Health inspection·July 18, 2025

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 10) had a follow up on coordinating a Preadmission Screening and Resident Review Level II (PASRR IIthis evaluation determines the individuals specific needs and whether specialized services are required, ensuring the least restrictive setting for their care).This failure had the potential for Resident 10 to have a lack of necessary mental health services.Findings:During a review of Resident 10's admission Record, the admission Record indicated the facility admitted Resident 10 on 4/28/2023 with diagnosis of schizophrenia (a mental illness that can affect thoughts, mood, and behavior), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs).During a review of Resident 10's Minimum Data Set (MDS - a resident assessment tool) dated 5/10/2025, the MDS indicated the resident was alert and oriented to person but not time with good recall. The MDS indicated Resident 10 did not feel down, depressed, hopeless, or with no little interest in doing things. The MDS indicated the resident had hallucinations (sensory experiences that seem real but are not, involving things like seeing, hearing, or feeling things that aren't actually present).During an observation on 7/15/2025 at 11:47 AM in the activities room, Resident 10 was sitting in her wheelchair eating and participating in activities. Resident 10 stated she liked the care she received at the facility.During a concurrent interview and record review on 7/16/2025 at 11:00 AM with Register Nurse Supervisor 2 (RN 2), the PASRR Level I dated 4/28/2023 and Level II dated 5/12/2023 were reviewed. The PASRR Level I indicated a Level II mental Health Evaluation was required. The PASRR Level II indicated unable to complete Level II Evaluation due to the individual was isolated as a health or safety precaution and the case would be now closed, and to reopen please submit a new Level I screening. RN 2 stated a PASRR representative would call and interview the resident, and in the interview would determine if a representative would need to come out and perform an assessment. RN 2 reviewed the PASRR website and stated that there was no Level I or II PASRR submitted as indicated. RN 2 stated the licensed nurse (unidentified) who received the initial phone call would resubmit for another Level I PASRR. RN 2 stated Resident 10 would be at risk of not receiving the proper mental health assistance without a resubmission of a PASRR Level I or II.During a concurrent interview and record review on 7/16/2025 at 2:15 PM with RN 2, the Notice of PASRR Level I Screening Results dated 7/16/2025 were reviewed. RN 2 stated she (RN 2) submitted a new one on 7/16/2025.During an interview on 7/15/25 at 11:30 AM with the Director of Nursing (DON), the DON stated the registered nurse (unidentified) who took the call should have resubmitted a new Level I PASRR. The DON stated every Registered Nurse (in general) was aware how to resubmit for another PASRR I. The DON stated per the policy within 24 hours the resubmission should occur. The DON stated Resident 10 would be at risk of a lack of mental health services.During a review of the facility's policy and procedure titled, Preadmission Screening & Resident Review (PASRR) dated 1/10/2025, indicated, facility will participate in the Initial Page 1 of 14 056242 056242 07/18/2025 Westlake Convalescent Hospital 316 S Westlake Avenue Los Angeles, CA 90057

F 0644 Level of Harm - Minimal harm or potential for actual harm Assessment process within 24 hours of submitting the completed Level I Screening or upon request of the Level II Contractor and coordinate with the Level II Contractor to ensure the PASRR process is completed before admitting the individual to the facility. Facility will be required to restart the PASRR case closed by the Level II Contractor as an Attempt or Unavailable due to facility not providing required documentation to the Level II Contractor. Residents Affected - Few 056242 Page 2 of 14 056242 07/18/2025 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** Based on observation, interview, and record review, the facility failed to maintain safe resident smoking practices by failing to ensure one of one sampled resident (Resident 17) did not have a lighter in her possession. This deficient practice had the potential to cause injury to Resident 17.Findings:During a review of Resident 17's admission Record, the admission Record indicated the facility admitted Resident 17 on 3/21/2025 with diagnoses that included acute respiratory failure with hypoxia (a serious condition that happens when your lungs cannot get enough oxygen into your blood), morbid obesity (more than 80 to 100 pounds above their ideal body weight), ataxic gait (a walking pattern that's unsteady and clumsy, like someone who's drunk), cardiomyopathy (a disease that affects the heart muscle, making it difficult for the heart to pump blood effectively), acute on chronic congestive heart failure ((CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), chronic kidney disease (your kidneys are damaged and can't filter blood properly, leading to a buildup of waste and other problems), anemia (a condition where your blood doesn't have enough red blood cells or hemoglobin, which are needed to carry oxygen throughout your body), a history of transient ischemic attack (a temporary disruption of blood flow to the brain that causes stroke-like