Health inspection·June 13, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. 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 staff failed to ensure call light was within reach for two of four sampled residents (Resident 3 and Resident 22). Residents Affected - Some This deficient practice had the potential for Resident 3 and 22 not to receive necessary assistance when needed, and experienced loss of self-esteem. Findings: During a review of Resident 3's admission Order, the admission Record indicated Resident 3 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses including paraplegia (paralysis that affects your legs, but not your arms), and unspecified epilepsy (disorder in which nerve cell activity in the brain is disturbed, causing seizures [involuntary muscle movements]) During a review of Resident 3's Minimum Data Sheet (MDS- a comprehensive assessment and care planning tool) dated 5/10/2024 indicated Resident 3 had moderate cognitive impairment (ability to learn, understand, and make decisions) and requires maximum assistance for toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 3's care plan revised on 8/14/2020, indicated Resident 3 was high risk for falls and has history of fall, seizure, and episodes of removing seatbelt. The Care Plan interventions including call light must be within reach and respond to call light in a timely manner. During a review of Resident 22's admission Order, the admission Record indicated Resident 22 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (high blood sugar), essential hypertension (high blood pressure) and unspecified dementia (a loss of thinking, remembering, and reasoning skills). During a review of Resident 22's MDS dated [DATE] indicated Resident 22 had severe cognitive impairment and requires assistance for all activities of daily living (ADL'S). During a review of Resident 22's care plan revised on 8/17/2020, i8ndicated Resident 22 was at risk for falls/risk for injury related to noncompliance. The Care Plan indicated interventions including call light must be within reach and respond to call light in a timely manner. During an observation on 6/10/2024 at 10:48 a.m.,11:45 a.m.12:47 p.m., and 2:10 p.m. observed Resident 3 call light hanging at the side of the bed and not within reach. Page 1 of 43 056308 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 6/11/2024 at 9:05 a.m.,10:03 a.m., and 11:01 a.m., observed Resident 22's call light was on the floor and not within reach. During an interview on 6/11/2024 at 2:50 p.m., the Director of Staff Development (DSD) stated if resident cannot reach the call light to ask for help, it will frustrate them and affect their psychosocial wellbeing and may feel like less important and unwanted. During an interview on 6/11/2024 at 2:57 p.m., Certified Nursing Assistant (CNA 2) stated call light should be within reach to prevent fall and injury and Resident 3 and 22's needs will be provided in a timely manner. During an interview on 6/13/2024 at 8:54 a.m., Licensed Vocational Nurse (LVN 4) stated if residents' call light was not within reach, Resident 3 and 22 will not be able to call for help when needed and had the potential to affect their psychosocial wellbeing and delayed the care needed. During a record review of the facility's policy and procedure (P&P) titled Answering the Call Light (undated) indicated, The purpose of this procedure was to respond to the resident's requests and needs. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Some residents may not be able to use their call light. Be sure you check these residents frequently. Report all defective call lights to the Nurse Supervisor promptly. Answer the resident's call as soon as possible. Be courteous in answering the resident's call. 056308 Page 2 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

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 comfortable room temperature on one of five sampled residents (Resident 25). This deficient practice had the potential to place Resident 25 at risk for disturbed sleep and can negatively impact resident's comfort and health. Findings: During a review of Resident 25's admission Record, indicated the Resident 25 was initially admitted on [DATE] and was readmitted on [DATE] to the facility with diagnoses including presence of cardiac pacemaker( small electrical device implanted in the chest to treat abnormal heart rhythms), end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis) , cardiomyopathy( heart muscles became stretched, weakened and unable to pump blood or function well) and diabetes( high blood sugar). During a review of Resident 25's Minimum Data Set ([MDS] standardized assessment and care screening tool) dated 4/25/2024, the MDS indicated Resident 25 had an intact cognition ((ability to think, understand, learn, and remember) and required partial /moderate assistance (helper does less than half the effort) with bed mobility and transferring from to and from a bed to chair. During a concurrent observation and interview on 6/11/2024, at 9:05 a.m., in Resident 25's room, Resident 25 was lying in bed covered with three blankets and a towel covering her head. Observed an electric fan located in Resident 25's roommate's bed. Resident 25 stated the facility put the air conditioner so high that she could not sleep at night and had to use four blankets to keep her warm. Resident 25 stated she had told an unnamed nurse and unnamed certified nursing assistant (CNA) and they had told her they are going to fix the room temperature. Resident 25 stated it was useless to talk about being cold especially during the night where the staff would just give her all the blankets they could find in the facility because nobody had helped her. Resident 25 stated she felt like she was going to get sick and had lost sleep because the room temperature was too cold for her. During an interview on 6/11/2024, at 4:28 p.m. with CNA 7, CNA 7 stated she gave Resident 25 because Resident 25 was complaining her room was cold. CNA 7 stated she did not notify anyone about Resident 25's complaint of being cold in her room. CNA7 stated the resident would remain cold and uncomfortable if her concern will not be addressed. During a telephone interview on 6/12/2024, at 9:22 a.m., with CNA 6, CNA 6 stated whenever she would go to Resident 25's room, the resident would ask to turn off the air conditioner because she was cold. CNA 6 stated Resident 25's roommate preferred the room to be cold and liked the electric fan turn on in her room at times. CNA 6 stated she offered blankets and towel for the head to Resident 25 when she was complaining of being cold. CNA 6 stated she did not notify the charge nurse because Resident 25's roommate liked her room cold. CNA 6 stated Resident 25's roommate would sometimes turn on the electric fan at night and liked the room temperature cold because of her asthma (condition in which the airways narrow and swell causing extra mucus production) and fibromyalgia (long term condition that involves widespread body pain and tiredness). CNA 6 stated she should have reported Resident 25's complaint about the room temperature being cold to the charge nurse. CNA 6 stated Resident 25 056308 Page 3 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0584 could get sick and might catch a cold (viral infection) if her concern was not properly addressed. Level of Harm - Minimal harm or potential for actual harm During an interview on 6/12/2024, at 2:28 p.m., with Maintenance Director (MD), MD stated the air conditioning was centralized and he usually received a call from the staff if something needs to be repaired in the facility. The MD stated he only received a call from the staff on 6/11/2024 evening to check the thermostat because Resident 25's complaint of being cold in her room. MD stated Resident 25's roommate complained the room was hot and wanted the room to be cold but Resident 25 liked her room warm. MD stated he checked residents' room temperature everyday and had to maintain a temperature of 70 to 74 degrees Fahrenheit ([°F] unit of measurement). MD stated he did not keep a temperature log or document temperatures of the room. MD stated checking the temperatures of residents' room temperature was important to ensure the residents are comfortable. MD stated Resident 25 might not be able to sleep well if her room was cold. Residents Affected - Few During an interview on 6/12/2024, at 2:43 p.m., with Social Service Director (SSD), SSD stated she spoke to Resident 25 yesterday evening after Licensed Vocational Nurse (LVN 8) told her about Resident 25's complaint of being cold in her room. SSD stated Resident 25 would not feel comfortable and might lose sleep if the temperature of the room is too cold for her. During an interview on 6/13/2024, at 3:31 p.m., with the Director of Nursing (DON), the DON stated she was not informed of Resident 25's complaint of being cold in her room. The DON stated cold room would cause discomfort to the resident. During a review of facility's policy and procedure(P&P) titled Homelike Environment revised 2/2021, indicated the facility's staff and management will maximize the characteristics of the facility that will reflect a personalized and homelike setting including a comfortable and safe temperature to the residents. The P&P indicated the staff will provide person-centered care that emphasizes the resident's comfort, and personal needs or preferences. 056308 Page 4 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. 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 one sampled resident (Resident 73) was free of unnecessary physical restraints (any object or device that an individual cannot remove easily which restricts freedom of movement) by failing to: Residents Affected - Few 1.Ensure on-going assessment and reevaluation of physical restraints' continuous use were conducted and documented. 2. Follow policy and procedure (P&P) regarding the use of restraints. These deficient practices had the potential to place Resident 73 at risk for unnecessary prolonged use of physical restraints, impaired blood circulation, skin injuries and contracture (permanent tightening of muscles that causes tissues and joints to become stiff and short). Findings: During a review of Resident 73's admission Record , indicated the Resident 73 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including unspecified dementia (loss of cognitive functioning such as thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities) without behavioral disturbance, bilateral primary osteoarthritis of knee((degenerative joint disease both knees), pressure ulcer of sacral region stage 4,and attention/ concentration deficit. During a review of Resident 73's History and Physical (H&P) dated 5/9/2024, the H&P indicated Resident 73 was not able to express needs, communicate nor follow commands and talked in full sentences. The H& P indicated the resident did not have a capacity to make decisions. During a review of Resident 73's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 5/1/2024, the MDS indicated Resident 73 was dependent on staff with bed mobility, moving from sitting on side of bed to lying flat on bed, toileting hygiene, bathing, dressing, personal hygiene, and oral hygiene. The MDS indicated the resident was not on any form of restraints. During a review of Resident 73's Physician Order Summary Report dated 2/25/2024, indicated a physician's telephone order of applying hand mittens to bilateral (both) hands every shift for prevention of pulling out nasogastric tube([NGT] thin, soft tube that goes in through the nose, down the throat, and into the stomach used to give medicines, liquids, and liquid food). During a review of Resident 73's Physician Order Summary Report dated 11/7/2023, indicated to remove hand mittens and inspect skin integrity for any redness, swelling or open area every shift and to change hand mittens as needed if soiled. During a review of Resident 73's Care Plan titled Bilateral hand mittens for tendency of pulling out NGT initiated 11/6/2023 with goal of Resident 73 will not develop any complication related to the use of bilateral hand mittens. The Care Plan interventions including assessment for possible discontinuance of bilateral hand mittens. 