. Resident 32 was yelling unintelligible words. Restorative Nursing Assistant 1 (RNA 1) lowered the HOB into a flat position and turned off the lights. Resident 32 fell asleep. On 3/30/2022, at 9:35 AM, Resident 32 continued to sleep while lying flat in bed wearing a hospital gown. 056242 Page 7 of 28 056242 04/01/2022 Westlake Convalescent Hospital 316 S Westlake Avenue Los Angeles, CA 90057

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 3/30/2022, at 10:35 AM, Certified Nursing Assistant 3 (CNA 3) stated that Resident 32 received a shower yesterday morning. CNA 3 stated she assisted Resident 32 with breakfast in the morning, changed the bed linen, and changed the incontinence brief. In the afternoon, CNA 3 anticipated that CNA 3 would assist Resident 32 with lunch and will change the incontinence brief after lunch. During an observation on 3/30/2022, at 12:27 PM, in the resident's room, Resident 32 was sleeping flat on his back in bed wearing hospital gown. CNA 3 fully elevated the HOB in preparation for lunch. After lunch, CNA 3 informed Resident 32 to remain in bed with the HOB elevated for at least 20 minutes after the meal. On 3/30/2022, at 2:30 PM, Resident 32 continued to lay in bed wearing a hospital gown. During an observation on 3/31/2022, at 8:06 AM, in the resident's room, Resident 32 laid flat on his back wearing a hospital gown. Resident 32 was awake and mumbling unintelligible speech. A review of Resident 32's Activity Attendance Record for March 2022 indicated the facility brought Resident 32 to the activity room three times on 3/1/2022, 3/7/2022, and 3/8/2022. Resident 32 received room visits 27 times from 3/2/2022 to 3/6/2022 and 3/9/2022 to 3/30/2022. During an interview and record review on 3/31/2022, at 8:08 AM, the Activity Director (AD) reviewed Resident 32's Activity Attendance Record for March 2022 and stated Resident 32 received mainly room visits for the entire month. The AD stated staff was encouraged to bring residents to the activity room and did not know the reason for staff not assisting Resident 32 to the activity room daily. During an interview on 3/31/2022, at 12:43 PM, the Director of Nursing (DON) stated residents should be out of bed daily or as tolerated for their mental health, to maintain their ADL ability, and to maintain their mobility. The DON stated that residents should be dressed in regular clothes to provide a home-like environment. A review of the facility's undated policy titled, Quality of Life - Dignity, indicated residents shall be encouraged and assisted to dress in their own clothes rather than in hospital gowns. A review of the facility's undated policy titled, Activities of Daily Living (ADL), indicated residents will be out of bed (OOB) and dressed appropriately each day. b. A review of Resident 32's Physician's Order, dated 4/24/2019, indicated to provide an RNA feeding program for breakfast and lunch. A review of Resident 32's care plan for ADL Maintenance, initiated on 4/24/2019, indicated to encourage independence in eating and assist as needed. A review of Resident 32's care plan for weight loss, initiated on 3/14/2020, to monitor for signs or symptoms of choking or aspiration (when food or liquid goes into the airway) and report to the physician. A review of Resident 32's care plan for poor oral intake, initiated on 7/27/2020, indicated to provide the feeding program as ordered. During an observation and interview on 3/29/2022, at 12:33 PM, in the resident's room, Resident 32 laid in bed with the head-of-bed (HOB) fully elevated. Certified Nursing Assistant 3 (CNA 3) sat in a chair on the right side of the bed while feeding Resident 32. Resident 32 mumbled and coughed while chewing the meal and did not attempt to feed himself. Resident 32 drank chocolate milk from a straw and immediately coughed loudly multiple times. CNA 3 stated Resident 32 coughed loudly, all the 056242 Page 8 of 28 056242 04/01/2022 Westlake Convalescent Hospital 316 S Westlake Avenue Los Angeles, CA 90057

F 0676 time during meals. Level of Harm - Minimal harm or potential for actual harm During an observation on 3/30/2022, at 12:27 PM, in the resident's room, Resident 32 was sleeping flat on his back in bed. CNA 3 fully elevated the HOB for lunch. Resident 32 coughed as CNA 3 elevated the HOB. CNA 3 sat in a chair on the right side of the bed to feed Resident 32. Resident 32 did not attempt to feed himself. Resident 32 ate steamed vegetables and potatoes but began to cough loudly. Resident 32 forcefully coughed up steamed vegetables onto a towel placed on the chest. CNA 3 continued to feed Resident 32 steamed vegetables, potatoes, and ice cream. CNA 3 then offered warm milk at the end of the meal which caused Resident 32 to cough immediately. Residents Affected - Few During an observation on 3/31/2022, at 12:14 PM, in the resident's room, Resident 32 was sleeping flat on his back when CNA 3 fully elevated the HOB for lunch. Resident 32 began coughing while CNA 3 elevated the HOB, continued to cough when the HOB was fully elevated, but finally cleared the throat prior to eating. CNA 3 sat in a chair to feed Resident 32. Resident 32 did not attempt to feed himself. During an observation and interview on 3/31/2022, at 12:24 PM, with the Director of Nursing (DON) in the resident's room, CNA 3 fed Resident 32 chocolate milk, causing the resident to cough immediately. The DON stated coughing while eating or drinking could indicate problems with swallowing. The DON stated Resident 32's coughing was not reported to nursing, who could have contacted the physician for a Speech Therapy (SLP, profession aimed in the prevention, assessment, and treatment of speech, language, communicative, and swallowing disorders) evaluation. DON stated it was important to report to nursing any resident who coughed consistently while eating as the resident could be choking or could develop aspiration pneumonia (occurs when food, saliva, liquids, or vomit is breathed into the lungs or airways leading to the lungs, instead of being swallowed into the stomach). During a follow-up interview on 3/31/2022, at 12:43 PM, the DON stated the RNA feeding program provided assistance and cueing to residents while eating. The DON stated an RNA should have assisted Resident 32 with feeding since there was a physician's order for the RNA feeding program. The DON stated the RNAs had specific training in feeding and would have reported Resident 32's coughing to the nurses. A review of the facility's undated policy titled, Restorative Nursing Program, indicated the Restorative Nursing Program was a service provided by the facility generally under nursing, to ensure maintenance of a patient's optimum level of function. The patients on this program are encouraged or assisted to achieve and maintain their highest level of self-care and independence. These services must be performed daily. The policy indicated feeding was a component of the RNA program. 056242 Page 9 of 28 056242 04/01/2022 Westlake Convalescent Hospital 316 S Westlake Avenue Los Angeles, CA 90057