symptoms), and cerebral infarction (a stroke that occurs when blood flow to a part of the brain is blocked, causing brain tissue to die due to lack of oxygen and nutrients) without residual deficits (the lasting impairments or problems that remain after an illness, injury, or medical treatment has run its course). During a review of Resident 17's History and Physical (H&P - a comprehensive document that records a patient's medical history and a detailed physical examination performed by a healthcare provider) dated 3/21/2025, the H&P indicated Resident 17 had the capacity (ability) to understand and make decisions. The H&P indicated Resident 17 had COPD (chronic obstructive pulmonary disease -a chronic lung disease causing difficulty in breathing). During a review of Resident 17's care plan titled non-compliant (not following the rules, directions, or requirements that are set by someone or something, like a law, a contract, or a doctor's instructions) with smoking policy - refuse to leave lighter with staff and not does follow smoking time, dated 3/22/2025, indicated interventions for Resident 17's cigarettes and lighter should be kept at the nurses station at all times.During a review of Resident 17's Interdisciplinary Team (IDT - a group of experts with different specialties who work together to solve a problem or help someone) Notes dated 6/8/2025 indicated Resident 17 was non-compliant with smoking schedule and policy; refuses to wear smoking apron and refuses to follow smoking schedule and storage of cigarette and lighter. The IDT note indicated MD (medical doctor) and resident were made aware of risks and possible negative outcomes of resident's behaviors.During a review of Resident 17's Minimum Data Set (MDS - a resident assessment tool) dated 6/19/2025, the MDS indicated Resident 17 had the ability to make herself understood and could underhand others. The MDS indicated Resident 17 used a wheelchair.During a review of Resident 17's Smoking Risk Managment assessment dated [DATE], the Smoking Risk Managment assessment indicated Resident 17 was a high-risk smoker. The Smoking Risk Managment indicated Resident 17 was impulsive- poor safety, requires supervision in regard to safety judgement. The smoking assessment indicated Resident had issues with balance while standing and walking, was jerking or unstable when making turns, had decreased muscular coordination, and required the use of an assistive device (cane, walker, or wheelchair). During a review of Resident 17's physician orders dated 7/18/2025, the physician orders indicated Resident 17 had an order for oxygen at 2 liters per minute (a unit that expresses a rate of flow) for respiratory (breathing) discomfort. During a review of Resident 17's Health Status Note 056242 Page 3 of 14 056242 07/18/2025 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 dated 7/14/2024 at 7:07 AM, the Health Status Note indicated Resident 17 used oxygen inhalation (breathing in) via nasal cannula (a simple, flexible tube with two small prongs that fit into your nose for oxygen) at 2 liters per minute. During a review of Resident 17's Health Status Note dated 7/14/2024 at 2:04 PM, the Health Status Note indicated Resident 17 was aware of the smoking schedule and policy. The Health Status Note indicated Resident 17 was offered a smoking apron (a fire-resistant apron designed to protect people, particularly those in wheelchairs or with limited mobility, from accidental burns while smoking) every time she smokes but she refused, risk and possible negative outcomes explained but resident (Resident 17) continue not to follow facility smoking protocols (a set of rules or procedures that govern how something is done). During an interview with the Director of Nursing (DON) on 7/15/2025 at 1:25 PM. The DON stated she was aware Resident 17 was in possession of cigarette lighters. The DON stated Resident 17 ordered cigarette lighters from Amazon and Resident 17 was not compliant with the facility's care plan or smoking policy. The DON stated the facility could be at risk for fire if Resident 17 had a cigarette lighter in her possession, especially if she was using oxygen. The DON removed the lighters from Resident 17.During a concurrent observation and interview on 7/17/2025 at 1:03 PM with Resident 17 in the smoking patio, Resident 17 was observed seated in her wheelchair. Resident 17 stated she kept her lighters on her person and was observed storing one fluorescent green cigarette lighter and one fluorescent yellow cigarette lighter in a black bag in Resident 17's possession. Resident 17 stated she kept both cigarette lighters (green and yellow, fluorescent lighters) in empty cigarette boxes and stored them in her bag that she kept in her possession. Resident 17 stated she did not use the smoking apron provided by the facility. During a review of the facility's policy and procedure (P&P) titled, Smoking Policy - Residents, dated 1/10/2025, the P&P indicated only facility-approved ashtrays and other smoking equipment/paraphernalia shall be used in resident living or sleeping areas. The P&P indicated the facility may impose smoking restrictions on residents at any time if it isdetermined that the resident cannot smoke safely with the available levels of support and supervision. The P&P indicated any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. The P&P indicated residents without independent smoking privileges may not have or keep any types of smoking articles, including cigarettes, tobacco, etc., except when they are under direct supervision. The P&P indicated this facility may check periodically to determine if residents have any smokingarticles in violation of our smoking policies. Staff shall confiscate any such articles (items) and shall notify the Charge Nurse/Unit Manager that they have done so. 056242 Page 4 of 14 056242 07/18/2025 Westlake Convalescent Hospital 316 S Westlake Avenue Los Angeles, CA 90057