056308 Page 5 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 6/10/2024, at 10:09 a.m., in Resident 73's room, Resident 73 was lying in bed turned to the right side, moaning, and groaning with bilateral hand mittens on and NGT on the left nares (nostril). During a subsequent interview on 6/12/2024, at 11:45 a.m., and on 6/12/2024, at 3:02 p.m. with Certified Nursing Assistant (CNA 5), CNA 5 stated she did not know what the name of the device on her (Resident 73) both hands but whenever she takes care of Resident 73, she would change both mittens, check the skin, and make sure they were not tight. CNA5 stated the mittens could cause poor circulation if they are not checked and too tight. During a concurrent interview and record review on 6/12/2024 at 10:45 a.m., with Registered Nurse (RN) 2 stated Resident 73 had bilateral hand mittens which was a form of restraint and were used to prevent removal of NGT. Reviewed Resident 73's electronic health record (EHR) RN 2 stated there was no documentation about assessment and monitoring of the usage of bilateral hand mittens. During a concurrent interview and record review on 6/12/2024, at 11:04 a.m., with Assistant Director of Nursing (ADON), ADON confirmed there was no documentation restraints were reassessed and evaluated for continued use. The ADON confirmed the physician order of bilateral hand mittens was ordered on 2/25/2024, and the order had no end date. ADON validated thru record review Resident 73's Interdisciplinary Team Meeting ([IDT] group of professional and direct care staff that have primary responsibility for the development of a plan for the care of a resident) Notes dated 2/6/2024 and 4/30/2024 did not address the restraint's use. ADON stated the CNAs could remove the bilateral hand mittens with the supervision of a licensed nurse. ADON stated licensed nurses were responsible for monitoring, removal, and assessment of restraints. ADON stated the resident could be a high risk for skin breakdown, and impairment of circulation due to restricted movement if the resident was not being monitored and reassess for the use of the bilateral hand mittens. During an interview on 6/13/2024, at 2:45 p.m., with RN 1, RN 1 stated the facility monitor and assess the restraints every 2hours by assessing skin integrity, circulation, and presence of contractures. RN1 stated Resident 73 might end up with contracture, impaired circulation, blood clots due to immobility if not monitored or reassessed with the usage of bilateral hand mittens. During a review of Resident 73's Medication Administration Record (MAR) for the month of June 2024, MAR indicated to remove hand mittens and inspect for any redness, swelling or open area every shift. The MAR indicated removal of hand mittens are performed every shift. The MAR indicated only a check (check symbol meant it was administered) and initials of licensed nurse. During a concurrent interview and record review on 6/13/2024, at 3:31 p.m. with Director of Nursing (DON), the DON stated the facility evaluates resident if there was a medical necessity on using restraints, and consent was obtained if resident required restraints. The DON stated restraint order included indication, monitoring and duration on how long restraints will be used on the resident. The DON stated the facility conducted quarterly restraint assessment, and care plan was initiated. DON confirmed the last quarterly restraint assessment was done last January 2024. The DON stated not monitoring and assessing continued use of hand mittens on Resident 73 could place resident at risk for skin breakdown, decreased functional use of both hands and the facility would not know if resident had developed contracture. During a review of facility's policy and procedure (P&P) titled Use of Restraints revised April 2017, the P&P indicated Restraints shall only be used upon the written order of a physician and the 056308 Page 6 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few order should include the specific reason for the restraint, how the restraint will be used to benefit the medical symptom, the type of restraint and the period of time for the use of restraint. The P&P indicated a resident placed in a restraint will be observed at least every thirty minutes by nursing personnel and documentation of the use of restraints included length of effectiveness of the restraint time, observation, range of motion and repositioning. The P&P indicated restrained individuals will be reviewed regularly at least quarterly to determine whether they are candidates for restraint reduction or total restraint elimination. 056308 Page 7 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 complete a preadmission screening and annual resident review (PASARR) I accurately for one of one sampled resident (Resident 50) who has a diagnosis of major depressive disorder (affects how you feel, think, and behave that can lead to a variety of emotional and physical problems). Residents Affected - Few This deficient practice had the potential to result in inappropriate placement and delay of needed services for Resident 50. Findings: During a review of Resident 50's admission Record, Resident 50 was admitted to the facility on [DATE] with a diagnosis of major depressive disorder. During a review of Resident 50's Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 4/5/2024, indicated Resident 50 was assessed in needing maximal assistance for all activities of daily living (ADL). During a review of Resident 50's Physician Order Summary Report, Resident 50 was prescribed Quetiapine Fumarate (medication used to treat certain mental/mood disorders) for psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) manifested by hostility (emotionally charged aggressive behavior) and agitation (unable to relax and be still). During a review of the PASARR I, dated 4/24/2024, the PASARR I indicated a negative level I screen. The PASARR I indicated Resident 50 has a serious mental disorder (conditions that affect your thinking, feeling, mood, and behavior). During an interview on 6/13/2024 at 10:14 a.m., with the medical records director (MRD), the MRD stated she was responsible for overseeing the PASARR and ensuring it was done correctly. MRD stated Resident 50 has a negative PASARR I because she has dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and that was what she was taught. During an interview on 6/13/2024 at 3:20 p.m., with the Director of Nursing (DON), the DON stated that if a resident has a mental disorder and was prescribed medications for the mental disorder, the PSARR I should reflect as positive. The DON stated the PASARR I should have been corrected and was missed by us. The DON stated any resident with a mental disorder should be evaluated accurately so they could be treated and cared for correctly. During a review of the facility's policy and procedure (P&P) titled, admission Criteria, revised January 2024, the P&P indicated If the Level I screen indicates that the individual may meet the criteria for a mental disorders (MD), intellectual disabilities (ID- when limitations in your mental abilities affect intelligence, learning, and everyday life skills), or related disorders (RD), he or she is referred to the states PASARR representative for the Level II (evaluation and determination) screening process. 056308 Page 8 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and/or implement an individualized person-centered plan of care with measurable objectives, timeframe, and interventions to meet the residents' needs for four of eight sampled residents (Residents 66 and 73, 9 and 103) by failing to: a. Develop a care plan for Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and joint mobility) services for Resident 66. b. Develop a care plan for RNA services for Resident 73 These deficient practices had the potential to negatively affect the delivery of necessary care and services for Residents 66 and 73. c.Follow the care plan interventions for Resident 9 and 103 who were at risk for bleeding while on Coumadin (blood thinner) therapy. This deficient practice had the potential to result in complications from the use of Coumadin such as bruising and bleeding. Findings: a. During a review of Resident 66's admission Record indicated Resident 66 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including muscle wasting and atrophy (decrease in size or wasting away of a body part of tissue) and ataxic gait (uncoordinated manner of walking). During a review of Resident 66's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 4/26/2024, the MDS indicated Resident 66 had severe cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 66 was dependent in eating, hygiene, toileting, bathing, and transfers (moving from one surface to another). The MDS indicated Resident 66 had functional limitations in range of motion (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in one leg (hip, knee, ankle, foot). During a review of Resident 66's Physician's Orders, dated 5/3/2024, the Physician's Orders indicated for Resident 66 to receive RNA services for passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises to the left arm and PROM exercises to the right arm, seven times a week. During a review of Resident 66's Physician's Orders, dated 5/6/2024, the Physician's Orders indicated for Resident 66 to receive RNA services for PROM exercises to the left leg and PROM exercises to the right leg, every day, seven times a week. During a review of Resident 66's comprehensive care plan, the care plan did not indicate a care plan for RNA services. 056308 Page 9 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0656 Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 6/11/2024 at 4:26 p.m., Resident 66 was lying in bed with the head of the bed elevated. Resident 66 was unable to raise both arms to shoulder level, fully straighten both elbows, and make full fists with both hands. Resident 66's both legs were resting on a pillow with the toes on both feet pointing downwards. Resident 66 stated she was unable to bend and straighten both ankles and both knees. Residents Affected - Some During an interview and record review on 6/13/2024 at 10:37 a.m., the Minimum Data Set Nurse 1 (MDS 1) and Minimum Data Set Nurse 2 (MDS 2) stated the purpose of a comprehensive care plan was to provide an individualized plan of care to meet the specific needs of the residents. MDS 1 and MDS 2 reviewed Resident 66's electronic medical record and confirmed Resident 66 was receiving RNA services for PROM to both arms and both legs. MDS 1 and MDS 2 reviewed resident 66's comprehensive care plan and confirmed Resident 66 did not have a care plan for RNA services. MDS 1 and MDS 2 stated Resident 66 should have had a care plan for RNA services since Resident 66 was receiving RNA services to maintain her level of function and range of motion (ROM, full movement potential of a joint). MDS 1 and MDS 2 stated it was important for care plans to be developed, implemented, and accurate to ensure the appropriate care was provided to each individual resident. MDS 1 and MDS 2 stated the residents may not receive the treatment and services they required if it was not care planned. b. During a review of Resident 73's admission Record indicated Resident 73 admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including osteoarthritis (loss of protective cartilage that cushions the ends of your bones) of both knees and chronic kidney disease (gradual loss of kidney function). During a review of Resident 73's MDS, dated [DATE], the MDS indicated Resident 73 had severe cognitive impairment. The MDS indicated Resident 73 was dependent in eating, hygiene, toileting, bathing, and bed mobility. The MDS indicated Resident 73 had functional limitations in range of motion in one arm (shoulder, elbow, wrist, hand). During a review of Resident 73's Physician's Orders, dated 10/31/2023, the Physician's Orders indicated for Resident 73 to receive RNA services for PROM exercises to the left leg, PROM exercises to the right leg, PROM exercises to the left arm, and PROM exercises to the right arm, every day, seven times a week. During a review of Resident 73's comprehensive care plan, the care plan did not indicate a care plan for RNA services. During an observation on 6/12/2024 at 9:47 a.m., Resident 73 was sleeping with the head turned to the right. The right elbow was bent upwards, and the right hand was in fist with a white, mesh mitt on top of it. During an interview and record review on 6/13/2024 at 10:37 a.m., the Minimum Data Set Nurse 1 (MDS 1) and Minimum Data Set Nurse 2 (MDS 2) stated the purpose of a comprehensive care plan was to provide an individualized plan of care to meet the specific needs of the residents. MDS 1 and MDS 2 reviewed Resident 73's electronic medical record and confirmed Resident 73 was receiving RNA services for PROM to both arms and both legs. MDS 1 and MDS 2 reviewed resident 73's comprehensive care plan and confirmed Resident 73 did not have a care plan for RNA services. MDS 1 and MDS 2 stated Resident 73 should have had a care plan for RNA services since Resident 73 was receiving RNA services to maintain his level of function and range of motion (ROM, full movement potential of a joint). MDS 1 and MDS 2 stated it was important for care plans to be developed, implemented, and accurate to ensure the 056308 Page 10 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some appropriate care was provided to each individual resident. MDS 1 and MDS 2 stated the residents may not receive the treatment and services they required if it was not care planned. During an interview on 6/13/2024 at 1:55 p.m., the Director of Nursing (DON) stated the comprehensive care plan was a communication tool used to identify and address the care needs of the residents. The DON stated it was important for care plans to be up to date and accurate to ensure the current care needs of the resident were accurately and appropriately addressed. c.During a review of Resident 9's admission Record, indicated Resident 9 was re-admitted to the facility on [DATE] with diagnoses including atrial fibrillation (an irregular and often very rapid heart rhythm) and congestive heart failure (CHF- heart does not pump blood as efficiently as it should). During a review of Resident 9's Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 5/26/2024, indicated Resident 9 was assessed in needing maximal assistance with bathing and dressing. During a review of Resident 9's Physician Order's, the Physician Order's indicated Resident 9 order for Coumadin for atrial fibrillation. During a review of Resident 9's care plan, the care plan indicated Resident 9 has the potential for bleeding gums, bruises on arms or legs, petechiae (tiny spots of bleeding under the skin), nosebleeds, melena (black stools that comes from bleeding in your stomach), hematuria (blood in urine), and hematemesis (vomiting of blood) secondary to Coumadin therapy. During an interview on 6/12/24 at 1:40 p.m., Licensed Vocational Nurse (LVN) 6 stated that there was no documentation that Resident 9 was being assessed for sign and symptoms of bleeding and bruising. LVN 6 stated there should be assessment for signs and symptoms of bleeding as Resident 9 was on Coumadin therapy. During a review of Resident 103's admission Record, Resident 103 was readmitted to the facility on [DATE] with diagnoses including of atrial fibrillation and cerebral infarction (stroke- loss of blood flow to part of the brain causing tissue damage). During a review of Resident 103's MDS, dated [DATE], indicated Resident 103 was assessed in needing maximal assistance with bathing, dressing, and transferring. During a review of Resident 103's Physician Orders, the Physician Order's indicated Resident 103 order for Coumadin for atrial fibrillation. During a review of Resident 103's care plan, the care plan indicated Resident 103 was at risk for ecchymosis (bruising), bleeding, epistaxis (nose bleeds), hematuria, gum bleeding, and bleeding from other sources secondary to Coumadin therapy. During an interview on 6/12/24 at 1:55 p.m., with the Registered Nurse Supervisor (RNS) 2, RNS 2 stated Resident's 9 and 103 were taking Coumadin and confirmed there was no documentation that the residents were being monitored for the side effects and complications of Coumadin therapy as indicated in the care plan. RNS 2 stated they should be following the care plan for Resident's 9 and 103 to prevent complications of Coumadin therapy such as internal bleeding or death. 