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to endure residents received treatment and care in accordance with professional standards for three of eight sampled residents (Residents 2, 11, and 58). The physician's orders were not followed these residents causing an increased risk in worsening pressure related skin injuries and the potential for increased harm and infection. Residents Affected - Few Findings: A review of Resident 2's Face sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including Chronic Respiratory Failure (condition that results in the inability to effectively exchange carbon dioxide and oxygen, and induces chronically low oxygen levels or chronically high carbon dioxide levels), Tracheostomy (opening surgically created through the neck into the trachea (windpipe) to allow direct access to the breathing tube) status, Pressure induced deep tissue damage (serious form of pressure ulcer caused by direct pressure to the skin and soft tissue that causes ischemia) of the right heel and Contracture of muscle (occurs when your muscles, tendons, joints, or other tissues tighten or shorten causing a deformity). A review of the Physician's Orders dated 12/26/2021 indicated Resident 2 was to receive a low air loss mattress with comfort control set between #3 - #4 for wound management every shift. A review of Resident 11's Face sheet indicated Resident 11 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including Chronic respiratory failure, Tracheostomy status, Pressure ulcer (localized damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of usually long-term pressure, or pressure in combination with shear or friction) of the right and left heel and Contracture of muscle. A review of the Physician's Order summary dated 1/3/2022 indicated Resident 11 was to receive a low air loss mattress with comfort control set between #3 - #4 for wound management every shift. A review of Resident 58's Face sheet indicated Resident 58 was admitted to the facility on [DATE] with a readmission on [DATE] with diagnoses including Chronic Respiratory Failure, Tracheostomy status, Pressure ulcer of the sacral region (bottom of the spine and lies between the fifth segment of the lumbar spine (L5) and the coccyx (tailbone), Pressure induced deep tissue damage of the right and left heel and non-pressure chronic ulcer of buttock limited to breakdown of skin. A review of the Physician's Order summary dated 3/22/2022 indicated Resident 58 was to receive a low air loss mattress with comfort control set between #3 - #4 for wound management every shift. During an observation and initial tour of the facility on 3/29/2022, Resident's 2, 11, and 58's low air loss mattresses was noted set in the static mode setting. During an interview with Licensed Vocational Nurse (LVN) 6 on 3/29/2022 at 8:45 AM, LVN 6 stated and confirmed Resident 2's low air loss mattress was set in static mode. LVN 6 stated that it should be in alternating pressure mode and that static mode was to be used when the resident was receiving care. During a concurrent observation LVN 6 changed the setting to alternating pressure mode, as Resident 2 was not currently receiving resident care at the time. 056242 Page 10 of 28 056242 04/01/2022 Westlake Convalescent Hospital 316 S Westlake Avenue Los Angeles, CA 90057

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with Treatment Nurse (TN) 1 on 3/29/2022 at 9 AM, TN 1 stated and confirmed Resident 58's low air loss mattress was set in static mode and that it should be in alternating pressure mode. During a concurrent observation, TN 1 changed the setting to alternating pressure mode, as Resident 58 was not currently receiving resident care at the time. During an interview with LVN 7 on 3/29/2022 at 9:20 AM, LVN 7 stated and confirmed Resident 11's low air loss mattress was set in static mode and that it should be in alternating pressure mode. LVN 7 stated she was unsure why it was currently in static mode and would change to alternating pressure mode, as Resident 11 was not currently receiving resident care at the time. During an interview with the Director of Nursing (DON) on 3/31/2022 at 9:45 AM, the DON stated the low air loss mattress static mode setting was used for when residents were receiving resident care. The low air loss mattress should remain in the alternating pressure mode per the physician's orders, when resident was not receiving care. A review of the facility policy and procedure titled, Mattress, low air loss, undated, indicated the purpose was to reduce the mechanical forces of pressure, shear, friction and moisture, which contribute to skin breakdown and to promote wound healing. A review of the facility policy and procedure titled, Physician Orders, undated, indicated the Physician's Orders were obtained to provide a clear direction in the care of the resident. 056242 Page 11 of 28 056242 04/01/2022 Westlake Convalescent Hospital 316 S Westlake Avenue Los Angeles, CA 90057

F 0688 Level of Harm - Minimal harm or potential for actual harm Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, interview, and record review, the facility failed to provide one of 16 sampled residents (Resident 42) with: Residents Affected - Few -appropriate passive range of motion exercises (PROM, movement of a joint through the range of motion with no effort from resident) and -equipment to prevent further range of motion (ROM, full movement potential of a joint) loss in the left leg. These deficient practices placed Resident 42 at increased risk for the development of contractures (chronic loss of joint motion associated with deformity and joint stiffness), which could lead to increased pain. Cross reference F726 Findings: a. A review of Resident 42's admission Record indicated the facility admitted Resident 42 on 11/15/2021 with diagnoses including chronic respiratory failure (airways carrying air to lungs become narrow and damaged, limiting air movement in the body), dependence on ventilator (machine that mechanically assists with breathing), dependent on renal dialysis (process of filtering blood), dysphagia (difficulty swallowing), encounter for attention to gastrostomy (G-tube, tube placed directly into the stomach for long-term feeding), and seizures (burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness). A review of the Physician's Order, dated 11/16/2021, indicated to provide Resident 42 with RNA for PROM exercises for both arms and legs, every day, seven times per week as tolerated. A review of Resident 42's Joint Mobility Assessment (brief assessment of a resident's range of motion in both arms and both legs), dated 11/16/2021, indicated the ROM in both arms and both legs were within function limits (WFL, sufficient joint movement to functionally complete daily routines). Recommendations included a Restorative Nursing Aide (RNA, nursing aide program that helps residents to maintain their function and joint mobility) program for PROM to maintain Resident 42's ROM. A review of the quarterly Joint Mobility Assessment, dated 2/26/2022, indicated Resident 42 maintained WFL ROM in both arms and both legs. The recommendations included to continue with RNA services for PROM exercises to both arms and both legs. A review of the Minimum Data Set (MDS, a comprehensive assessment used as a care planning tool), dated 2/26/2022, indicated Resident 42 was severely impaired for daily decision making and totally dependent for bed mobility, transfers between surfaces, dressing, eating, personal hygiene, and bathing. The MDS indicated Resident 42 did not have any functional ROM limitations to both arms and both legs. During an interview on 3/30/2022, at 9:25 AM, the Director of Rehabilitation (DOR) stated it was 056242 Page 12 of 28 056242 04/01/2022 Westlake Convalescent Hospital 316 S Westlake Avenue Los Angeles, CA 90057