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 ensure to label the nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) oxygen tubing for two of two sampled residents (Resident 84 and Resident 24).This failure had the potential for Resident 84 and Resident 24 to be at risk for infection.Findings:a. During a review of Resident 24's admission Record, the admission Record indicated the facility admitted the resident on 09/03/2015 with diagnoses including chronic congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and adult failure to thrive (insufficient weight gain).During a review of Resident 24's Minimum Data Set (MDS - a resident assessment tool) dated 6/4/2025, the MDS indicated the resident was oriented to place and person and had good recall. The MDS indicated Resident 24 had interest in doing things, and did not feel down, depressed (sad), or hopeless. During a concurrent observation and interview on 7/16/2025 at 11:17 AM in Resident 24's room, with Licensed Vocational Nurse 10 (LVN 10). Resident 24 was lying in bed with padded siderails (adjustable metal or rigid plastic bars that attach to the bed) up, the call light (a device used by a patient to signal his or her need for assistance) was within reach. Resident 24's humidifier (device that puts moisture into the air) was labeled with a date of 7/14/2025. LVN 10 stated Resident 24 was on oxygen as needed and that the nasal cannula tubing was not labeled. LVN 10 stated Resident 24 would be at risk of infection if the nasal cannula tubing was not labeled with a date. During a review of Resident 24's Order Summary Report dated 1/23/2025 indicated to change the oxygen tubing every Sunday and Wednesday.b. During a review of Resident 84's admission Record, the admission Record indicated the facility admitted the resident on 1/25/2024 with diagnoses of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), CHF, and acute respiratory failure with hypoxia (a critical condition where the lungs can't adequately oxygenate the blood, leading to dangerously low oxygen levels (hypoxia) in the body).During a review of Resident 84's MDS dated [DATE], the MDS indicated Resident 84 was oriented and had good recall. The MDS indicated the resident did not feel down, depressed or hopeless and did not have little interest in doing things. The MDS indicated Resident was on continuous high concentration oxygen therapy.During a review of Resident 84's Physician Order dated 7/12/2025, the Physician Order indicated for Resident 84 to receive oxygen at 2 liters per minute (LPM -this is a unit of measurement for flow rate, often used in medical settings (oxygen flow) via nasal cannula for respiratory comfort).During a concurrent observation and interview on 7/16/2025 at 11:10 AM in Resident 84's room with LVN 10, Resident 84 was lying in bed, the head of the bed elevated at 30 degrees, the call light was within reach. Resident 84 was on oxygen via nasal cannula with the oxygen set at 2 liters per minute. Resident 84's humidifier was labeled with a date of 7/14/2025 and the nasal cannula tubing was not labeled. LVN 10 stated the nasal cannula tubing should be labeled. LVN 10 stated every Thursday the tubing and humidifier would be changed. LVN 10 stated Resident 84 would be at risk for an infection control issue without the proper nasal cannula tubing labeling. During an interview on 7/17/2025 at 11:30 AM with the Director of Nursing (DON), the DON stated oxygen tubing should be changed weekly and dated on the date the tubing was changed. The DON stated the reason to date the oxygen tubing would be for infection control. The DON stated Resident 84 and Resident 24 would be at risk of the nursing staff (in general) unaware of when the tubing was changed which could lead to days or weeks without changing it. During review of the facility's policy and procedure titled, Oxygen Use, dated 1/10/2025, indicated the oxygen devise (nasal cannula, mask or nasal catheter) is changed weekly and dated with the date of change. Residents Affected - Few 056242 Page 5 of 14 056242 07/18/2025 Westlake Convalescent Hospital 316 S Westlake Avenue Los Angeles, CA 90057