056308 Page 11 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0656 Level of Harm - Minimal harm or potential for actual harm During an interview on 6/13/24 at 3:34 p.m., with the Director of Nursing (DON), the DON stated Resident 103 has been on Coumadin since May of 2023. The DON stated there was no documentation that Resident 103 was being monitored for side effects and complications of Coumadin therapy as indicated in the care plan. The DON stated not following the care plan for Coumadin therapy could potentially lead to blood loss and death. Residents Affected - Some During a review of the facility's undated policy and procedure (P/P) titled, Care Plan - Comprehensive, the P/P indicated comprehensive care plans are developed and maintained for each resident that identified the highest level of functioning the resident may be expected to attain. The P/P indicated the comprehensive care plan was developed for each resident and included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs. The P/P indicated each resident's comprehensive care plan was designed to .identify the professional services that are responsible for each element of care, aid in preventing or reducing declines in the resident's functional status and/or functional levels, enhance the optimal functioning of the resident by focusing on a rehabilitative program, and reflect currently recognized standards of practice for problem areas and conditions. 056308 Page 12 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatments and services to five of eight sampled residents (Residents 23, 66, 84, 117, and 43) to prevent and/or limit a decline in joint (where two bones meet) range of motion ([ROM] full movement potential of a joint) and mobility (ability to move). a. For Resident 23, the facility failed to provide Restorative Nursing Aide ([RNA] nursing aide program that helps residents maintain their function and joint mobility) ROM exercises to Resident 23's both legs and assist with arm bicycle (stationary piece of equipment using a cycling motion for the arms to provide a cardiovascular and strength workout exercises, seven (7) times a week as ordered. b. For Resident 66, the facility failed to provide RNA ROM exercises to both arms and both legs, 7 times a week as ordered. c.For Resident 84, the facility failed to provide RNA services for: 1.ROM exercises to the left arm, 7 times a week as ordered. 2.Right arm strengthening exercises on the arm bicycle, 7 times a week as ordered. 3.Ambulation (walking) exercises, three (3) times a week as ordered. 4.Sit to stand exercises, 3 times a week as ordered. 5.Gentle passive stretching of the left ankle, 7 times a week as ordered. 6.Application of a left-hand splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint), 3 times a week as ordered. d.For Resident 117, the facility failed to provide RNA ROM exercises to the right arm, the right leg, ambulation exercises, and arm bicycle exercises, seven times a week as ordered. e. For Resident 43, the facility failed to provide RNA exercises on 6/11/2024. These deficient practices had the potential to cause residents 23, 66, 84, 117 and, 43 to have a decline in mobility, lead to further contractures (loss of motion of a joint) and have a decline in physical functioning such as the ability to eat, dress, and walk. Findings: a. During a concurrent observation and interview on 6/12/2024 at 9:22 a.m., in Resident 23's room, with Resident 23, observed Resident 23 was lying in bed. Resident 23 was able to bend both elbows and make a fist with both hands. Resident 23's both legs resting on a pillow with both knees slightly bent and the toes on both feet were pointing downwards. Resident 25 bent both knees and hips slightly and was unable to bring the toes of both feet upwards. Resident 23 stated RNA staff did not visit regularly and assisted with exercises about 3 times a week if she was lucky. 056308 Page 13 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 23's admission Record, the admission Record indicated Resident 23 was admitted to the facility on [DATE] and re-admitted the resident on 3/14/2014 with diagnoses including right sided hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following a cerebral infarction (stroke, blockage of the flow of blood brain, causing or resulting in brain tissue death), paraplegia (paralysis or weakness of the legs and lower body, typically caused by spinal injury or disease), and contractures of both ankles and both feet. During a review of Resident 23's Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 4/19/2024, the MDS indicated Resident 23 had moderate cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 23 required set-up assistance for eating and was dependent for oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility, and transfers (moving from one surface to another). The MDS indicated Resident 23 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) of both legs (hip, knee, ankle, foot). During a review of Resident 23's Physician Order Summary Report, the Order Summary Report dated 10/8/2014 indicated a physician order, for the RNA to assist Resident 23 with arm cycle exercises, seven times a week. During a review of Resident 23's Physician Order Summary Report, dated 6/22/2024 indicated a physician order, for RNA to provide active assistive ROM (AAROM, movement at a given joint with a person's own effort and assistance from an external force or another person) to the left leg with gentle passive (requiring total assistance from another person or equipment) stretch at the end of knee flexion (knee in a bent position), seven times a week. During a review of Resident 23's Physician Order Summary Report, dated 6/22/2024 indicated a physician order, for RNA to provide AAROM exercises to the right leg with gentle passive stretch at the end of knee flexion, seven times a week. During a review of Resident 23's May RNA Documentation Survey Report, indicated for RNA to assist Resident 23 with arm bicycle exercises, seven times a week as tolerated. The squares on the Survey Report were blank on the following days: 5/2/2024, 5/3/2024, 5/5/2024 to 5/9/2024, 5/11/2024 to 5/17/2024, 5/19/2024, 5/21/2024, 5/23/2024 to 5/31/2024. During a review of Resident 23's May RNA Documentation Survey Report, indicated for RNA to provide AAROM exercises to Resident 23's left leg, seven times a week as tolerated. The squares on the Survey Report were blank on the following days: 5/2/2024, 5/3/2024, 5/5/2024 to 5/9/2024, 5/11/2024 to 5/17/2024, 5/19/2024, 5/21/2024, 5/23/2024 to 5/31/2024. During a review of Resident 23's May RNA Documentation Survey Report, indicated for RNA to provide AAROM exercises to Resident 23's right leg, seven times a week as tolerated. The squares on the Survey Report were blank on the following days: 5/2/2024, 5/3/2024, 5/5/2024 to 5/9/2024, 5/11/2024 to 5/17/2024, 5/19/2024, 5/21/2024, 5/23/2024 to 5/31/2024. During a review of Resident 23's June RNA Documentation Survey Report, indicated for RNA to assist Resident 23 with arm bicycle exercises, seven times a week as tolerated. The squares on the Survey Report were blank on the following days: 6/1/2024, 6/3/2024 to 6/8/2024, and 6/10/2024. 056308 Page 14 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 23's June RNA Documentation Survey Report, indicated for RNA to provide AAROM exercises to Resident 23's right leg, seven times a week as tolerated. The squares on the Survey Report were blank on the following days: 6/1/2024, 6/3/2024 to 6/8/2024, and 6/10/2024. During a review of Resident 23's June RNA Documentation Survey Report, indicated for RNA to provide AAROM exercises to Resident 23's left leg, seven times a week as tolerated. The squares on the Survey Report were blank on the following days: 6/1/2024, 6/3/2024 to 6/8/2024, and 6/10/2024. b. During a concurrent observation and interview on 6/11/2024 at 4:26 p.m., with Resident 66 in Resident 66's room, observed Resident 66 lying in bed with the head of the bed elevated. Resident 66 was unable to raise both arms to shoulder level, fully straighten both elbows, and make full fists with both hands. Resident 66's both legs were resting on a pillow with the toes on both feet pointing downwards. Resident 66 stated she was unable to bend and straighten both ankles and both knees. During a review of Resident 66's admission Record, the admission Record indicated Resident 66 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including muscle wasting and atrophy (decrease in size or wasting away of a body part of tissue) and ataxic gait (uncoordinated manner of walking). During a review of Resident 66's MDS, dated [DATE], the MDS indicated Resident 66 had severe cognitive impairment. The MDS indicated Resident 66 was dependent in eating, hygiene, toileting, bathing, and transfers. The MDS indicated Resident 66 had functional limitations in ROM of one leg (hip, knee, ankle, foot). During a review of Resident 66's Physician Order Summary Report, dated 5/3/2024, indicated for RNA to provide passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises to Resident 66's left arm, seven times a week. During a review of Resident 66's Physician Order Summary Report dated 5/3/2024, indicated for RNA to provide PROM exercises to Resident 66's right arm, seven times a week. During a review of Resident 66's Physician Order Summary Report dated 5/6/2024, indicated for RNA to provide PROM exercises to Resident 66's left leg, seven times a week. During a review of Resident 66's Physician Order Summary Report, dated 5/6/2024, indicated for RNA to provide PROM exercises to Resident 66's right leg, seven times a week. During a review of Resident 66's May RNA Documentation Survey Report, indicated for RNA to provide PROM exercises to Resident 66's left arm, seven times a week. The squares on the Survey Report were blank on the following days: 5/5/2024 to 5/9/2024, 5/11/2024 to 5/14/2024, 5/16/2024, 5/21/2024, 5/23/2024 to 5/25/2024, and 5/27/2024 to 5/30/2024. During a review of Resident 66's May RNA Documentation Survey Report, indicated for RNA to provide PROM exercises to Resident 66's right arm, seven times a week. The squares on the Survey Report were blank on the following days: 5/5/2024 to 5/9/2024, 5/11/2024 to 5/14/2024, 5/16/2024, 5/17/2024, 5/19/2024, 5/21/2024, 5/23/2024 to 5/25/2024, and 5/27/2024 to 5/30/2024. During a review of Resident 66's May RNA Documentation Survey Report, indicated for RNA to provide PROM exercises to Resident 66's left leg, seven times a week. The squares on the Survey Report were 056308 Page 15 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some blank on the following days: 5/6/2024 to 5/9/2024, 5/11/2024 to 5/14/2024, 5/16/2024, 5/17/2024, 5/19/2024, 5/21/2024, 5/23/2024 to 5/25/2024, and 5/27/2024 to 5/30/2024. During a review of Resident 66's May RNA Documentation Survey Report, indicated for RNA to provide PROM exercises to Resident 66's right leg, seven times a week. The squares on the Survey Report were blank on the following days: 5/6/2024 to 5/9/2024, 5/11/2024 to 5/14/2024, 5/16/2024, 5/17/2024, 5/19/2024, 5/21/2024, 5/23/2024 to 5/25/2024, and 5/27/2024 to 5/30/2024. c. During a concurrent observation and interview on 6/11/2024 at 3:33 p.m., with Resident 84 in Resident 84's room, observed Resident 84 lying in bed with a hand splint was sitting on the table next to Resident 84's bed. Resident 84's left arm was positioned with the elbow bent at a 90-degree angle, the wrist straight, the fingers of the hand were bent, and the thumb was resting on top of the pointer finger (finger next to the thumb). Resident 84's toes of both feet were pointing downwards. Resident 84 was unable to actively move the left hip and left knee. Resident 84 stated RNA staff assisted with exercises of both arms and both legs, walking, standing, and placement of the splint on the left hand but did not come every day. During a review of Resident 84's admission Record, the admission Record indicated Resident 84 was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy and ataxia (decreased muscle control). During a review of Resident 84's MDS, dated [DATE], the MDS indicated Resident 84 was cognitively intact. The MDS indicated Resident 84 required set-up assistance for eating and oral hygiene, substantial/maximal assistance for upper body dressing, partial/moderate assistance for rolling to both sides and personal hygiene, and dependent in toileting, bathing, lower body dressing, and transfers. The MDS indicated Resident 84 had functional limitations in ROM in one arm (shoulder, elbow, wrist, hand) and one leg (hip, knee, ankle, foot). During a review of Resident 84's Physician Order Summary Report, dated 2/14/2022, indicated for RNA to provide PROM exercises to Resident 84's left arm in all planes and gentle passive stretching of the left elbow, wrist, fingers, and shoulder, seven times a week. During a review of Resident 84's Physician Order Summary Report, dated 2/14/2022, indicated for RNA to provide strengthening exercises to Resident 84's right arm using an arm bicycle, for 15 minutes, seven times a week. During a review of Resident 84's Physician Order Summary Report, dated 12/1/2023, indicated for RNA to provide Resident 84 with walking exercises, three times a week. During a review of Resident 84's Physician Order Summary Report, dated 12/1/2023, indicated for RNA to assist Resident 84 with sit to stand exercises, three times a week. During a review of Resident 84's Physician Order Summary Report, dated 12/1/2023, indicated for RNA to provide gentle passive stretching of Resident 84's left ankle, seven times a week. During a review of Resident 84's Physician Order Summary Report dated 7/18/2023, indicated for RNA to apply a resting hand splint (medical device that supports the hand, wrist, and fingers) to Resident 84's left hand for a maximum of four hours daily, seven times a week. 056308 Page 16 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0688 Level of Harm - Minimal harm or potential for actual harm During a review of Resident 84's May RNA Documentation Survey Report, indicated for RNA to provide PROM exercises to Resident 84's left arm in all planes and gentle passive stretching of the left elbow, wrist, fingers, and shoulder, seven