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few important to provide residents with RNA services to prevent stiffness and contractures. The DOR stated the therapy staff did not train the RNAs when a resident was referred to RNA services. A review of the facility's undated policy titled, Resident Mobility and Range of Motion, indicated residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. During an observation on 3/31/2022, at 8:50 AM, in the resident's room, Restorative Nursing Aide 2 (RNA 2) performed PROM exercises to Resident 42's arms and legs while Resident 42 laid in bed. RNA 2 did not fully straighten and bend the elbows, did not lift either arm overhead at the shoulder joints, did not fully bend both knees, and did not fully bend both hips. During an observation and interview on 3/31/2022, at 9:51 AM, in the resident's room, the DOR performed a PROM assessment to Resident 42's arms and legs while Resident 42 laid in bed. The DOR lifted each of Resident 42's arms at the shoulder joint and bent the elbow to bring Resident 42's hand to the forehead and to the mouth. The DOR also bent each of Resident 42's legs, starting from a completely straightened leg and then bent the knee and hip together toward the torso. The DOR stated Resident 42's arms and legs PROM were WFL. During an interview on 3/31/2022, at 12:43 PM with the Director of Staff Development (DSD) and Director of Nursing (DON), the DON stated the facility did not evaluate the RNAs for the provision of ROM exercises. The DON stated there was no way to ensure the RNAs were providing the appropriate ROM exercises. b. During an observation on 3/30/2022, at 2:12 PM, Resident 42's left ankle was positioned into plantarflexion (bent away from body). During an observation and interview on 3/31/2022, at 8:50 AM, in the resident's room, Restorative Nursing Aide 2 (RNA 2) performed PROM exercises to Resident 42's arms and legs. Resident 42's left ankle continued to be positioned into plantarflexion. RNA 2 attempted to bend the left ankle toward the body but had difficulty. RNA 2 stated, The ankle is a little bit stiff. During an interview on 3/31/2022, at 9:03 AM, RNA 2 stated Resident 42's ankle had been stiff since Resident 42's admission to the facility. During an observation and interview on 3/31/2022, at 9:51 AM, in the resident's room, the DOR performed a PROM assessment to Resident 42's arms and legs while Resident 42 laid in bed. The DOR initially stated Resident 42's PROM in both arms and legs were WFL. During another observation and interview on 3/31/2022, at 9:56 AM, in the resident's room, the DOR further evaluated Resident 42's left ankle. The DOR stated that Resident 42's left ankle was positioned in plantarflexion and was unable to completely bend the ankle to neutral (the ankle's position when standing). The DOR stated Resident 42 had tightness to the back of the left lower leg, which could lead to increased plantarflexion if not positioned appropriately. The DOR stated Resident 42 would benefit from an ankle foot orthosis (AFO, brace applied to the leg to hold the foot and ankle in the correct position) to the left foot to prevent further ankle contracture. The DOR stated the RNA staff did not inform the DOR that Resident 42's ankle had worsened into plantarflexion and it was important for the RNAs to inform the DOR of worsening ROM to provide equipment that could prevent further contractures. 056242 Page 13 of 28 056242 04/01/2022 Westlake Convalescent Hospital 316 S Westlake Avenue Los Angeles, CA 90057

F 0688 A review of the facility's undated policy titled, Restorative Nursing Program, indicated the RNA will report any change in the patient's status to the therapist, DON, Dietitian, etc., in a timely manner. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 056242 Page 14 of 28 056242 04/01/2022 Westlake Convalescent Hospital 316 S Westlake Avenue Los Angeles, CA 90057

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 32's admission Record indicated the facility re-admitted Resident 32 on 4/24/2019 with diagnoses including gastroesophageal reflux disease (digestive disorder that occurs when acidic stomach juices, or food and fluids back up from the stomach into the throat), acute embolism and thrombosis (types of blood vessel blockage) of deep veins in the lower extremity (leg), and dependence on wheelchair. A review of Resident 32's MDS dated [DATE], indicated Resident 32 was moderately impaired for daily decision making and required extensive assistance (resident involved in activity while staff provided weight-bearing support) with two person's physical assistance for transfers between surfaces. The MDS indicated Resident 32 required extensive assistance with one person's physical assistance for bed mobility, dressing, and eating. A review of Resident 32's Fall Risk Assessment, dated 1/20/22, indicated Resident 32 was a high risk for fall. During an observation on 3/31/2022, at 9:06 AM, in the resident's room, Resident 32 was seated in a wheelchair. A transfer sling (fabric placed underneath a person for use with a mechanical lift to safely transfer the person from one surface to another) was positioned between Resident 32's body and the wheelchair. Resident 32 wore a T-shirt and pants with AFOs placed to both feet. Resident 32's legs were resting on a pillow, which was positioned over the wheelchair's leg rest and footplate. Resident 32's AFOs were dangling over the pillow while seated in the chair. During an interview on 3/31/2022, at 9:23 AM, Restorative Nursing Assistant 1 (RNA 1) stated RNA 1 will bring Resident 32 to the activity room. During an observation on 3/31/2022, at 10:11 AM, Certified Nursing Assistant 3 (CNA 3) asked Licensed Vocational Nurse 5 (LVN 5) for assistance with Resident 32 in the activity room. Resident 32 was observed in the activity room. Resident 32's hips slid forward in wheelchair and the torso was positioned toward the bottom of the wheelchair's backrest. CNA 3 and LVN 5 attempted to lift Resident 32 back into the chair using the transfer sling positioned between Resident 32's body and the wheelchair but were unsuccessful. RNA 1, RNA 3, CNA 3, and LVN 5 manually lifted Resident 32 back into the wheelchair. During an interview on 3/31/2022, at 10:19 AM, the Activity Director (AD) stated Resident 32 slid down from the wheelchair while the AD was passing out cakes to the other residents in the activity room. The AD stated there was a pillow underneath Resident 32's feet which stopped Resident 32 from sliding to the ground. During an interview on 3/31/2022, at 10:24 AM, the Director of Rehabilitation (DOR) stated the leg rests and footplates on the wheelchair optimize a person's sitting position, posture, and alignment. The DOR stated residents wearing AFOs while seated in the wheelchair should have both feet on the leg rests and footplates since AFOs could be heavy. The DOR was informed that Resident 32's AFOs were dangling over a pillow placed on top of the wheelchair's leg rest and footplate. The DOR stated there was nothing under Resident 32's AFOs to prevent the resident from slipping out of the chair. A review of the facility's undated policy titled, Transfer of Residents, indicated to utilize 056242 Page 15 of 28 056242 04/01/2022 Westlake Convalescent Hospital 316 S Westlake Avenue Los Angeles, CA 90057