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) emergency kit (e-kit, collection of supplies that you might need during a time of emergency) at bedside for one of seven sampled residents on dialysis (Resident 85). This failure had the potential for Resident 85 to receive delayed intervention in managing complications such as bleeding.Findings:During a review of Resident 85's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included, but not limited to end stage renal disease with dependence on dialysis, diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), gastroesophageal reflux disease (GERD - a condition in which stomach acid flows back up into the esophagus (food pipe) causing heartburn), hypertension (HTN-high blood pressure), and quadriplegia (a condition in which both the arms and legs are paralyzed). During a review of Resident 85's Subacute Nursing Assessment, dated 7/11/2025, the Subacute Nursing Assessment indicated Resident 85 was responsive to tactile stimulation (any form of touch or physical contact that is perceived by the skin).During a review of Resident 85's Functional Abilities & Goals Admission, dated 7/11/2025, the Functional Abilities & Goals admission indicated the resident was dependent on staff for self-care activities such as oral and toileting hygiene, bathing, and dressing.During a review of Resident 85's Order Summary Report, dated 7/11/2025, the Order Summary Report indicated for the resident to have bedside hemodialysis every Monday, Wednesday, and Friday and to check dialysis e-kit at bedside every shift.During a review of Resident 85's care plan dated 7/12/2025, the care plan indicated the resident was at risk for adverse effect such as bleeding at the access site. The care plan indicated interventions that included checking dialysis e-kit at bedside every shift. The care plan indicated a goal for Resident 85 to be free from bleeding. During a concurrent observation and interview on 7/15/2025 at 10:21 AM, with Licensed Vocational Nurse (LVN) 1, in Resident 85's room, the resident was observed lying in bed. There was no e-kit observed at Resident 85's bedside, cabinet, or drawer. LVN 1 stated Resident 85 did not have an e-kit present at bedside. LVN 1 stated Resident 85 could bleed out as a complication of dialysis so it would be important to have an e-kit at the bedside at all times.During an interview on 7/15/2025 at 10:35 AM, with LVN 2, LVN 2 stated the e-kit is usually hung on a pole or in the drawer. LVN 2 stated Resident 85 could have a bleeding problem so there should be an e-kit at the bedside all the time. During an interview on 7/17/2025 at 12:19 PM, with Registered Nurse (RN) 1, RN 1 stated every resident on dialysis should have an e-kit at the bedside at all times. RN 1 stated an e-kit contains gauze, scissor, tape, tourniquet, alcohol swabs, and a clamp. RN 1 stated not having an e-kit at bedside would be a big issue because staff (in general) would not be able to act immediately if there was an emergency.During an interview on 7/18/2025 at 8:08 AM, with the Director of Nursing Designee (DOND), the DOND stated staff would check dialysis access site for bleeding as a complication after dialysis for Resident 85 is completed. The DOND stated the e-kit is used for emergency to stop bleeding or to prevent bleeding from getting worse. The DOND stated not having an e-kit at bedside would delay treating an emergency for Resident 85 and it would be very important to have an e-kit at the bedside at all times. During a review of the facility's Policy and Procedure (P&P) titled Pre/Post Dialysis Assessment and Care, dated 1/10/2025, the P&P indicated Post dialysis assessment will include the following .signs and symptoms of bleeding especially on dialysis access site .Complications post dialysis such as hypotension or bleeding . Emergency dialysis kit at the bedside of a dialysis resident which contains but not limited: Residents Affected - Few 056242 Page 6 of 14 056242 07/18/2025 Westlake Convalescent Hospital 316 S Westlake Avenue Los Angeles, CA 90057

F 0698 clamp, tourniquet, alcohol swabs, gauze . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 056242 Page 7 of 14 056242 07/18/2025 Westlake Convalescent Hospital 316 S Westlake Avenue Los Angeles, CA 90057

F 0759 Ensure medication error rates are not 5 percent or greater. 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 that its medication error rate was less than five percent (%). Two errors out of 29 opportunities contributed to an overall error rate of 6.9 % affecting one of four residents observed for medication administration (Resident 31). The errors noted were as follows:1. Attempted administration of approximately 7.5 milliliters (mL) of vitamin C (a vitamin supplement) liquid, instead of 5mL as per physician's orders.2. Attempted administration of approximately 7.5mL of levetiracetam (a medication used to treat seizures) liquid, instead of 5mL as per physician's orders.The deficient practice of failing to administer medications in accordance with the physician's orders increased the risk that Resident 31 may have experienced medical complications that could result in hospitalization.Findings:During a review of Resident 31's admission Record (a document containing diagnostic and demographic information), dated 7/17/25, the admission record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including epilepsy (periodic uncontrolled electrical activity in the brain leading to seizures.)During a review of Resident 31's Order Summary Report (a monthly summary report of all active physician orders), dated 7/17/25, the order summary report indicated Resident 31's attending physician prescribed the following:1. Ascorbic Acid oral liquid (vitamin C) 500 milligrams (mg - a unit of measure for mass) per 5 ml to give 500 mg (5 ml) via gastrostomy tube (g-tube - a tube surgically inserted into the stomach for the administration of medication and nutrition) one time a day.2. Levetiracetam oral solution 100 mg/ml to give 500 mg (5 ml) via g-tube every 12 hours related to epilepsy.During an observation on 7/16/25 at 9:59 AM, LVN 3 was observed entering Resident 31's room to administer the vitamin c and levetiracetam liquid as prepared