times a week. The squares on the Survey Report were blank on the following days: 5/2/2024, 5/3/2024, 5/5/2024 to 5/9/2024, 5/11/2024 to 5/16/2024, 5/19/2024, 5/21/2024 to 5/31/2024. Residents Affected - Some During a review of Resident 84's May RNA Documentation Survey Report, indicated for RNA to provide strengthening exercises to Resident 84's right arm using an arm bicycle, for 15 minutes, seven times a week. The squares on the Survey Report were blank on the following days: 5/2/2024, 5/3/2024, 5/5/2024 to 5/9/2024, 5/11/2024 to 5/16/2024, 5/19/2024, 5/21/2024 to 5/31/2024. During a review of Resident 84's May RNA Documentation Survey Report, indicated for RNA to provide Resident 84 with walking exercises, three times a week. The squares on the Survey Report were blank on the following days: 5/2/2024, 5/3/2024, 5/5/2024 to 5/9/2024, 5/11/2024 to 5/16/2024, 5/19/2024, 5/21/2024 to 5/31/2024. During a review of Resident 84's May RNA Documentation Survey Report, indicated for RNA to assist Resident 84 with sit to stand exercises, three times a week. The squares on the Survey Report were blank on the following days: 5/2/2024, 5/3/2024, 5/5/2024 to 5/9/2024, 5/11/2024 to 5/16/2024, 5/19/2024, 5/21/2024 to 5/31/2024. During a review of Resident 84's May RNA Documentation Survey Report, indicated for RNA to provide gentle passive stretching of Resident 84's left ankle, seven times a week. The squares on the Survey Report were blank on the following days: 5/2/2024, 5/3/2024, 5/5/2024 to 5/9/2024, 5/11/2024 to 5/16/2024, 5/19/2024, 5/21/2024 to 5/31/2024. During a review of Resident 84's May RNA Documentation Survey Report, indicated for RNA to apply a resting hand splint to Resident 84's left hand for a maximum of four hours daily, seven times a week. The squares on the Survey Report were blank on the following days: 5/2/2024, 5/3/2024, 5/5/2024 to 5/9/2024, 5/11/2024 to 5/16/2024, 5/19/2024, 5/21/2024 to 5/31/2024. During a review of Resident 84's June RNA Documentation Survey Report, indicated for RNA to provide PROM exercises to Resident 84's left arm in all planes and gentle passive stretching of the left elbow, wrist, fingers, and shoulder, seven times a week. The squares on the Survey Report were blank on the following days: 6/1/2024, 6/3/2024 to 6/8/2024, 6/10/2024, and 6/11/2024. During a review of Resident 84's June RNA Documentation Survey Report, indicated for RNA to provide strengthening exercises to Resident 84's right arm using an arm bicycle, for 15 minutes, seven times a week. The squares on the Survey Report were blank on the following days: 6/1/2024, 6/3/2024 to 6/8/2024, 6/10/2024, and 6/11/2024. During a review of Resident 84's June RNA Documentation Survey Report, indicated for RNA to provide Resident 84 with walking exercises, three times a week. The squares on the Survey Report were blank on the following days: 6/1/2024, 6/3/2024 to 6/8/2024, 6/10/2024, and 6/11/2024. During a review of Resident 84's June RNA Documentation Survey Report, indicated for RNA to assist Resident 84 with sit to stand exercises, three times a week. The squares on the Survey Report were blank on the following days: 6/1/2024, 6/3/2024 to 6/8/2024, 6/10/2024, and 6/11/2024. 056308 Page 17 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 84's June RNA Documentation Survey Report, indicated for RNA to provide gentle passive stretching of Resident 84's left ankle, seven times a week. The squares on the Survey Report were blank on the following days: 6/1/2024, 6/3/2024 to 6/8/2024, 6/10/2024, and 6/11/2024. During a review of Resident 84's June RNA Documentation Survey Report, indicated for RNA to apply a resting hand splint to Resident 84's left hand for a maximum of four hours daily, seven times a week. The squares on the Survey Report were blank on the following days: 6/1/2024, 6/3/2024 to 6/8/2024, and 6/10/2024. d. During a concurrent observation and interview on 6/11/2024 at 9:51 a.m., with Resident 117 in Resident 117's room, observed Resident 117 was lying in bed. Resident 117 made a partial fist with the right hand and was unable to move his right wrist, elbow, and shoulder. Resident 117 was unable to actively move his right leg and stated he needs help walking. Resident 117 stated staff did not assist with walking and exercises for his arms and legs every day. During a review of Resident 117's admission Record, the admission Record indicated Resident 117 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including right-sided hemiplegia and hemiparesis following an intracranial hemorrhage (bleeding of the brain), dysarthria (motor speech disorder in which the muscles used to produce speech are damaged or weak), and muscle wasting and atrophy. During a review of Resident 117's MDS, dated [DATE], the MDS indicated Resident 117 was cognitively intact. The MDS indicated Resident 117 was dependent in eating, hygiene, toileting, bathing, and transfers. The MDS indicated Resident 117 had functional limitations in ROM in one arm (shoulder, elbow, wrist, hand) and one leg (hip, knee, ankle, foot). During a review of Resident 117's Physician Order Summary Report, dated 4/20/2024, indicated for RNA to provide PROM exercises to Resident 117's right leg, seven times a week. During a review of Resident 117's Physician Order Summary Report, dated 4/20/2024, indicated for RNA to provide PROM exercises to Resident 117's right arm, seven times a week. During a review of Resident 117's Physician Order Summary Report, dated 5/28/2024, indicated for RNA to provide exercises to Resident 117's both arms using an arm bicycle, seven times a week. During a review of Resident 117's Physician Order Summary Report, dated 5/29/2024 indicated for RNA to provide Resident 117 with walking exercises wearing an ankle foot orthosis (AFO, brace to hold the foot and ankle in the correct position) and using a hemi-walker (assistive device that allows a person to lean on one side while walking for support), seven times a week. During a review of Resident 117's May RNA Documentation Survey Report indicated for RNA to provide PROM exercises to Resident 117's right leg, seven times a week. The squares on the Survey Report were blank on the following days: 5/2/2024 to 5/9/2024, 5/11/2024 to 5/17/2024, 5/19/2024, and 5/21/2024 to 5/31/2024. During a review of Resident 117's May RNA Documentation Survey Report, indicated for RNA to provide PROM exercises to Resident 117's right arm, seven times a week. The squares on the Survey Report were blank on the following days: 5/2/2024 to 5/9/2024, 5/11/2024 to 5/17/2024, 5/19/2024, and 5/21/2024 to 5/31/2024. 056308 Page 18 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 117's May RNA Documentation Survey Report, indicated for RNA to provide Resident 117 with walking exercises wearing an AFO and using a hemi-walker, 7 times a week. The squares on the Survey Report were blank on the following days: 5/29/2024, 5/30/2024, and 5/31/2024. During a review of Resident 117's May RNA Documentation Survey Report, indicated for RNA to provide exercises to Resident 117's both arms using an arm bicycle, seven times a week. The squares on the Survey Report were blank on the following days: 5/6/2024 to 5/9/2024, 5/11/2024 to 5/14/2024, 5/16/2024, 5/17/2024, 5/19/2024, 5/21/2024, 5/23/2024 to 5/25/2024, and 5/27/2024 to 5/30/2024. During a review of Resident 117's June RNA Documentation Survey Report, indicated for RNA to provide PROM exercises to Resident 117's right leg, seven times a week. The squares on the Survey Report were blank on the following days: 6/1/2024, 6/3/2024 to 6/10/2024. During a review of Resident 117's June RNA Documentation Survey Report, the Survey Report indicated for RNA to provide PROM exercises to Resident 117's right arm, seven times a week. The squares on the Survey Report were blank on the following days: 6/1/2024, 6/3/2024 to 6/10/2024. During a review of Resident 117's June RNA Documentation Survey Report, indicated for RNA to provide Resident 117 with walking exercises wearing an AFO and using a hemi-walker, seven times a week. The squares on the Survey Report were blank on the following days: 6/1/2024, 6/3/2024 to 6/10/2024. During a review of Resident 117's June RNA Documentation Survey Report, indicated for RNA to provide exercises to Resident 117's both arms using an arm bicycle, seven times a week. The squares on the Survey Report were blank on the following days: 6/1/2024, 6/3/2024 to 6/10/2024. During a concurrent interview and record review on 6/13/2024 at 10:54 a.m., the Director of Staff Development (DSD) reviewed the RNA May 2024 and June 2024 Documentation Survey Reports and physician's orders for Residents 23, 66, 84, and 117. The DSD confirmed Residents 23, 66, and 117 had physician orders for RNA to provide RNA services seven times a week. The DSD confirmed Resident 84 had physician's orders for RNA to provide RNA services three times a week and seven times a week. The DSD stated a blank square on the RNA Survey Report indicated the resident was not seen for RNA treatment that day. The DSD confirmed Resident 23 missed 25 RNA sessions for AAROM exercises of both legs and arm bicycle exercises for the month of May. The DSD confirmed Resident 23 missed eight (8) RNA sessions for AAROM exercises for both legs and arm bicycle exercises for the month of June. The DSD confirmed Resident 66 missed 19 RNA sessions for left arm PROM exercises and 20 RNA sessions for PROM of the right arm and both legs for the month of May. The DSD confirmed Resident 84 missed 8 RNA sessions for walking exercises and sit to stand exercises for the month of May. The DSD confirmed Resident 84 missed 25 RNA sessions for left ankle ROM exercises, application of a left-hand splint, PROM of the left arm, and strengthening exercises on the arm bike for the month of May. The DSD confirmed Resident 84 missed three RNA sessions for walking exercises and sit to stand exercises for the month of June. The DSD confirmed Resident 84 missed nine (9) RNA sessions for left ankle ROM exercises, application of a left-hand splint, PROM of the left arm, and strengthening exercises on the arm bike for the month of June. The DSD confirmed Resident 117 missed 27 RNA sessions for PROM exercises of the right leg and right arm for the month of May. The DSD confirmed Resident 117 missed three RNA sessions for walking exercises and arm bike exercises for the month of May. The DSD confirmed Resident 117 missed nine RNA sessions for PROM exercises of the right leg, PROM exercises of the right leg, walking exercises, and arm bike exercises for the month of June. The DSD stated Residents 23, 66, 84, and 117 did not receive RNA treatments as ordered by the physician due to insufficient RNA staffing in the months of May and June 2024. The DSD stated it was important for RNA to provide services as 056308 Page 19 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some prescribed by the physician because missed treatments could place residents at risk for a functional decline and contractures. During an interview on 6/13/2024 at 1:55 p.m., the Director of Nursing (DON) stated the purpose of the RNA program was to maintain and/or improve a resident's current level of function and prevent declines in ROM and functional mobility. The DON stated missed RNA treatments could potentially cause a resident to experience a decline in overall function and mobility. e. During a review of Resident 43's admission Order, the admission Record indicated Resident 43 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease ([COPD] a lung condition that cause breathing difficulties), hypertensive heart disease with heart failure (heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), and bilateral primary osteoarthritis of knee (a degenerative joint disease that affects both knees, causing pain, stiffness, swelling, and decreased mobility). During a review of Resident 43's Minimum Data Sheet (MDS a comprehensive assessment and care screening tool) dated 4/12/2024 indicated Resident 43 had no cognitive impairment (ability to learn, understand, and make decisions) and dependent assistance for toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 43's care plan revised on 10/12/2023, Resident 43 had potential for impaired physical mobility related to limited movement due to hemiplegia (refers to a severe or complete loss of strength and hemiparesis (refers toa relatively mild loss of strength), osteoarthritis and COPD and one of the interventions is to provide RNA program for both upper and lower arm bike exercises daily times seven days a week as tolerated, provide both lower extremities active range of motion (AROM movement at a given joint) exercises daily seven times a week as tolerated. During a concurrent interview and record review on 6/12/2024 at 10:03 a.m., with RNA 3, reviewed RNA Documentation Survey Report dated 6/11/2024 which indicated the squares on the Survey Report was signed by RNA 3 and recorded that RNA exercises was given to Resident 43. RNA 3 stated she did not provide RNA exercises to Resident 43 on 6/11/2024 but documented in the RNA Documentation Survey Report that RNA exercises was provided on 6/11/2024. RNA 3 stated if range of motion exercises were not given according to the order, it had the potential to cause decline in Resident 43's physical functioning. During a review of the facility's undated policy and procedure (P&P), titled Rehabilitative Nursing Care, the P&P indicated rehabilitative nursing care was provided for each resident admitted and was designed to assist each resident to achieve and maintain an optimal level of self-care and independence. The P&P indicated RNA was performed daily for those residents who required such services and included assisting residents use their prosthetic devices, assisting resident to carry out prescribed therapy exercises, and assisting resident with ROM exercises. During a record review of the facility's P&P titled Range of Motion Exercises (undated), indicated: The purpose of this procedure was to exercise the resident's joints and muscles. The following information should be recorded in the resident's medical record: 1. The date and time that the exercises were performed. 2. The name and title of the individual(s) who performed the procedure. 