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some postural supports and/or positioning devices per .resident need after transferring residents to the wheelchair. c. During an observation on 3/29/2022, at 9:21 AM, in the resident's room, a 13-inch television was on top of Resident 108's moveable bedside table. The television was unplugged and not bolted down to the bedside table. During an interview on 3/29/2022, at 9:25 AM, Registered Nurse 2 (RN 2) stated the facility used the television with residents confined to the bed for sensory stimulation. RN 2 stated the television was a safety hazard since it could fall off the rolling bedside table. d. During an observation on 3/29/2022, at 12:18 PM, in the resident's room, Resident 56 was lying in bed wearing a nasal cannula (tube placed in nostrils to deliver oxygen), which was connected to an oxygen concentrator (medical device used for delivering oxygen) at bedside. There was no sign in front of Resident 56's room indicating the presence of oxygen. During an interview on 3/29/2022, at 12:18 PM, Licensed Vocational Nurse 1 (LVN 1) confirmed Resident 56 was receiving three liters of oxygen through the nasal cannula. LVN 1 confirmed there was no sign at the doorway to indicate the presence of oxygen in Resident 56's room. LVN 1 stated it was important to post a sign for the residents who smoked to prevent an explosion. A review of the facility's policy titled, Oxygen Administration, revised 10/2010, indicated steps for oxygen administration which included to place an 'Oxygen in Use' sign on the outside of the room entrance door. Based on observation, interview, and record review, the facility failed to ensure the environment remained free of accident hazards for four of 28 sampled residents (Resident 32, 46, 108, and 56) by failing to: -Ensure the wheelchair brakes were locked while assisting Resident 46 with transfers from standing to sitting in the wheelchair. -Prevent Resident 32 from slipping out of the wheelchair while wearing ankle foot orthoses (AFO, brace applied to the leg to hold the foot and ankle in the correct position). -Remove an unsecured television from Resident 108's rolling bedside table. -Post appropriate signage outside Resident 56's doorway to indicate the presence of oxygen in accordance with the facility's policy. These deficient practices had the potential to result in injury to the residents and place the facility at risk for fire hazards. Findings: a. A review of Resident 46's Facesheet (admission record), dated 3/30/2022, indicated Resident 46 was originally admitted to the facility on [DATE] with diagnoses including dependence on wheelchair. A review of Resident 46's Minimum Data Set (MDS - a standardized assessment and care screening 056242 Page 16 of 28 056242 04/01/2022 Westlake Convalescent Hospital 316 S Westlake Avenue Los Angeles, CA 90057

F 0689 Level of Harm - Minimal harm or potential for actual harm tool), dated 2/26/2022, indicated Resident 46 required limited assistance or was totally dependent on staff for activities of daily living (ADL - surface transfer, bed mobility, locomotion on and off the unit, dressing, eating, toilet use, personal hygiene, bathing). The MDS indicated Resident 46 used a wheelchair and Resident 46's balance during transitions was not steady, only able to stabilize with staff assistance for surface-to-surface transfer. Residents Affected - Some A review of Resident 46's Fall Risk Assessment, dated 2/23/2022, indicated Resident 46 had balance problems while standing and walking, and required the use of assistive devices, such as a wheelchair. The fall risk assessment indicated Resident 46 was a high risk for falls with a risk assessment score of 14. A score of 10 or higher indicated a high fall risk. A review of Resident 46's Care Plan, dated 2/23/2022, indicated Resident 46 was at risk for falls as manifested by poor safety awareness. The care plan further indicated interventions include to assist Resident 46 with all transfers or ambulation and out of bed as tolerated. During an observation on 3/29/2022, at 10 AM, CNA 1 was observed assisting Resident 46 with hand hygiene in Resident 46's bathroom. After assisting Resident 46, CNA 1 was observed transferring Resident 46 to their wheelchair. Resident 46's wheelchair was observed with unlocked wheels. As Resident 46 was placed on the wheelchair by CNA 1, Resident 46's wheelchair moved back a couple of inches. During an interview with CNA 1 on 3/29/2022, at 10:08 AM, CNA 1 stated she did not lock the wheels on the wheelchair prior to transferring Resident 46 from standing to sitting on the wheelchair. CNA 1 stated the wheelchair should have been locked when placing Resident 46 onto the wheelchair. CNA 1 further stated the reason the wheelchair should be locked prior to transfer onto the wheelchair was to protect the resident from falls and injury. During an interview with the Infection Preventionist (IP) on 3/31/2022, at 9 AM, the IP stated wheelchairs should be locked prior to transfer from standing to sitting. The IP further stated the reason wheelchairs should be locked prior to transferring from standing to sitting was for resident safety and so the wheelchair would not move while transferring the resident. During an interview with the Director of Nursing (DON) on 3/31/2022, at 9:12 AM, the DON stated wheelchairs should be locked before and after transfers. The DON further stated wheelchairs should be locked for safety and to prevent resident falls from occurring. During an interview with Licensed Vocational Nurse (LVN) 1 on 3/31/2022, at 9:16 AM, LVN 1 stated wheelchairs should be locked prior to transferring a resident to the wheelchair. LVN 1 further stated wheelchairs should be locked to prevent the wheelchair from rolling, prevent accidents, and prevent falls from occurring with residents. A review of the facility's policy and procedure (P&P) titled, Transfer of Residents, undated, indicated residents must be lifted or transferred according to the determined procedure and members of the nursing staff were trained to use good body mechanics, knowing the proper procedures and properly operating assistive devices. The P&P further indicated if using a wheelchair, make sure the footrests were not in the way and the wheels were locked. 056242 Page 17 of 28 056242 04/01/2022 Westlake Convalescent Hospital 316 S Westlake Avenue Los Angeles, CA 90057