and was stopped by the surveyor. During a concurrent observation and interview, LVN 3 stated the dose for vitamin C and levetiracetam liquid should have been 5 ml. After visual inspection of the dosage cups, LVN 3 stated she poured too much medicine into the dosage cups for the vitamin C and levetiracetam liquid and the dose she prepared was closer to 7.5 ml for both medications. LVN 3 stated it was sometimes difficult to see the dosage indicator lines on the plastic dosage cups in order to pour accurately. LVN 3 stated she did not mark the dosage on the cup with a marker in order to pour more accurately. LVN 3 stated not measuring the dose carefully could lead to Resident 31 receiving more medication than was prescribed possibly leading to an increase in the adverse (negative) effects of the medications. LVN 3 stated this could cause a decrease in Resident 31's quality of life or possibly cause medical complications leading to hospitalization.A review of the facility's policy Administering Medications, dated 1/10/25, indicated Medications shall be administered in a safe and timely manner, and as prescribed. Medication must be administered in accordance with the orders, including any timeframe. The individual administering the medication must check the label THREE (3) times to verify the right medication, right dosage, right time and right method (route) of administration before giving the medication. Residents Affected - Few 056242 Page 8 of 14 056242 07/18/2025 Westlake Convalescent Hospital 316 S Westlake Avenue Los Angeles, CA 90057

F 0760 Ensure that residents are free from significant medication errors. 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 one of four residents observed for medication administration (Resident 31) was free of significant medication errors (an observed or identified incident in the preparation or administration of medications that causes the patient discomfort or jeopardizes their health or safety) when on 7/16/2025 Licensed Vocational Nurse 3 (LVN 3) was observed attempting to administer 7.5 milliliters (mL) of levetiracetam liquid (a medication used to treat seizures) instead of 5mL ordered by the physician.The deficient practice of failing to administer medications in accordance with the physician's orders increased the risk that Resident 31 may have experienced medical complications resulting in hospitalization.Findings:During a review of Resident 31's admission Record (a document containing diagnostic and demographic information) dated 7/17/25, the admission record indicated he was admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses including epilepsy (periodic uncontrolled electrical activity in the brain leading to seizures.)During a review of Resident 31's Order Summary Report (a monthly summary report of all active physician orders) dated 7/17/25, the order summary report indicated Resident 31's attending physician prescribed the following:1. Levetiracetam oral solution 100 milligrams (mg - a unit of measure for mass) per ml to give 500 mg (5 ml) via gastrostomy tube (g-tube - a tube surgically inserted into the stomach for the administration of medication and nutrition) every 12 hours related to epilepsy.During an observation of medication administration on 7/16/25 at 9:44 AM with the Licensed Vocational Nurse (LVN 3), LVN 3 was observed preparing the following medications for Resident 31:1. Approximately 7.5 to 10 milliliters (ml - a unit of measure for volume) of levetiracetam liquid.During an observation on 7/16/25 at 9:59 AM, LVN 3 was observed entering Resident 31's room to administer the levetiracetam liquid as prepared and was stopped by the surveyor. During a concurrent interview, LVN 3 stated the dose for levetiracetam liquid should have been 5 ml. After visual inspection of the dosage cup, LVN 3 stated she poured too much medicine into the dosage cup for the levetiracetam liquid and the dose she prepared was closer to 7.5 ml. LVN 3 stated it was sometimes difficult to see the dosage indicator lines on the plastic dosage cups in order to pour accurately. LVN 3 stated she did not mark the dosage on the cup with a marker in order to pour more accurately. LVN 3 stated not measuring the dose carefully could lead to Resident 31 receiving more medication than was prescribed possibly leading to an increase in the adverse (negative) effects of the medications. LVN 3 stated this could cause a decrease in Resident 31's quality of life or possibly cause medical complications leading to hospitalization.A review of the facility's policy Administering Medications, dated 1/10/25, indicated Medications shall be administered in a safe and timely manner, and as prescribed. Medication must be administered in accordance with the orders, including any timeframe. The individual administering the medication must check the label THREE (3) times to verify the right medication, right dosage, right time and right method (route) of administration before giving the medication. Residents Affected - Few 056242 Page 9 of 14 056242 07/18/2025 Westlake Convalescent Hospital 316 S Westlake Avenue Los Angeles, CA 90057