056308 Page 20 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0688 3. The type of ROM exercise given. Level of Harm - Minimal harm or potential for actual harm 4. Whether the exercise was active or passive. 5. How long the exercise was conducted. Residents Affected - Some 6. If and how the resident participated in the procedure or any changes in the resident's ability to participate in the procedure. 7. Any problems or complaints made by the resident related to the procedure. 8. If the resident refused the treatment, the reason(s) why and the intervention taken. 9. The signature and title of the person recording the data. CROSS REFERENCE TO F725 056308 Page 21 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to prevent the resident's unplanned severe weight loss (a weight loss greater than 5 % in one month, greater that 7.5% in three months and greater than 10 % in 6 months) of nine (9) pounds ([lbs.] 9.57 percent [%] in one month for one of two sampled residents (Resident 129). The facility failed to: Residents Affected - Few 1. Ensure the Registered Dietician's ([RD] a health professional who has a special training in diet and nutrition) recommendation to increase Resident 129's enteral (form of nutrition that is delivered into the digestive system as liquid) feeding from 250 milliliter ([ml] unit of measurement) four times per day to 250 ml five times per day totaling 1500 calories ([kCal] energy people get from the food and drink they consume, and the energy they use in physical activity) were followed and provided. 2.Ensure staff monitored Resident 129's weight and reported the resident's five pounds weigh loss to Resident 129's physician and RD in accordance with the care plan titled Risk for Malnutrition (lack of significant nutrients [substance used in the body to function] leading to physical decline). 3. Ensure the facility's staff informed the RD when Resident 129 had a 9.57 % weight loss from 4/29/2024 through 6/1/2024 for RD to evaluate and make necessary recommendations on Resident 129's enteral feeding formula to provide Resident 129 with a sufficient amount of calories and nutrients to prevent Resident 129's severe weight loss of 9.57 % in 34 days in accordance with the facility's policy and procedure (P&P) titled, Nutrition (Impaired/Unplanned Weight Loss-Clinical Protocol. 4. Ensure licensed staff followed facility's P&P titled, Weight Assessment and Intervention and immediately notified the Dietician in writing of Resident 129's weight loss of 5% or more since the last weight assessment on 4/29/2024. 5. Ensure the RD completed Resident 129's full nutritional assessment upon admission to the facility on 4/27/2024 and monitor Resident 129's weight and caloric intake, who was receiving tube feeding nutrition, and makes appropriate recommendations for intervention to enhance tolerance and nutritional adequacy of tube feedings per facility's P & P. These deficient practiced resulted in Resident 129's severe weight loss of 9.57 % in 34 days and placed Resident 129 at risk for malnutrition, dehydration (dangerous loss of body fluid caused by illness, sweating, or inadequate intake), skin break down, having feelings of depression and hopelessness. Findings: During a review of Resident 129's admission Record, indicated Resident 129 was admitted to the facility on [DATE], with diagnoses including amyotrophic lateral sclerosis ( a nervous system disease that affects nerve cells in the brain and spinal cord), dysphagia (difficulty of swallowing), gastrostomy tube ([GT] a soft tube surgically inserted directly into the stomach to administer medication, fluids and nutrition), deep tissue injury ([DTI] purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure) to a sacral (tailbone) area, and muscle wasting (loss of muscle tissue). 056308 Page 22 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0692 During a review of Resident 129's History and Physical (H&P), dated 4/28/2024, the H&P indicated, Resident 129 did not have decision making capacity. Level of Harm - Actual harm Residents Affected - Few During a review of Resident 129's Minimum Data Set ([MDS], a standardized assessment and care screening tool]) dated 5/1/2024, the MDS indicated Resident 129 was dependent (helper does all of the effort) on staff with oral hygiene, toileting hygiene, and personal hygiene. The MDS indicated Resident 129 height was five feet (unit of measurement) and three inches (unit of measurement) and weighed 94 pounds ([lbs.] unit of weight). The MDS indicated Resident 129 was receiving nutrition via GT. During a review of Resident 129's Weights and Vitals Summary from 4/29/2024 to 6/1/2024, the Weights and Vitals Summary indicated the following resident's weekly weight: 1. On 4/29/2024 - 94 pounds. 2. On 5/5/2024- 93.4 pounds. 3. On 5/12/2024- 87 pounds (7.0 pounds [7.45%] weight loss). 4. On 5/19/2024- 87.4 pounds (6.6 pounds [7.02%] weight loss). 5. On 5/26/2024- 85.4 pounds (8.6 pounds [9.15 %] weight loss). 6. On 6/1/2024- 85 pounds (9.0 pounds [9.57 %] weight loss). During an interview on 6/12/2024 at 10:30 a.m., the License Vocational Nurse (LVN 5) stated when Resident 129 had a weight loss of nine (9) pounds from 4/29/2024 to 6/1/2024, a change of condition (COC) documentation should have been done, Resident 129's physician and RD should have been informed and an Interdisciplinary team ([IDT]- group of healthcare professional s working together to plan the care needed for each residents) meeting should be held immediately in order to address the resident's weight loss and recommend interventions to prevent further resident's weight loss. LVN 5 stated Resident 129 was getting weighed weekly due to a weight loss. LVN 5 stated she did not report Resident 129's severe weight loss of 9 pounds (9.57 %) to RD and the physician. LVN 5 stated severe weight loss should be reported immediately to Resident 129's physician and RD because Resident 129 could lose more weight that can lead to hospitalization due to malnutrition. During a review of Resident 129's care plan titled, Risk for Malnutrition, dated 4/28/2024 indicated a goal for Resident 129 was not to have significant weight loss of five lbs. in one month (5 % in one month, 7.5 % in 3 months, 10 % in 6 months). The care plan interventions included to monitor the resident's weight and report five lbs. weight loss to the physician and RD promptly and notify the physician of significant weight change and refer to dietician. During a review of Resident 129's Care Plan titled GT feeding, dated 4/28/2024 indicated a goal for Resident 129 was to maintain adequate nutrition and hydration (fluid intake) status and to have a stable weight with no signs and symptoms of malnutrition or dehydration. During a review of RD's Nutrition/Dietary Progress Note dated 4/28/2024 and timed at 6:55 p.m., the Nutrition/Dietary Progress Note indicated Resident 129 was receiving 250 ml of enteral feeding with formula Fibersource 1.2 four times daily. Resident 129 body mass index ([BMI] measure body weight to height and whether a resident has a healthy weight) was 17.9 (BMI between 18.5 and 24.9 056308 Page 23 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0692 Level of Harm - Actual harm Residents Affected - Few -underweight, BMI healthy range -between 25 and 29.9, and BMI between 30 and 39.9- overweight). The RD's Nutrition/Dietary Progress Note indicated RD's recommendation to change GT enteral feeding formula to 250 ml five times a day to provide Resident 129 with 1250 ml (1500 kcal) daily. The RD's Nutrition/Dietary Progress Note indicated the RD's full assessment of Resident 129 nutritional needs will follow. During a review of Resident 129's Nutritional Review Screening, dated 4/29/2024 completed by Dietary Supervisor (DS) indicated based on Resident 129's usual body weight (UBW) of 115 lbs. the resident's estimated daily need for calories were 1495-1709 kcal. The Nutritional Review Screening indicated recommendation including change enteral feeding to 250 ml five times daily to provide 1250 ml equal to 1500 kcal, 67 grams of protein, 1512 ml of free water (fluids with no salt content), and Multivitamins (dietary supplement containing all or most of the vitamins) with Minerals. During a review of Resident 129's Medication Administration Record (MAR) dated 5/2024, the MAR indicated the Enteral Feeding Order for Fibersource HN 1.2 four times a day as follows: 250 ml (Breakfast), 500 ml (Lunch), 250 ml (Dinner), 250 ml (Bedtime). During a review of Resident 129's Physician Order Summary dated 5/2024, indicated Enteral Feeding Order for Fibersource HN 1.2 four times a day as follows: 250 ml (Breakfast), 500 ml (Lunch), 250 ml (Dinner), 250 ml (Bedtime). During a review of Resident 129's MAR for the month 5/2024 indicated Resident 129 only received 250 ml of Fibersource for lunch instead of 500 ml as ordered: 1. From 5/3/2024 to 5/13/2024 (10 days) - Fibersource 250 ml. 2. On 5/14/2024- Fibersource 300 ml. 3. From 5/18/2024 to 5/20/2024 (there days)- Fibersource 250 ml. 4. On 5/27/2024- Fibersource 250 ml. During a concurrent interview and record review on 6/12/2024 at 11:05 a.m., the Director of Nursing (DON) stated residents (in general) with weight loss will trigger for weekly weight variance review (report generated to determine how much weight a resident has lost and recommendations to prevent further weight loss) and a weekly weight variance meeting to discuss the plan of care for a residents (in general). The DON stated Resident 129 was triggered for a weight variance weekly review meetings because the resident was at high risk for weight loss. The DON stated weekly weight variance meeting allows the facility to monitor Resident 129's weight and allows the facility to ensure that implemented interventions were successful. The DON stated weekly weight variance meeting also allows to evaluate if other interventions could be implemented to prevent further weight loss. The DON stated the weekly weight variance meetings were documented on the Progress Notes by nursing and the RD. After a review of Resident 129's Nurses Progress Notes and RD Progress Notes the DON stated, there was no documentation from nursing and the RD for the weekly variance meetings to address the resident's weight loss. The DON stated, if there was no documentation it means it was not done. After the DON reviewed Resident 129's Initial Nutritional Assessment, the DON confirmed the last documentation from the RD was the initial mini nutritional assessment (nutrition screening and assessment tool that can identify residents who are malnourished or at risk of malnutrition) done on 4/29/2024. The DON stated 9.57 % weight loss was considered a severe weight loss and required weekly monitoring by the 056308 Page 24 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0692 Level of Harm - Actual harm Residents Affected - Few facility. The DON stated the RD should have monitor Resident 129 to ensure the resident did not lose additional weight. The DON stated the staff communicates with the RD via text message regarding the weekly weight variance meetings. The DON stated it was the licensed nurses responsibility to ensure Resident 129's weight loss was communicated to the resident's physician and RD in order to prevent negative outcomes such as severe weight loss and dehydration. The DON stated when residents (in general) do not receive adequate nutrition they could have negative effects such as skin break down and malnutrition. During a concurrent interview and record review on 6/12/2024 at 1:30 p.m. with RD, the RD stated she was responsible for nutritional assessments of residents on admission and quarterly assessment which includes evaluating and addressing residents' (in general) high risk for weight loss. RD stated residents (in general) who were on GT feedings should be weighed weekly and a weekly variance meeting should be held to discuss interventions to prevent weight loss. The RD stated she does not attend the weight variance meeting; the licensed staff communicates with her via text message about any weight loss and other concerns discussed during the weight variance meeting. The RD stated she follows up with residents (in general) that have weight loss weekly. The RD stated she has done Resident 129's mini nutritional assessment on 4/29/2024 and a full assessment of Resident 129 nutritional status and needs should have been done as well. The RD confirmed that Resident 129's full assessment had not been done since the resident's admission to the facility on 4/27/2024. After RD reviewed her weekly progress notes, for Resident 129, she stated there was no weekly documentation for Resident 129's weight loss. Resident 129's Nutrition/Dietary Progress, dated 4/28/2024, indicated recommendation to change GT feeding to 250 ml five times daily to provide 1250 ml equivalent of 1500 kcal. with full assessment to follow. Reviewed Resident 129's MAR date 5/2024, the MAR indicated Enteral Feed Order four times a day Fibersource HN 1.2 250 ml (Breakfast), 500 ml (Lunch), 250 ml (Dinner), 250 ml (Bedtime). The RD stated Resident 129's enteral feeding order for 250 ml four times a day was not providing enough calories to Resident 129 and confirmed the facility's staff did not follow with her recommendation to increase the feeding to 250 ml five times a day. The RD stated Resident 129 did not receive the estimated needs of 1511 to 1727 kcal a day. The RD stated 9.57 % weight loss in 34 days was considered a severe weight loss and the facility's staff should have reported it immediately to Resident 129's physician and her. The RD stated Resident 129 could have become malnourished which would cause further skin breakdown from not receiving enough calories and protein per day. During a concurrent interview and record review on 6/12/2024 at 2:09 p.m., with LVN 1, LVN 1 stated during weekly weight variance meetings residents (in general) weight loss was discussed. LVN 1 stated any recommendations from the weekly weight variance meetings were communicated to the RD via text message and documented on the Nurses Progress Notes. LVN 1 reviewed Resident 129's Nurses Progress Notes and stated there was no documentation RD was notified about Resident 129's severe weight loss. LVN 1 confirmed that there was no documentation for Resident 129's weekly weight variance meeting and it was not held since Resident 129's admission on [DATE]. LVN 1 stated if it was not documented it means it was not done. LVN 