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on observation, interview, and record review, the facility failed to ensure six of six Restorative Nursing Aides (RNA, nursing aide program that helps residents to maintain their function and joint mobility) demonstrated competency for the provision of range of motion (ROM, full movement potential of a joint) exercises. One of six RNAs did not provide adequate passive range of motion (PROM, movement of a joint through the range of motion with no effort from resident) exercises to one of 16 sampled residents (Resident 42). This deficient practice had the potential for 47 residents with physician's orders for RNA services to receive ROM exercises to experience a decline in ROM, which increased the likelihood of developing contractures (chronic loss of joint motion associated with deformity and joint stiffness). Cross reference F688 Findings: A review of Resident 42's admission Record indicated the facility admitted Resident 42 on 11/15/2021 with diagnoses including chronic respiratory failure (airways carrying air to lungs become narrow and damaged, limiting air movement in the body), dependence on ventilator (machine that mechanically assists with breathing), dependent on renal dialysis (process of filtering blood), dysphagia (difficulty swallowing), encounter for attention to gastrostomy (G-tube, tube placed directly into the stomach for long-term feeding), and seizures (burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness). A review of Resident 42's Minimum Data Set (MDS, a comprehensive assessment used as a care planning tool), dated 2/26/2022, indicated Resident 42 did not have any functional ROM limitations in both arms and both legs. A review of Resident 42's Joint Mobility Assessment (brief assessment of a resident's range of motion in both arms and both legs), dated 11/16/2021, indicated the ROM in both arms and legs were within function limits (WFL, sufficient joint movement to functionally complete daily routines). Recommendations included an RNA program for PROM to maintain Resident 42's ROM. A review of the quarterly Joint Mobility Assessment, dated 2/26/2022, indicated Resident 42 maintained WFL ROM in both arms and both legs. Recommendations included to continue with RNA services for PROM exercises to both arms and both legs. A review of Resident 42's Physician's Order, dated 11/16/2021, indicated RNA for PROM exercise for both arms and legs, every day, seven times per week as tolerated. A review of Resident 42's care plan, initiated on 11/16/2021, indicated the resident was at risk for decline in ROM and the development of contractures. The care plan interventions included to provide RNA services for PROM exercises to both arms and legs, every day, seven times per week as tolerated. During an interview on 3/30/2022, at 9:25 AM, the Director of Rehabilitation (DOR) stated it was 056242 Page 18 of 28 056242 04/01/2022 Westlake Convalescent Hospital 316 S Westlake Avenue Los Angeles, CA 90057

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some important to provide residents with RNA services to prevent stiffness and contractures. The DOR stated that the therapy staff did not train the RNAs when a resident was referred to RNA services. During an observation on 3/31/2022, at 8:50 AM, in the resident's room, Restorative Nursing Aide 2 (RNA 2) performed PROM exercises to Resident 42's arms and legs while Resident 42 laid in bed. RNA 2 did not fully straighten and bend the elbows, did not lift either arm overhead at the shoulder joints, did not fully bend both knees, and did not fully bend both hips. During an observation and interview on 3/31/2022, at 9:51 AM, in the resident's room, the DOR performed a PROM assessment to Resident 42's arms and legs while Resident 42 laid in bed. The DOR lifted each of Resident 42's arms at the shoulder joint and bent the elbow to bring Resident 42's hand to the forehead and to the mouth. The DOR also bent each of Resident 42's legs, starting from a completely straightened leg and then bent the knee and hip together toward the head. The DOR stated Resident 42's arms and legs PROM were WFL. During an interview on 3/31/2022, at 12:43 PM, the Director of Staff Development (DSD) and Director of Nursing (DON) stated RNA services were important to ensure residents did not experience a decline in ROM, prevent contractures, and maintain mobility. The DON stated qualifications for an RNA included experience as a Certified Nursing Assistant and an RNA training certification. The DSD stated there were six (6) RNAs on staff. RNA 2's personnel file, was provided which included an RNA training certification from 11/2002 (20 years ago). The DON stated there was no documentation in the RNA employee files, including RNA 2, that they received any recent training in the provision of RNA services, including ROM exercises. The DON stated the facility did not have a specific competency skills evaluation for the RNA staff. The DON stated there was no way to ensure the RNAs were providing the appropriate services since the facility did not evaluate each RNA's skills for the provision of RNA services and the therapy staff did not train the RNAs when a resident was referred to RNA services. During a follow-up interview on 4/1/2022, at 11:03 AM, the DON stated it was important for RNAs to provide a correct return demonstration of their skills to ensure the RNAs were providing the exercises and services according to the physician's orders. A review of the facility's undated policy titled, Restorative Nursing Program, indicated Restorative Nurse's Aides (RNA) will be responsible for administering the restorative program on a daily basis and will assure that each patient is treated according to the therapist guidelines. 056242 Page 19 of 28 056242 04/01/2022 Westlake Convalescent Hospital 316 S Westlake Avenue Los Angeles, CA 90057