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review, the facility failed to ensure the standardized recipes for lunch menu were followed on 7/15/2025 by failing to ensure puree diet (foods that do not require chewing and are easily swallowed. All food should be smooth and pureed to the consistency of pudding.) received rice texture in form that meet their needs and in accordance with the International Dysphagia Diet Initiative (IDDSI - a framework made up of levels and describes food textures and drink thickness) Level Four (pureed foods and extremely thick drinks) when the texture of the pureed rice was thick and stuck to the spoon and the roof of the mouth.This failure had the potential to result in meal dissatisfaction and increased choking risk for residents on pureed diet.Findings:1.During an observation of the tray line (tray line-a system of food preparation, in which trays move along an assembly line) service for lunch on 7/15/2025 at 12:00PM, the pureed rice looked thick and sticky. During the serving of the pureed rice observed the rice stuck to the serving scoop. During a concurrent interview and taste test of the pureed rice with the Dietary Supervisor (DS) on 7/15/2025 at 12:30PM, the pureed rice looked dry and thick. The pureed rice was stuck on the spoon and did not fall on the plate when spoon was tilted. During the taste test, the pureed rice was stuck to the roof of the mouth, and it was difficult to clear from the mouth. The DS agreed that the rice is sticky, and stated residents would need to drink fluids to clear the mouth. The DS stated sticky texture was hard for residents to swallow and could cause choking. The DS stated the cook needed to add more liquid to the puree rice to create a softer texture.During an interview with the cook (Cook1) on 7/15/2025 at 12:35PM, Cook1 stated cook1 added water to the rice and blended the mixture and did not need to add any thickener. Cook1 stated the pureed food should not be sticky or dry and should fall from the spoon easily when spoon is tilted. Cook1 stated cook1 should added more liquid to make the pureed rice soft. During a review of the facility's recipe titled Recipe: Pureed (IDDSI Level 4) Starch (Rice, Pasta, Polenta, Potatoes) (dated 2023) the recipe indicated, 1)complete regular recipe.2)puree on low to a paste.3)Gradually add warm milk4)add thickener if needed.5)the finished pureed item should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The finished pureed item must pass IDDSI level 4 testing requirements (the fork drip, fork pressure, and spoon tilt test.During a review of the IDDSI guideline website titled IDDSI, dated 7/2019, the IDSSI guideline indicated that Level 4 Pureed is usually eaten with spoon, falls off spoon in a single spoonful when tilted and continues to hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid. Food testing method: Spoon tilt test and Fork drip test. During a review of facility's policy and procedure (P&P) titled Food Preparation (dated 2023) the p&p indicated, The facility will use approved recipes, standardized to meet the resident census. Recipes are specific as to portion yield, method of preparation, quantities of ingredients. 056242 Page 10 of 14 056242 07/18/2025 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when:1.The temperature of the walk-in refrigerator was 45 degrees Fahrenheit, and the gasket (door seal) of the walk-in refrigerator glass display door was broken, not allowing for the glass door to close tight. The temperature of the milk located by the glass display door was 44 degrees Fahrenheit. 2.Dishwasher 1 (DW1) working in the dish machine area did not wash hands and/or replace gloves when removing the clean and sanitized dishes form the dish machine.3.The base of the Dietary tray card holders was rusted. (Card Holder with a round base which sets firmly on resident meal tray with a holder to grip the diet cards-diet cards have the resident name and the diet order with resident preferences and allergies written on them).4. Food brought to residents from outside the facility was stored in the resident's food refrigerator unsealed, 5. The resident refrigerator was not clean and had brown color stains on the bottom shelf. The freezer section was not clean and had a thick layer of ice and brown stains on it. 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 food borne illness in residents who received food from the facility and including residents who had food stored in the resident refrigerator. Findings:1.During a concurrent observation in the facility kitchen and interview with the Dietary Supervisor (DS) on 7/15/2025 at 9:00 AM, the temperature of the walk-in refrigerator was 45 degrees Fahrenheit. The DS stated the refrigerator door was kept open for food delivery and during breakfast service.During a concurrent observation of the facility kitchen and interview with DS on 7/16/2025 at 8:50AM, the temperature of the walk-in refrigerator was 44 degrees Fahrenheit (F). During the same observation the gasket of the walk-in refrigerator glass display door was broken, not allowing for the glass door to close tight. The DS stated the temperature of the walk-in refrigerator that morning (7/16/2025) was 38 degrees F. The DS stated the broken gasket of the glass display door allowed warm air to enter the refrigerator throughout the day. During the same observation and interview, the temperature of the milk located by the glass display door was checked with the facility thermometer and was 44 degrees F. The DS stated that cold food had to be kept at 41 degrees or lower and the milk was not kept at the right temperature and would be discarded. The DS stated food not kept at temperatures of 41 and below could go bad and make the