1 stated 9.57 % weight loss in 34 days was considered a severe and had the potential to cause a negative outcome for Resident 129's health. During an interview on 6/12/2024 at 2:23 p.m., the Dietary Supervisor (DS) stated she attends the weekly weight variance meetings. The DS stated she communicates with RD on Mondays regarding the weekly weight variance meeting. The DS stated there was no weight variance meeting held for Resident 129's severe weight loss of 9.57 % in 34 days from 4/27/2024 to 6/1/2024. The DS stated it was important to monitor Resident 129's weight to ensure that the interventions were effective in order to prevent further weight loss. The DS stated Resident 129's severe weight loss put the resident at risk for dehydration, 056308 Page 25 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0692 Level of Harm - Actual harm Residents Affected - Few malnutrition, skin breakdown and hospitalization. The DS stated nursing staff document the weekly weight variance meetings in a resident's (in general) Progress Notes. The DS stated 9.57% of weight loss in 34 days was considered a severe weight loss. During a review of the facility's P&P titled, Weight Assessment and Intervention dated 9/2008, indicated, Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. The Dietician will review the unit weight record by the 15th of the month for follow individual weight trends over time. During a review of the facility's P&P titled, Enteral Nutrition, dated 11/2018, the P&P indicated, The dietician with input from the provider and nurses: estimate calorie, protein, nutrients, and fluid needs. Determine whether the resident's current intake is adequate to meet his or her nutritional needs. The dietician monitors residents who are receiving enteral nutrition and makes appropriate recommendations for intervention to enhance tolerance and nutritional adequacy of enteral feedings. During a review of the facility's P&P titled, Nutritional Assessment, [undated], indicated, The Dietician, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that place the resident at risk for impaired nutrition. During a review of the facility's P&P titled, Nutrition Impaired/Unplanned Weight Loss-Clinical Protocol, [undated], indicated, The Physician and staff will closely monitor residents who have been identified as having impaired nutrition or risk factors for developing impaired nutrition. Such monitoring may include evaluating the care plan to determine if the interventions are being implement and whether they are effective in attaining the established nutritional and weight goals. 056308 Page 26 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - 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 resident, who had a Stage 4 pressure ulcer (wound that penetrate all layers of skin exposing muscles, tendons [tissue that unites a muscle with a bone] cartilage {tissue that lines a joints}, and bones caused by prolonged pressure on the skin) to sacrum (tailbone area), did not experience unnecessary pain and suffering during pressure ulcer treatment and repositioning for one of five sampled residents (Resident 73). The facility failed to: Residents Affected - Few 1. Ensure the Registered Nurse (RN 6) provided Resident 73 with effective pain relieve when Resident 73 loudly screamed and moaned during the sacral pressure ulcer treatment. 2. Evaluate the pain relieve effectiveness of Tylenol (pain medication) 325 milligrams ([mg]-a unit of measurement) two tablets given to Resident 73's as ordered prior to pressure ulcer treatment before the start of pressure ulcer treatment. 3. Notify Resident 73's physician (MD 1) of Resident 73's pain management with Tylenol was unsuccessful when Resident 73 continue to moan and scream during the pressure ulcer treatment on 6/10/2024 and 6/13/2024. 4. Ensure RN 6 identified frequency, location, quality, onset, and manner of pain when Resident 73's experienced pain, in accordance with the resident's Care Plan titled, Potential for altered comfort which maybe evidenced by grimacing or moaning related to a Stage 4 pressure ulcer to the sacral area, bilateral knee osteoarthritis (degenerative joint disease) and pancreatic mass (tumor that forms in the cells of pancreas) dated 4/20/2023. These failures resulted in Resident 73's to experience severe, unrelieved, and uncontrolled pain manifested by loud screaming and moaning during pressure ulcer treatment and personal care on 6/10/2024 and 6/13/2024. Findings: During an observation and concurrent interview on 6/10/2024, at 10:09 a.m., Resident 73 was observed screaming, groaning, and moaning with facial grimaces (facial expression usually suggesting pain or disgust). Concurrently, during an interview, Resident 73 nodded the head Yes and grimaced when asked if she was having pain. During an interview on 6/10/2024, at 10:09 a.m. with Resident 62 (Resident 73's roommate) Resident 62 stated Resident 73 was constantly groaning and moaning especially when staff was cleaning or doing personal care. Resident 62 stated staff members were aware of Resident 73's moaning and screaming. During an observation of RN 6 preparation for Resident 73's sacral pressure ulcer treatment on 6/10/2024, at 10:30 a.m., in Resident 73's room, Resident 73's physician (MD 1) entered the resident 's room and informed RN 6 he (MD 1) will put an order for Norco (narcotic [used to treat moderate to severe pain] pain medication) to administer prior to pressure ulcer treatment as Resident 73 was observed moaning and screaming. RN 6 replied to MD 1 that Resident 73 does not need Norco as Resident 73 will receive Lidocaine spray (anesthetic topical [applied to the skin] spray) prior to the pressure 056308 Page 27 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0697 ulcer treatment. Level of Harm - Actual harm During an observation Resident 73's pressure ulcer treatment on 6/10/2024, at 10:32 a.m., Resident 73 was observed screaming and moaning when RN 6 positioned Resident 73 on her back with head of the bed in a flat position. RN 6 left Resident 73's room and ask another staff member to assist during pressure ulcer treatment. RN 6 came back with the Director of Staff Development (DSD). RN 6 and DSD turned Resident 73 to her right side. Resident 73 continuously moaned and screamed. RN 6 was observed to spray Resident 73's sacral Stage 4 pressure ulcer surrounding area with Lidocaine spray before the start of treatment. Resident 73 screamed and moaned louder when RN 6 cleaned the reddened surrounding area of Stage 4 sacral pressure ulcer with Hibiclens (liquid antibacterial cleanser) and applied Collagen powder (wound dressing that is applied topically) to the pressure ulcer. RN 6 completed the pressure ulcer treatment despite Resident 73's moaning and screaming. Residents Affected - Few During a review of Resident 73's admission Record, the admission Record indicated Resident 73 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including unspecified dementia (loss of cognitive functioning such as thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), osteoarthritis of both knee (degenerative joint disease), a Stage 4 pressure ulcer to the sacral region, and attention/ concentration deficit. During a review of Resident 73's History and Physical (H& P) dated 5/9/2024, indicated Resident 73 was not able to express needs, communicate, not to follow commands and talked in full sentences. Resident 73 had no decisions making capacity. During a review of Resident 73's Minimum Data Set ([MDS] standardized assessment and care screening tool) dated 5/1/2024, indicated Resident 73 was dependent on staff for bed mobility, moving from sitting on side of bed to lying flat on bed, toileting hygiene, bathing, dressing, personal hygiene, and oral hygiene. The MDS indicated Resident 73 had a Stage 4 pressure ulcer on the sacrum (sacral area). During a review of Resident 73's Physician's Order dated 6/10/2024, the Physician's Order indicated the order for Lidocaine spray to apply to the resident's sacral area topically every day for pain management during sacral pressure ulcer treatment. During a review of Resident 73's Physician Order dated 4/20/2024, the Physician order indicated to cleanse sacral wound with Hibiclens, pat dry, apply Collagen powder to the pressure ulcer base then apply Hydrofera Blue (special dressing type) then cover with Allevyn (dressing) every day (7 a.m.to 3 p.m.) Monday, Wednesday, and Friday. During an interview on 6/10/2024, at 10:45 a.m., and subsequent interview on 6/10/2024, at 11:22 am., with RN 6, RN 6 stated the Lidocaine spray was the only medicine he used to help with Resident 73's pain during pressure ulcer treatment. During a concurrent interview and record review on 6/12/2024 at 9:36 a.m., with DSD, the DSD stated for residents, who are not able to verbalize pain, the facility was using the facial pain scale tool (a picture with of different facial expressions referencing different pain level to help a resident effectively communicate the severity of their physical pain) to assess pain level. The DSD stated Resident 73 screamed loudly when RN 6 cleansed Resident 73's pressure ulcer with Hibiclens and when the Collagen powder was applied to the resident's Stage 4 sacral pressure ulcer. The DSD stated when 056308 Page 28 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0697 Level of Harm - Actual harm Residents Affected - Few Resident 73 screamed loudly during the pressure ulcer treatment, RN 6 should have stopped the treatment, assessed Resident 73 pain level, including the non-verbal cues like facial grimacing, notified the physician, and provide Resident 73 pain medication. The DSD reviewed Resident 73's Medication Administration Record (MAR) and stated Resident 73 received Tylenol 325 mg two tablets on 6/10/2024, at 10:07 a.m., prior to pressure ulcer treatment for pain level 3 out of 10 on a pain scale rating from zero to ten (pain screening tool using numerical value to assess the level of pain ranging from 0 to 3-mild pain, from 4 to 6- moderate pain, and from 7 to 9-severe pain, and 10- the worse pain possible). The DSD stated based on Resident 73 screaming and moaning during sacral pressure ulcer treatment Tylenol given at 10:07 a.m. was not effective to alleviate Resident 73's pain. The DSD stated Resident 73 experienced excruciating (extremely painful, causing intense suffering) pain and discomfort during the pressure ulcer treatment which was unnecessary pain. The DSD stated RN 6 should have asked the physician for a stronger pain medication after the resident screamed during sacral pressure ulcer treatment on 6/10/2024. During an interview on 6/12/2024, at 3:31 p.m., with Treatment Nurse (TN 1), the TN 1 stated she coordinated Resident 73's pressure ulcer treatment with the charge nurse in order to give pain medication to the resident before pressure ulcer treatment. TN 1 stated for residents, who could not verbalize pain and its severity, the staff used non-verbal indication of pain like screaming, moaning, or crying, and facial grimace. TN 1 stated Resident 73 screamed and moaned during pressure ulcer treatment, and it was an indication the resident was in excruciating pain. TN 1 stated Lidocaine spray was used topically and only applied on the skin and would not be enough to help with the pain during treatment. TN 1 stated if the resident screamed and moaned during pressure ulcer treatment RN 6 should have stopped the treatment, call the physician because the Lidocaine spray was not effective in managing Resident 73's pain. TN 1 stated Resident 73 should be assessed for pain before and during pressure ulcer treatment. TN 1 stated Resident 73's unrelieved pain could affect her health and comfort if her pain was not managed effectively. During an interview and record review on 6/12/2024 at 4:08 p.m., RN 6 stated when Resident 73 screamed from pain during the pressure ulcer treatment, he should stopped the treatment and notified the Resident 73's MD 1. RN 6 stated on 6/10/2024, MD 1 came to the resident's room and told him (RN 6) about ordering Norco for pain because of the moaning and crying, and confirmed he told MD 1 Resident 73 did not need Norco because the Lidocaine spray was being applied to the pressure ulcer. RN 6 stated Resident 73's family did not want the resident to have any strong pain medication. RN 6 confirmed thru record review of Interdisciplinary Team Meeting ([IDT]-a healthcare team members and resident / family representative collaborate, solve problems, plan, and coordinate care of the resident) Notes and Care Plan there was no documentation of Resident 73's family not wanting strong pain medication to be given to Resident 73 during pressure ulcer treatment. RN 6 stated Resident 73 was suffering from pain during a sacral pressure ulcer treatment manifested by the resident's screaming and moaning. RN 6 stated Resident 73 continued to suffer from pain because her pain was not addressed and managed during the pressure ulcer treatment on 6/10/2024. RN 6 stated Tylenol's pain relieve effectiveness was not evaluated prior to begin the treatment. During an observation on 6/13/2024, at 10:54 a.m., with TN 1 and Certified Nursing Assistant (CNA 5) in Resident 73's room, Resident 73 was observed starting moaning during repositioning. Resident 73 observed moaned louder as the TN 1 started to clean the surrounding skin area of the sacral pressure ulcer and applying the Collagen powder on the pressure ulcer. TN 1 observed to pause the pressure ulcer treatment and started reassuring the resident and massaging the resident's skin. TN 1 was observed to resume the treatment when Resident 73 stopped moaning. 