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 unopened insulin (a medication used to control high blood sugar) was stored in the refrigerator per the manufacturer's requirements for one of three inspected medication carts (Sub-Acute Medication Cart 3) affecting Resident 57. -Remove expired insulin from one of three inspected medication carts (Sub-Acute Medication Cart 4) affecting Resident 18. These deficient practices increased the risk that Residents 18 and Resident 57 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization or death. Findings: During an observation on [DATE] at 2:11 PM of the Sub-Acute Medication Cart 3, with the Licensed Vocational Nurse (LVN 5), 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: -One unopened insulin lispro pen (a type of insulin) for Resident 57 was found stored at room temperature. During a concurrent interview, LVN 5 stated the unopened insulin lispro for Resident 57 should be stored in the refrigerator because it was unopened. LVN 5 stated, Once opened, this insulin is only good for 28 days. LVN 5 stated that if insulin was unopened and not stored in the refrigerator, there was a risk that it may be kept longer than the 28 days allowed by the manufacturer. LVN 5 stated administering insulin that was stored at room temperature longer than allowed by the manufacturer could result in it being ineffective to control blood sugar and could result in medical complication to the resident. A review of the manufacturer's product labeling indicated, unopened insulin lispro pens should be stored in the refrigerator. During an observation on [DATE] at 2:17 PM of Sub-Acute Medication Cart 4 with the LVN 4, 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: -One opened insulin lispro pen for Resident 18 was found labeled with an open date on [DATE]. During a concurrent interview, LVN 4 stated Resident 18's insulin was good for 28 days once opened. LVN 4 stated, This insulin pen is expired since it has been opened since [DATE] and giving expired insulin to the resident could result in the medication being ineffective. LVN 4 stated that if 056242 Page 20 of 28 056242 04/01/2022 Westlake Convalescent Hospital 316 S Westlake Avenue Los Angeles, CA 90057

F 0761 Level of Harm - Minimal harm or potential for actual harm insulin in ineffective, the resident could develop complications from diabetes (a medical condition characterized by impaired blood sugar control.) A review of the manufacturer's product labeling indicated, insulin lispro pens should used or discarded within 28 days of opening. Residents Affected - Few A review of the facility's undated policy titled, Storage of Medications, indicated the facility shall not use discontinued, outdated, or deteriorated drugs. All such drugs shall be returned to the dispensing pharmacy or destroyed. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station. 056242 Page 21 of 28 056242 04/01/2022 Westlake Convalescent Hospital 316 S Westlake Avenue Los Angeles, CA 90057

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based observation, interview, and record review, the facility failed to provide an appropriate meal for one of 28 sampled residents (Resident 32). Resident 32 consistently coughed during three meal observations which was not reported to nursing. This deficient practice placed Resident 32 at increased risk for aspiration. Cross reference F676 Findings: A review of Resident 32's admission Record indicated the facility re-admitted Resident 32 on 4/24/2019 with diagnoses including dysphagia (difficulty swallowing) gastroesophageal reflux disease (digestive disorder that occurs when acidic stomach juices, or food and fluids back up from the stomach into the throat), acute embolism and thrombosis (types of blood vessel blockage) of deep veins in the lower extremity (leg) and dependence on wheelchair. A review of Resident 32's Physician's Order, dated 4/24/2019, indicated to provide a regular, mechanical soft (texture modified for people with chewing or swallowing difficulties) fortified diet (diet enhanced to increase caloric intake), with hot chocolate at breakfast and lunch. A review of Resident 32's care plan for weight loss, initiated on 3/14/2020, indicated to monitor for signs or symptoms of choking or aspiration (when food or liquid goes into your airway) and report to the physician. A review of the Minimum Data Set (MDS, a comprehensive assessment used as a care planning tool), dated 1/30/2022, indicated Resident 32 was moderately impaired for daily decision making (unable to make decisions). The MDS also indicated Resident 32 required extensive assistance with one person's physical assistance for bed mobility, dressing, and eating. During an observation on 3/29/2022, at 12:33 PM, in the resident's room, Resident 32 laid in bed with the head-of-bed (HOB) fully elevated. Certified Nursing Assistant 3 (CNA 3) sat in a chair on the right side of the bed while feeding Resident 32. Resident 32 mumbled and coughed while chewing the meal. Resident 32 drank chocolate milk from a straw and immediately coughed loudly multiple times. During a concurrent interview, CNA 3 stated Resident 32 coughed loudly, all the time during meals. During an observation on 3/30/2022, at 12:27 PM, in the resident's room, Resident 32 was sleeping flat on his back in bed. CNA 3 fully elevated the HOB for lunch. Resident 32 coughed as CNA 3 elevated the HOB. CNA 3 sat in a chair on the right side of the bed to feed Resident 32 and the resident ate steamed vegetables and potatoes but began to cough loudly. Resident 32 forcefully coughed up steamed vegetables onto a towel placed on the chest. CNA 3 continued to feed Resident 32 steamed vegetables, potatoes, and ice cream. CNA 3 then offered warm milk at the end of the meal which caused Resident 32 to cough immediately. During a telephone interview on 3/31/2022, at 12:03 PM, the Speech Therapist (SLP 1, professional trained in the prevention, assessment, and treatment of speech, language, communicative, and swallowing disorders) stated coughing while eating was a sign and symptom of aspiration. SLP 1 stated SLP 1 would need to perform an assessment to determine the appropriate diet for a resident who coughed 056242 Page 22 of 28 056242 04/01/2022 Westlake Convalescent Hospital 316 S Westlake Avenue Los Angeles, CA 90057