residents sick. During a concurrent observation in the facility kitchen and interview with DS on 7/16/2025 at 12:01PM the temperature of the Walk in refrigerator was 42degrees F.During a review of facility's policy and procedures titled Procedure for Refrigerated Storage (Dated 2023), the policy indicated Refrigerator 41 degrees F or lower.to keep food at a specific temperature, the air temperature in the refrigerator usually must be about 2 degrees F lower. For example, to hold chicken at 41 F, the air temperature must be 39F.During a review of facility's policy and procedures titled Refrigerator and Freezer (Dated 2023) indicated, How to keep your refrigerator and freezer working efficiently: 1) close the door when not in use and do not prop open, 2) Periodically, check door gaskets and replace, if damaged.During a review of the 2022 U.S. Food and Drug Administration Food Code 3-501.16 titled Time/Temperature control for safety food, hot and cold holding indicated, except during preparation, cooking or cooling, time/temperature control for safety food shall be maintained at 135degrees F or above, and at 41 degrees F or below. 2. During an observation in the dishwashing area on 7/15/2025 at 8:20AM, Dishwasher (DW1) was observed rinsing soiled dishes and loading the dirty dishes in the dish machine. DW1 had gloves on his hands, and after the dish machine stopped DW1 wore new gloves without washing hands and proceeded to remove the clean and sanitized dishes 056242 Page 11 of 14 056242 07/18/2025 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 from the dish machine without washing hands. DW1 was then observed with gloves on, started cleaning the dishwashing area counters with soap and water, then removed gloves dried hands with paper towel and wore new gloves without washing hands and proceeded to remove and store away clean and sanitized dishes.During an interview with DW1 on 7/15/2025 at 8:30AM, DW1 confirmed by stating he (DW1) did not wash his hands after removing gloves and before touching the clean dishes. DW1 stated that not washing hands could contaminate clean dishes.During an interview on 7/15/2025 at 8:35AM, the DS stated staff could cross contaminate the dishes when moving from dirty dishes to clean dishes without washing hands. During a review of facility's policy and procedure titled Handwashing procedure (dated 2023) indicted, Hand washing is important to prevent the spread of infections. When hands need to be washed: after handling soiled dishes and utensils.During a review of the 2022 U.S. Food and Drug Administration Food Code, Code 2-301.14 titled When to wash. The Code indicated, Food employees shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and E) After handling soiled equipment or utensils. 3.During a tray line observation in the facility kitchen for lunch service (tray line-a system of food preparation, in which trays move along an assembly line) on 7/15/2025 at 11:50AM, the dietary card holders were placed on resident's meal tray. The base of the Dietary tray card holders was observed to be rusted.During an interview on 7/15/2025 at 3:00PM, the DS stated the card holders are made of metal. The DS stated the card holders were washed in the dishwasher and the chemicals used eroded the metal card holder. The DS stated the card holders were rusty and look unsightly. The DS stated the rust could result in contamination of resident's meal trays.During a review of facilities policy and procedures titled Sanitation (dated 2023) indicated, All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks and chipped areas.4.During an observation in the resident refrigerator located in the utility room on the 2nd floor on 7/16/2025 at 9:20AM, there was one open package of hot dogs in the freezer section of the small refrigerator. The freezer was covered with a thick layer of ice. The open package of hot dogs was stored on the thick layer of ice, there were brown color stains on the ice. There were brown color stains and drippings on the bottom shelf of the refrigerator.During a concurrent observation and interview with Infection prevention nurse (IP) on 7/16/2025 at 9:20AM, IP stated resident leftover food had to be covered, labeled and dated. The IP stated food that was not covered could be exposed and get contaminated.During an interview with housekeeping supervisor (HS) on 7/16/2025 at 9:30AM, the HS stated housekeeping was responsible for cleaning the refrigerator and defrosting the ice in the freezer. The HS did not have a record of the refrigerator cleaning and did not know when the refrigerator was last cleaned.During a review of facility's policy titled Foods Brought by Family/Visitor (not dated), Indicated, Perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. Container will be labeled with the resident's name, the item and the use by date.During a review of facility's policy titled Refrigerator and Freezer (dated 2023) indicated, Maintaining a clean refrigerator and freezer can improve the safety and quality of our foods. Refrigerator and freezer should be on a weekly cleaning schedule, wipe up spills immediately. 056242 Page 12 of 14 056242 07/18/2025 Westlake Convalescent Hospital 316 S Westlake Avenue Los Angeles, CA 90057