056308 Page 29 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0697 Level of Harm - Actual harm During an interview on 6/13/2024, at 12:45 p.m. the TN 1 stated Resident 73 moaned during pressure ulcer treatment due to pain. TN 1 stated the resident had dementia and it was hard to tell when the resident was in pain, but the presence of pain should still be addressed by staff by using the resident's facial clues, grimacing, moaning and jerky movement during treatment. Residents Affected - Few During an interview on 6/13/2024, 2:04 p.m., CNA 5 stated every time she would clean and change Resident 73 after a bowel movement, the resident would moan and cry. CNA 5 stated Resident 73 would also moan during pressure ulcer treatment. During a review of Resident 73's Care Plan titled Potential for altered comfort evidenced by grimacing or moaning related to a Stage 4 pressure ulcer to the sacrum, bilateral knee osteoarthritis and pancreatic mass (tumor that forms in the cells of pancreas), dated 4/20/2023, the goal for Resident 73 was to be comfortable. The Care Plan's interventions included to identify frequency, location, quality, onset, and manner of expressed pain and administer medication as ordered. During a review of Resident 73's Care Plan titled, Resident has a Stage 4 sacral pressure ulcer on admission, initiated on 10/30/2023 indicated one of the interventions was to assess pain and discomfort at site of the altered skin area. During a concurrent interview and record review of Resident 73's Physician Order on 6/13/2024, at 3:31 p.m. with Director of Nursing (DON), the DON confirmed the physician order for Tylenol 325 mg two tablets for pain relief did not include the pain parameters, however, Resident 73 had an order to monitor the intensity of pain using numerical pain rating scale. The DON stated pain level was not assessed properly and Resident 73's pain was not managed effectively during pressure ulcer treatment. The DON stated Resident 73 should be assessed for pain during and after pressure ulcer treatment. The DON stated if the resident was experiencing pain by screaming and moaning, the pressure ulcer treatment should be stop, the staff should have assessed the resident for pain, addressed the pain if pain was present, called Resident 73's physician to notify about the presence of pain. The DON stated Resident 73 had experienced undue suffering which could have been prevented if the resident was assessed properly for pain management. During a review of facility's policy and procedure (P&P) titled Pain Assessment and Management, undated, the P&P indicated to observe the resident during rest and movement for physiologic and behavioral (non-verbal) signs of pain. The P& P indicated possible behavioral signs of pain are verbal expressions such as groaning, crying, screaming, facial expressions such as grimacing, frowning, behavior such as resisting care, irritability, or depression. The P&P indicated to review resident's treatment record to identify any situations or interventions where an increase in the resident's pain may be anticipated such as treatment like wound care or dressing changes. During a review of facility's P&P titled Pressure Ulcer Treatment, undated, the P&P indicated to review the resident's care plan to assess for any special needs of the resident. The P&P indicated for residents who had a Stage 4 Pressure Injury one of the guidelines was to manage pain during wound care. According to a review the article titled The Symptoms of Pain with Pressure Ulcer: A Review of the Literature, dated 5/2008 on website for Wound Care Leading Management and Prevention, pain is an issue in persons with pressure ulcers, measuring and managing pain will become more important for effective care with an aging population at risk for pressure ulcer development. 056308 Page 30 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0697 https://www.hmpgloballearningnetwork.com/site/wmp/content/the-symptom-pain-with-pressure-ulcers-a-review-literature Level of Harm - Actual harm Residents Affected - Few 056308 Page 31 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on interview and record review, the facility failed to provide adequate and sufficient nursing staff to provide care for residents requiring Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and joint mobility) services. This deficient practice had the potential for 95 residents with physician's orders for RNA to experience a decline in range of motion (ROM, full movement potential of a joint) and mobility (ability to move). Findings: During a review of the Order Listing Report of RNA orders for 6/2024 indicated 95 residents had physician's orders for RNA to provide either assistance with sit-to-stand transfers, ROM exercises to the arms, ROM exercises to the legs, application of splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and / or increase range of motion), ambulation (walking), stair climbing exercises, or exercises on the arm bicycle (stationary piece of equipment using a cycling motion for the arms to provide a cardiovascular and strength workout). During a review of the facility's Nursing Staffing Assignment and Sign in Sheets for the month of May 2024 indicated the following total number of RNAs present for the day (7 a.m. to 3 p.m. shift and 6:30 a.m. to 3 p.m. shift): Wednesday, 5/1/2024: Four (4) RNAs Thursday, 5/2/2024: Three (3) RNAs Friday, 5/3/2024: 4 RNAs Saturday, 5/4/2024: Two (2) RNAs Sunday, 5/5/2024: 2 RNAs Monday, 5/6/2024: 3 RNAs Tuesday, 5/7/2024: 4 RNAs Wednesday, 5/8/2024: 3 RNAs Thursday, 5/9/2024: 3 RNAs Friday, 5/10/2024: 3 RNAs Saturday, 5/11/2024: 3 RNAs Sunday, 5/12/2024: 2 RNAs Monday, 5/13/2024: 3 RNAs 056308 Page 32 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0725 Tuesday, 5/14/2024: 3 RNAs Level of Harm - Minimal harm or potential for actual harm Wednesday, 5/15/2024: 4 RNAs Thursday, 5/16/2024: 3 RNAs Residents Affected - Some Friday, 5/17/2024: 4 RNAs Saturday, 5/18/2024: 2 RNAs Sunday, 5/19/2024: 2 RNAs Monday, 5/20/2024: 4 RNAs Tuesday, 5/21/2024: 4 RNAs Wednesday, 5/22/2024: 2 RNAs Thursday, 5/23/2024: 4 RNA Friday, 5/24/2024: 4 RNAs Saturday, 5/25/2024: 3 RNAs Sunday, 5/26/2024: 2 RNA Monday, 5/27/2024: 4 RNA Tuesday, 5/28/2024: 3 RNAs Wednesday, 5/29/2024: 3 RNAs Thursday, 5/30/2024: Five (5) RNAs Friday, 5/31/2024: 4 RNAs During a review of the facility's Nursing Staffing Assignment and Sign in Sheets for the month of June 2024 indicated the following total number of RNAs present for the day (7 a.m. to 3 p.m. shift and 6:30 a.m. to 3 p.m. shift): Saturday, 6/1/2024: 4 RNAs Sunday, 6/2/2024: 3 RNAs Monday, 6/3/2024: 4 RNAs Tuesday, 6/4/2024: 2 RNAs Wednesday, 6/5/2024: 2 RNAs 056308 Page 33 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0725 Thursday, 6/6/2024: 3 RNAs Level of Harm - Minimal harm or potential for actual harm Friday, 6/7/2024: 4 RNAs Saturday, 6/8/2024: 3 RNAs Residents Affected - Some Sunday, 6/9/2024: 3 RNAs Monday, 6/10/2024: 3 RNAs Tuesday, 6/11/2024: 3 RNAs During an interview on 6/11/2024 at 11:12 a.m., Restorative Nursing Aide 1 (RNA 1) stated she tried to provide RNA services to about 15 to 20 residents per day. RNA 1 stated RNA services included assisting residents with exercises, ROM, ambulation, feeding assistance, stationary bike exercises, application of splints, assisting Certified Nursing Assistants (CNA) with daily care, mechanical lift transfers (a mechanical piece of equipment that allows a person to be transferred from one surface to another), and weights (performed upon admission, daily, weekly, and monthly). RNA 1 stated many residents in the facility would not be seen for RNA treatment due to lack of staffing. During an interview 6/11/2024 at 3:16 p.m., RNA 4 stated the RNAs were unable to provide RNA services to all the residents on their daily schedule as ordered due to lack of time and staffing. RNA 4 stated the RNAs in the facility had a lot of tasks assigned to them daily and were often asked to assist the other CNAs with their daily care in addition to their current workload. RNA 4 stated if an RNA called out sick or got re-assigned for the day as a CNA, the RNA who was covering their shift would have double or triple their daily workload. RNA 4 stated the facility needed more RNAs to ensure all residents on the RNA program were seen as scheduled. During an interview on 6/13/2024 at 8:50 a.m., Restorative Nursing Aide 3 (RNA 3) stated the RNA staff were unable to provide services to all the residents who had RNA orders due to short staffing, particularly on weekends. RNA 3 stated she was re-assigned to perform CNA duties about one time a week and was asked to assist the other CNAs with their tasks daily in addition to her current daily workload. RNA 3 stated if an RNA was re-assigned as a CNA for the day or called out sick, the RNA who was covering for the day would have double or triple the workload and would be unable to provide RNA services to the residents as ordered. During a concurrent interview and record review on 6/13/2024 at 1:02 p.m., the Director of Staff Development (DSD) reviewed the Nursing Staffing Assignment and Sign in Sheets for the months of May 2024 and June 2024. The DSD stated the facility required a minimum of 4 RNAs on the floor daily to ensure all residents with RNA orders received RNA services as ordered. The DSD confirmed the RNA program was insufficiently staffed for the months of May 2024 and June 2024 - particularly on the weekends. The DSD stated many residents who required RNA services per physician's order were not receiving RNA services due to lack of RNA staff. The DSD stated there was potential for residents to experience a decline in function if RNA was not being provided as ordered. During an interview on 6/13/2024 at 1:55 p.m., the DON stated the purpose of the RNA program was to maintain and/or improve a resident's current level of function and prevent declines in ROM and functional mobility. The DON stated missed RNA treatments could potentially cause a resident to experience a decline in overall function and mobility. 056308 Page 34 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0725 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's undated Policy and Procedure (P&P), titled Staffing, the P&P indicated the facility provided adequate staffing on each shift to ensure the resident's needs and services were met. CROSS REFERENCE TO F688 Residents Affected - Some 056308 Page 35 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to: Residents Affected - Some 1.Ensure to keep a separate log of uses from the emergency medication supplies. 2.Ensure the licensed nurses would document inventory count (cycle count) of narcotics (medication used to moderate to severe pain) stored in the Cubex (an automated dispensing cabinet with a computer-controlled system that stores and dispense medications) at change of shift. Twenty-four of 124 shifts did not have nurses' signatures, and the existing signatures of the remaining 100 shifts had identical signatures for the performing and witnessing nurses. 3.Ensure there were administration record of narcotic medications for three (3) of 30 sampled residents (Residents 5, 43, 239). 4.Ensure the facility's consent policy is outdated and did not match with current regulations. These deficient practices had the potential for loss of accountability, medication errors, issues in residents' rights, and/or diversions or theft of medications. Findings: 1. During a concurrent observation, interview, and record review on 6/11/2024 at 11:43a.m., with Assistant Director of Nursing (ADON) in the medication storage room at the nursing station A, there was an Emergency Kit ([EKIT] an emergency drug supply) logbook. Reviewed the logbook and the Emergency Drug Supply Log Sheet with the ADON, the ADON stated licensed nurses document medication taken from the EKIT and the Cubex on the Emergency Drug Supply Log Sheet. During a review of the Cubex pharmacy transactions on 5/30/2024 indicated, there was a tablet of alprazolam (used to treat anxiety) 0.25 milligrams ([mg] a unit to measure mass) issued for Resident 5 on 5/30/2024 at 3:59 p.m. During a review of Resident 5's physician orders indicated an order dated 5/30/2024 at 2:28 p.m. for alprazolam 0.25 mg, give 1 tablet by mouth every eight (8) hours as needed for anxiety. During an interview on 6/11/2024 at 11:45 p.m., ADON stated this issuance of alprazolam was not recorded in the Emergency Drug Supply Log Sheet. During a review of the facility's policy and procedures (P&P), (undated), indicated . Cubex .Emergency STAT orders may be retrieved pursuant to the order of a prescriber for emergency or immediate administration to a resident of the facility . The CUBEX System keeps a complete and accurate record of all users accessing the cabinet . During a review of the facility's P&P, Emergency Equipment, Supplies and Medications (E-KIT) (undated), indicated . Separated records of use shall be maintained for drugs administered from the supply. Such records shall include the name and dose of the drug administered, name of the patient, the date and time of administration and the signature of the person administering the dose . 056308 Page 36 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. During an interview on 6/11/2024 at 11:45 p.m., with ADON stated the registered nurse (RN) of the incoming shift would perform the Cubex cycle count (a method of checks and balances by which the facility confirms physical inventory counts match their inventory records) with the outgoing RN of every shift. During a concurrent interview and record review on 6/11/2024 12:01 p.m. with RN 2 reviewed Cubex controlled substance count with shift change sheet, RN 2 stated she performed the cycle count of Cubex this morning with the outgoing RN, however, she stated she forgot to sign in the shift count sheet. During a review of the cycle count sheet, there are two columns, tilted Nurse 1 and Nurse 2, under each shift. A further review of the cycle count records indicated there were 24 of 124 total shifts did not have nurses' signatures between 5/1/24 to 6/11/2024 morning; 100 of the 124 shifts had identical signatures for both incoming and outgoing nurses. During an interview on 6/11/2024 at 12:11 p.m., the Director of Nursing (DON) stated two RNs perform the Cubex cycle count at each shift and there were three shifts per day. DON referred to the cycle count sheet and stated one of the columns would be signed by the outgoing nurse, the other column by the incoming nurse. DON confirmed the signatures of both columns looked identical for the shifts that had signatures, and there were multiple shifts without signatures. DON stated the RNs did not sign the sheet correctly. Also, DON stated some forgot to sign as they completed the count. During an interview on 6/11/2024 at 4 p.m., the DON stated she could not locate the Cubex cycle count policy. 