F 0805 consistently during meals. SLP 1 denied receiving any consultations to assess any resident at the facility. Level of Harm - Minimal harm or potential for actual harm During an observation on 3/31/2022, at 12:14 PM, in the resident's room, Resident 32 was sleeping flat on his back when CNA 3 fully elevated the HOB for lunch. Resident 32 began coughing while CNA 3 elevated the HOB, continued to cough when the HOB was fully elevated, but finally cleared the throat prior to eating. CNA 3 sat in a chair to feed Resident 32. Residents Affected - Few During an observation on 3/31/2022, at 12:24 PM, with the Director of Nursing (DON) in the resident's room, CNA 3 fed Resident 32 chocolate milk, causing the resident to cough immediately. During a concurrent interview, the DON stated coughing while eating or drinking could indicate problems with swallowing. The DON stated Resident 32's coughing during meals was not reported to nursing, who could have contacted the physician for a Speech Therapy evaluation. The DON stated it was important to report to nursing any resident coughing consistently while eating as the resident could be choking or could develop aspiration pneumonia (occurs when food, saliva, liquids, or vomit is breathed into the lungs or airways leading to the lungs, instead of being swallowed into the stomach). A review of the Speech Therapy SLP Evaluation and Plan of Treatment, dated 3/31/2022, indicated Resident 32 had moderate swallowing abilities due to difficulties maintaining lip closure and chewing. SLP 1 recommended treatment three times per week for four weeks to improve Resident 32's ability to eat. A review of the facility's undated policy titled, Dysphagia (difficulty swallowing) - Clinical Protocol, indicated staff will identify individuals who have difficulty swallowing or chewing food. Any staff member observing an incident or situation will document details of the circumstances or have a nurse observe and document those details. The policy further indicated if dysphagia was suspected, an appropriately trained practitioner, nurse, or speech therapist will perform a screening clinical evaluation of swallowing. 056242 Page 23 of 28 056242 04/01/2022 Westlake Convalescent Hospital 316 S Westlake Avenue Los Angeles, CA 90057

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 store food under sanitary conditions and maintain the kitchen in a sanitary manner as evidenced by: Residents Affected - Some -Food products stored past labeled use by dates. -Unlabeled plastic bag with hot dogs in kitchen freezer. -Kitchen floor with dirty particles, dust, and white substance. These deficient practices caused an increased risk to cross-contaminate food with pathogens (germs) that could expose residents receiving food from the kitchen; and place them at risk for developing food borne illness (food poisoning) leading to symptoms including an upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever which can lead to hospitalization and/or death. Findings: During an observation of the kitchen's walk-in refrigerator, on 3/29/2022 at 8:53 a.m., during the initial tour of the kitchen, a plastic jar of 1/8 Crinkle-Cut thin dill chips was labeled with an open date of 5/3/2021. The use by date indicated 10/29/2021 was observed. During a concurrent interview, the Dietary Supervisor (DS) confirmed the use by date was 10/29/2021, and stated, I'll throw that away. During an observation of the kitchen's walk-in freezer, on 3/29/2022 at 9:02 a.m., during the initial tour of the kitchen, an open plastic bag with hotdogs was observed unlabeled. During a concurrent interview the DS confirmed the plastic bag with hotdogs was unlabeled and stated he did not know when the hotdogs were opened. The DS stated, I don't know why those are there, I'll throw them away. During a observation of the kitchen shelf, on 3/29/2022 at 9:05 a.m., during the initial tour of the kitchen, an open container of spice curry powder had an open date of 7/17/2021 and a use by date of 8/17/2021. There was a plastic container of low sodium beef flavored soup base observed with an open date of 10/3/2021 and a use by date of 3/3/2022. During a concurrent interview, the DS stated both items should be disposed of, We'll get rid of it. During an interview on 3/29/2022 at 3:42 p.m., the DS stated unlabeled food and food past its use by date and expiration date should be discarded. The DS stated the proper practice would be to label all food items with the date it was opened and their use by date. The DS stated the proper practice would be to discard of the food once it was past its use by date, and properly label the food to prevent residents from becoming sick with food borne illness. During an observation on 3/30/2022 at 9:08 a.m., during a follow up visit to the kitchen, the floor and walls underneath the sink area used for the washing of vegetables were observed dirty. The floor was observed with a dry white substance, the wall was observed with dirt particles, and the top of the pest control contraption placed underneath the sink was observed dusty. During a concurrent interview, the DC stated the floor and area look dirty, covered with white substance. The DC stated, It looks dirty and dusty, and should be cleaned. The DC stated it was important to keep the kitchen area clean and sanitized to prevent infection and illness of the residents and staff. 056242 Page 24 of 28 056242 04/01/2022 Westlake Convalescent Hospital 316 S Westlake Avenue Los Angeles, CA 90057

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 3/30/2022 at 9:55 a.m. regarding the area underneath the kitchen sink used for the washing of vegetables, the DS stated, Yes, the area looks dirty, it looks white probably because of the hard water, we will try to clean it. The DS stated all areas of the kitchen should be kept clean to prevent illness of the residents and staff. A review of the facility's undated policy and procedure titled, Refrigerators and Freezers, indicated all food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of service) will be marked on cases and on individual items removed from cases for storage. Use by dates will be completed with the expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by date indicated once food was opened. A review of the facility's undated policy and procedure titled, Sanitation, indicated all kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies, and other insects. Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. A review of the Food and Drug Administration Food Code, dated 2017, indicated, foodborne illness in the United States is a major cause of personal distress, preventable illness and death, and avoidable economic burden . foodborne diseases cause approximately 48 million illnesses, 128,000 hospitalizations, and 3,000 deaths in the United States each year . For some, especially preschool age children, older adults in health care facilities, and those with impaired immune systems, foodborne illness is more serious and may be life threatening. 056242 Page 25 of 28 056242 04/01/2022 Westlake Convalescent Hospital 316 S Westlake Avenue Los Angeles, CA 90057