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure four of five trash bins in the dumpster area were maintained in a sanitary manner. One trash bins had the lid open and three trash bins were rusted, broken and had corrosion that resulted in holes exposing the content inside the trash bins. This deficient practice had the potential for harborage and feeding of pests.Findings:During an observation in the main dumpster area located outside of the facility kitchen back door on 7/15/2025 at 9:30AM; one large recycle bin lid was not covered, there were boxes inside the bin and flies inside and around the bin. Three large trash dumpsters were corroded resulted in large holes and the trash was seen through the holes, the trash bins had orange color rust and broken at the bottom. There was cigarette butts stuck under the open seam of the trash bins.During a concurrent observation and interview with dietary supervisor (DS) and maintenance supervisor (MS) on 7/15/2025 at 9:30AM, the MS stated the three large trash bins were old, rusted and there were large holes which could result in rodents and other pests going in the trash. The MS stated the lids of the trash bins had to be closed to prevent rodents and flies from going inside. The DS stated open trash bins attracted flies and other pests and creates an unsanitary environment in the trash area and the facility.During a review of the facility's policy titled, Miscellaneous Areas-Garbage and Trash (dated 2023) indicated, Adequate, clean, vermin-proof areas must be provided for storage or garbage and rubbish, Garbage and trashcans must be inspected daily that no debris is on the ground or surrounding area, and that the lids are closed, the trash collection area is a potential feeding ground for vermin and rodents and must kept clean-if a commercial rubbish service is used, arrangements must be made for periodic exchange of trash bins.A review of Food and Drug Administration (FDA) Food Code 2022, code number 5-501.113 titled Covering receptacles, indicated: receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered with tight-fitting lids or doors if kept outside the establishment. The Food Code also indicated under code number 5-501.110 titled Storing Refuse, Recyclables, and Returnable indicated refuse, recyclables, and returnable shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. Residents Affected - Some 056242 Page 13 of 14 056242 07/18/2025 Westlake Convalescent Hospital 316 S Westlake Avenue Los Angeles, CA 90057

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the call light (a device that alerts healthcare providers that the patient needs assistance) was within reach for one of one sampled resident (Resident 22).This deficient practice had the potential to result in delay in meeting Resident 22's need for assistance.Findings:During a review of Resident 22's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the most recent readmission on [DATE], with diagnoses that included, but not limited to chronic respiratory failure (a condition where the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), schizophrenia (a mental illness that is characterized by disturbances in thought), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), right and left foot drop (the inability to lift the front part of the foot, causing it to drag or drop when walking), muscle wasting (process when muscles shrink or waste away), dysphagia (difficulty swallowing), and gastrostomy tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).During a review of Resident 22's care plan, reviewed and revised on 3/29/2025, the care plan indicated Resident 22 was at risk for fall. The care plan indicated interventions that included having the call light within reach and answered promptly. The care plan indicated a goal for Resident 22 to have no fall or injury.During a review of Resident 22's Minimum Data Set (MDS-a resident assessment tool), dated 4/30/2025, the MDS indicated the resident was rarely understood and cognition (the ability to think, learn, remember, and understand) was severely impaired. The MDS indicated Resident 22 exhibited behavior symptoms such as hitting and scratching herself daily. The MDS indicated Resident 22 was dependent on staff for self-care activities such as oral and toileting hygiene, bathing, and dressing.During an observation on 7/15/2025 at 11:57 AM, in Resident 22's room, Resident 22 was observed lying in bed. Resident 22's call light was observed on the floor on the right side of the bed out of the resident's reach.During a concurrent observation and interview on 7/15/2025 at 12:17 PM, with Licensed Vocational Nurse (LVN) 1, in Resident 22's room, LVN 1 observed and stated the resident's call light was on the ground. LVN 1 stated Resident 22 could fall if Resident 22 could not reach the call light to call for help.During an interview on 7/16/2025 at 12:19 PM, with Registered Nurse (RN) 1, RN 1 stated staff (in general) would not know if Resident 22 was in distress or needed help if she could not reach the call light.During an interview on 7/18/2025 at 8:12 AM with the Director of Nursing Designee (DOND), the DOND stated staff (in general) would not be able to check on Resident 22 and the resident would not be able to receive assistance if the resident could not reach the call light. The DOND stated staff (in general) should put the call light near Resident 22 at all times.During a review of the facility's Policy and Procedure (P&P) titled Answering Call Lights dated 1/10/2025, the P&P indicated When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Residents Affected - Few 056242 Page 14 of 14