F 0880 Provide and implement an infection prevention and control program. 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 did not implement appropriate infection control practices to prevent the transmission of communicable diseases by failing to: Residents Affected - Some a. Ensure staff had access to a handwashing station in Resident 58 room, who was currently under transmission-based precautions (the second tier of basic infection control and are to be used in addition to Standard Precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission). b. Properly disinfect a cloth gait belt (assistive device placed around a person's waist to assist with safe transferring between surfaces or while walking) and front wheeled walker (FWW, an assistive device with two front wheels used for stability when walking) between residents' use for Resident 53, 26, and 46. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for residents and staff. Findings: a. A review of the face-sheet indicated Resident 58 was admitted to the facility on [DATE] with a readmission to the facility on 3/22/2022 with diagnoses including Chronic Respiratory Failure (condition that results in the inability to effectively exchange carbon dioxide and oxygen, and induces chronically low oxygen levels or chronically high carbon dioxide levels), tracheostomy (opening surgically created through the neck into the trachea (windpipe) to allow direct access to the breathing tube), and pressure ulcers (localized damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of usually long-term pressure, or pressure in combination with shear or friction). A review of the Medication admission Record, dated March 2022, indicated Resident 58 to remain in contact isolation for Clostridioides difficile (germ (bacterium) that causes severe diarrhea and colitis), from 3/23/2022 until 4/5/2022. During an observation of the facility on 4/1/2022 at 8 AM Resident 58's restroom door locked. There was no other sink located within this room to complete hand washing. Resident 58 was currently in this room alone, for contact isolation precautions. During an observation and concurrent interview with the Director of Nursing (DON) of Resident 58's room on 4/1/2022 at 8:05 AM, it was confirmed the restroom door was locked from inside the room with no one inside the restroom. The DON showed the surveyor that the restroom had two entrances, one being from the hallway of the facility, located outside of the resident's room and one from inside the resident's room. The DON showed surveyor the restroom door was locked from the inside of Resident 58's room and that the hallway entrance was open. The DON stated that Resident 58's room entrance should not be locked, and staff needs to have access to the restroom to complete handwashing before and after providing resident care. The DON stated that a padlock would be placed on the hallway entrance to the restroom, providing a single access to the restroom from Resident 58's room. During an interview, on 4/1/2022 at 8:15 AM. the Infection Control Preventionist (IP) stated 056242 Page 26 of 28 056242 04/01/2022 Westlake Convalescent Hospital 316 S Westlake Avenue Los Angeles, CA 90057

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 58 was on transmission-based precautions for Clostridioides difficile following admission to the hospital and that the staff needed to wash their hands prior to and after providing care to the resident. A review of the facility policy and procedure titled, Infection Prevention and Control, undated, indicated this facility's infection and prevention and control policies and practices were intended to facilities maintaining a safe, sanitary and comfortable environment and help to prevent and manage transmission of communicable diseases and infections. A review of the facility policy and procedure titled, Handwashing/Hand Hygiene, undated, indicated this facility considers hand hygiene the primary means to prevent the spread of infections. Employees must perform hand hygiene with either hand washing or using alcohol based hand rubs, unless otherwise specified, under the following conditions. After contact with a resident with diarrhea, infectious or not, including but not limited to infections caused by norovirus (very contagious virus that causes vomiting and diarrhea), Salmonella (type of bacteria that's the most frequently reported cause of food-related illness in the United States), Shigella (bacterium that causes a diarrheal illness) and Clostridioides difficile .The following equipment and supplies will be necessary when performing this procedure (handwashing), Running water, Soap (liquid or bar; anti-microbial or non-antimicrobial), Paper towels, and Trash Can. b. During an observation on 3/29/2022, at 9:56 AM, Resident 26 walked in the hallway with Restorative Nursing Assistant 1 (RNA 1), who held onto a white cloth gait belt that was fastened around Resident 26's waist. Resident 26 sat in a wheelchair after walking. RNA 1 removed the cloth gait belt from around Resident 26's waist and rolled it up without cleaning it. During an observation on 3/30/2022, at 8:51 AM, Resident 53 sat in a wheelchair while RNA 1 fastened a white cloth gait belt around Resident 53's waist. Resident 53 stood up from the wheelchair and held onto a FWW to walk down the hallway. RNA 1 was immediately next to Resident 53 holding onto the cloth gait belt as Resident 53 walked with the FWW. Resident 53 walked approximately 150 feet and sat down in the wheelchair. RNA 1 removed the cloth gait belt from around Resident 53's waist and rolled it up. The cloth gait belt and FWW were not disinfected after Resident 53's use. During an observation on 3/30/2022, at 9:11 AM, Resident 26 was seated in a wheelchair when RNA 1 fastened the white cloth gait belt around Resident 26's waist. Resident 26 stood from the wheelchair and held onto the FWW to walk down the hallway. RNA 1 was immediately next to Resident 26 holding onto the cloth gait belt as Resident 26 walked with the FWW. Resident 26 walked approximately 50 feet and sat down in the wheelchair. RNA 1 removed the cloth gait belt from around Resident 26's waist and rolled it up. The cloth gait belt and FWW were not disinfected after Resident 26's use. RNA 1 stored the FWW in a space between the wall and the refrigerator in a storage room. During an observation on 3/30/2022, at 1:02 PM, Resident 46 sat in a wheelchair while RNA 1 fastened a [NAME] rainbow-colored cloth gait belt around Resident 46's waist. RNA 1 placed the FWW, which was the same FWW used with Resident 53 and Resident 26, in front of Resident 46. Resident 46 stood from the wheelchair and held onto the FWW to walk down the hallway. RNA 1 was immediately next to Resident 46 and held onto the cloth gait belt as Resident 46 walked using the FWW. Resident 46 walked the hallways of the entire facility and then sat down in the wheelchair. RNA 1 removed the cloth gait belt from around Resident 46's waist and rolled it up. RNA 1 placed the FWW in the same space between the wall and the refrigerator in a storage room. The cloth gait belt and FWW were not disinfected after Resident 46's use. 056242 Page 27 of 28 056242 04/01/2022 Westlake Convalescent Hospital 316 S Westlake Avenue Los Angeles, CA 90057

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 3/30/2022, at 1:12 PM, RNA 1 stated that the cloth gait belts were placed in the laundry for cleaning once per week. During an interview and a review of manufacturer's instructions, on 3/30/2022, at 2:18 PM, the IP stated the FWW shared between residents should be cleaned after every use and that cloth gait belts were made of porous material and should be disinfected after every use with disinfectant wipes. The IP reviewed the manufacturer's instructions located on the disinfectant wipes, then stated the instructions indicated the disinfectant wipes should be used with hard, non-porous surfaces. The IP stated that the facility should use another type of gait belt that can be easily cleaned between residents and that it was important to sanitize equipment between residents to prevent the spread of infection. A review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated July 2014, indicated durable medical equipment, like the FWW must be cleaned and disinfected before reuse by another resident. The policy indicated reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturer's instructions. 056242 Page 28 of 28