3. During a review of Resident 5's physician orders indicated an order dated 5/30/2024 at 2:28 p.m., for alprazolam 0.25 mg, give 1 tablet by mouth every 8 hours as needed for anxiety. During a review of the Cubex transactions on 5/30/2024 indicated, there was a tablet of alprazolam 0.25 mg issued for Resident 5 on 5/30/2024 at 3:59 PM. During an interview on 6/12/2024 at 11:20 a.m., reviewed Resident 5's electronic medication administration record (eMAR) of May 2024. The DON stated the administering nurse did not record the administration of Resident 5's alprazolam on 5/30/2024. During an observation on 6/12/2024 at 2:22 p.m. at the medication cart labeled Station B1 (7-3 shift (morning shift), 3-11 shift (afternoon shift), the licensed vocation nurse (LVN 7) presented a bubble pack (form of tamper-evident packaging of medication) of hydrocodone-acetaminophen (potent narcotic for the treatment of pain) 5-325 mg for Resident 43. During a review of Resident 43's physician order of hydrocodone-acetaminophen 5-325 mg (dated 5/30/2024 at 6:44 PM) indicated to give 1 tablet by mouth every 6 hours as needed for severe pain. During a review of the Narcotic and Hypnotic Record for Resident 43's hydrocodone-acetaminophen 5-325 mg indicated there were three doses issued in June 2024: one dose on 6/1/2024 at 9:13 AM, 6/8/2024 at 2 p.m., and one dose on 6/11/2024 at 2:19 p.m. During a concurrent interview and record review on 6/12/2024 at 2:35 p.m. with the DON, reviewed Resident 43's eMAR. The DON stated there was no documentation in MAR for two of three doses shown on narcotic record; the doses on 6/8/2024 at 2 p.m., and on 6/11/24 at 2:19 p.m., did not have a 056308 Page 37 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0755 matching administration record in the resident's eMAR. Level of Harm - Minimal harm or potential for actual harm During an observation on 6/12/2024 at 2:55 p.m. at the nursing station A medication cart, the licensed vocational nurse (LVN 5) presented a bubble pack of Norco 10/325 mg for Resident 239. Residents Affected - Some During a review of Resident 239's physician order of Norco 10-325 mg dated 6/7/2024 at 12:13 p.m. indicated to give 1 tablet by mouth every 8 hours as needed for moderate to severe pain. During a review of the Narcotic and Hypnotic Record for Resident 239's Norco 10-325 mg indicated there was one dose issued on 6/1/2024 at 9:13 a.m. Norco narcotic record 6/12/24 at 6 AM. During a concurrent interview and record review on 6/12/2024 at 3:03 p.m., with the DON, reviewed Resident 239's eMAR. The DON stated there was no documentation in the eMAR for the following doses as indicated on the Narcotic Record: 6/7/2024 at 6 a.m., and 6/12/2024 at 6 a.m. The DON stated the administering nurses did not document the administrations of these two doses. During a review of the facility's P&P titled Oral Medication Administration (undated) indicated, . Return to the Medication Cart and document medication administration with initials in appropriate spaces on the MAR. 4. During an interview on 6/12/2024 at 9:54 a.m., the ADON stated the prescriber obtained informed consents for residents' psychotropic uses; when facility got the order, nurses contact resident and/or family member to inform them of such order and verify if they had given consent to receive the psychotropic medications. During a review of the facility's P&P, Consent Requirements For Psychotherapeutic Medications (undated), indicated . There is no requirement to obtain a new consent when a dosage change is made . The facility and nurses are neither responsible to determine that all risks are enumerated and disclosed .The facility is not responsible for obtaining a signature . During an interview on 6/12/2024 at 10:10 a.m., ADON acknowledged the facility P &P did not match the current regulatory requirements. During a telephone interview on 6/12/2024 at 3:27 p.m. the facility consultant pharmacist stated the facility was aware of the outdated consent policy and they were in the process of updating the policy. 056308 Page 38 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

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. Based on observation, interview, and record review, the facility failed to ensure the label of a bubble pack (unit-dose card that packages doses of medication within small, clear, or light-resistant plastic bubbles) reflected the current dosage, and/or a change in dosage, for one (1) of 30 sampled residents (Resident 239). This deficient practice had the potential for medication error. Findings: During an observation on 6/12/2024 at 2:55 p.m. at the nursing station A medication cart, the Licensed Vocational Nurse (LVN 5) presented a bubble pack belonged to Resident 239. The pharmacy label on the bubble read: hydrocodone-acetaminophen (potent narcotic for the treatment of pain) 10-325 milligrams ([mg] unit to measure mass), take one tablet by mouth every eight hours for pain management. During a review of Resident 239's physician orders indicated Norco 10-325 mg, give 1 tablet by mouth every 6 hours as needed (PRN) for moderate to severe pain (pain level 6-10), ordered on 6/7/2024 at 12:13 p.m. During an interview on 6/12/2024 at 3:03 p.m., the Director of Nursing (DON) stated Resident 239's routine order of Norco had been discontinued and replaced by a PRN order. The DON stated when there was a change of dosage and the remainder tablets can be used, the nurse should contact the pharmacy and obtain a change of dose sticker to be placed on the bubble pack. -+ During a review of the facility's policy and procedures (P&P) titled Guidelines for Medication Administration (undated) indicated, . If a discrepancy exists, . consult the appropriate resource(s) such as the pharmacist . If label directions are incorrect, the medication nurse is responsible for affixing a direction change sticker. If the Medication Administration Record and the medication labeling do not match, the medication nurse should investigate the discrepancy . 056308 Page 39 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and record review, the facility's Quality Assessment and Assurance ([QAA] a group which develops and implements appropriate plans of action to correct identified quality deficiencies) committee and Quality Assurance Performance Improvement ([QAPI] a group who takes a systemic, interdisciplinary, comprehensive, and data driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families) committee failed to: 1. Ensure on-going assessment and reevaluation of physical restraints' continuous use were conducted. 2. Identify, assess, and implement interventions on residents with severe weight loss. 3. Identify, assess, and implement interventions on residents with pain during wound care treatment. 4. Ensure Restorative Nurse Aide services were implemented to residents as ordered. These deficient practices placed the residents at risk for not receiving the quality-of-care treatment necessary to adequately meet their highest practicable well-being and placed the residents. Findings: During an interview with the Administrator, Quality Assurance Nurse and the Director of Nursing (DON) on 6/13/2024 at 3:09 p.m., the DON stated not being able to identify systemic issues identified even before the survey. The QA Nurse and the DON, both stated QAA was supposed to identify systemic issues and address it. The Administrator acknowledged the facility had opportunities for improvement of all mentioned deficient practices. During a record review of the facility's policy and procedure (P&P) titled Quality Assurance and Performance Improvement (QAPI) Program revised 3/2020, the policy indicated This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. To provide a means to measure current and potential indicators for outcomes of care and quality of life. To provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. To reinforce and build upon effective systems and processes related to the delivery of quality car and services. To establish systems through which to monitor and evaluate corrective actions. 056308 Page 40 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

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** 3. During a review of Resident 3's admission Order, the admission Record indicated Resident 3 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses including paraplegia (paralysis that affects your legs, but not your arms), and unspecified epilepsy (disorder in which nerve cell activity in the brain is disturbed, causing seizures [involuntary muscle movements]) Residents Affected - Many During a review of Resident 3's Minimum Data Sheet (MDS- a comprehensive assessment and care planning tool) dated 5/10/2024 indicated Resident 3 had moderate cognitive impairment (ability to learn, understand, and make decisions) and requires maximum assistance for toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. During an observation on 06/10/2024 at 10:48 a.m.,11:45 a.m., 12:47 p.m., and 2:10 p.m., observed Resident 3 nephrostomy tube bag on top of the bed next to the resident parallel to his body. During an interview on 6/11/2024 at 2:50 p.m., the Director of Staff Development (DSD) stated nephrostomy tube drainage must be below the Resident 3's kidney to prevent reflux (flow backwards) of the urine to prevent infection. During an interview on 6/13/2024 at 8:54 a.m., the Licensed Vocational Nurse (LVN 4) stated when nephrostomy tube bag was in the same level of the kidney urine does not flow by gravity and can create urine backflow and might lead to infection. During a review of facility's P&P titled Nephrostomy Tube, Care of(undated), indicated Drainage should be below the level of the kidneys. 2. During a review of Resident 96's admission Record indicated Resident 96 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including spinal stenosis (condition that occurs when the spaces in the spine narrow and put pressure on the spinal cord and nerve roots), metabolic encephalopathy (brain dysfunction caused by a chemical imbalance in the blood), and high white blood cell (part of the body responsible for protecting the body from infection) count. During an observation and interview on 6/11/2024 at 9:21 a.m., with RNA 1 in the hallway, RNA 1 was observed completing walking exercises with Resident 96. Resident 96 was walking down the hallway using a walker (type of mobility aid with wide base of support) and had a cloth gait belt around the waist. RNA 1 assisted Resident 96 to walk down the hall into an activity room and assisted Resident 96 onto a bicycle machine for further exercises. Once Resident 96 was seated on the bicycle machine, RNA 1 removed the cloth gait belt from Resident 96's waist, walked to the dining room, and sprayed the cloth gait belt on both sides with liquid in a clear spray bottle labeled 70% isopropyl alcohol. RNA 1 stated cloth gait belts were made of fabric and used either 70% isopropyl alcohol or bleach wipes to disinfect cloth gait belts in between resident use. RNA 1 stated it was important to properly clean and disinfect cloth gait belts before and after resident use to prevent the spread of infection. During an interview on 6/11/2024 at 11:46 a.m., the Administrator (ADM) stated the 70% isopropyl spray could be used as a disinfectant for many surfaces throughout the facility but was unsure if it was the appropriate cleaning agent to be used to disinfect porous (having small spaces or holes through which liquid or air may pass) materials such as fabric. 056308 Page 41 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview and record review on 6/12/2024 at 11:14 a.m., the Infection Preventionist nurse (IP) stated cloth gait belts were cleaned and disinfected using either the 70% isopropyl alcohol spray or the bleach germicidal wipes (disinfecting wipes) before and after resident use. The IP stated cloth gait belts were made of fabric, a porous material. The IP reviewed the manufacturer instructions for both the 70% isopropyl alcohol and the bleach germicidal wipes. The IP confirmed manufacturer instructions for the isopropyl alcohol spray indicated the alcohol spray could only be used on the skin for minor cuts or burns or on hard, non-porous surfaces and was ineffective on porous materials such as fabric. The IP confirmed the bleach germicidal wipes were to be used on non-porous, hard surfaces only and could not be used on fabric per manufacturer's instructions. The IP stated the isopropyl alcohol spray and bleach germicidal wipes were ineffective cleaning agents because cloth gait belts were made of porous materials. The IP stated the only way to properly clean and disinfect cloth gait belts was to launder them after each resident use. The IP stated it was important to clean and disinfect shared equipment properly to prevent the spread of infection and avoid cross contamination. During an interview on 6/13/2024 at 1:55 p.m., the Director of Nursing (DON) stated shared resident equipment such as gait belts must be cleaned and disinfected in between resident use. The DON stated it was important shared resident equipment was cleaned and disinfected appropriately and according to manufacturer's guidelines to prevent the spread of infection. During a review of the facility's undated policy and procedure (P&P), titled, Infection Control, the P&P indicated staff were to select equipment that could be easily cleaned and disinfected. The P&P indicated, do not use fabric-based equipment (e.g., chairs, stuffed toys, furry toys, transfer belts) if it will likely be contaminated with body fluids. During a review of the facility's P&P, revised 10/2018, titled, Cleaning and Disinfection of Resident-Care Items and Equipment, indicated Resident care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current Centers for Disease Control and Prevention (CDC) recommendations for disinfection and the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard. The P&P further indicated reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturer's instructions. Based on observation, interview, and record review, the facility failed to maintain and observe infection control practices by failing to: 1. Ensure Certified Nursing Assistant (CNA) 1 and 2, performed hand hygiene in between residents when passing lunch trays. 2. Ensure Restorative Nursing Aide 1 (RNA 1) use the appropriate cleaning agent to effectively clean and disinfect a cloth gait belt (safety device worn around the waist that can be used help safely transfer a person from one surface to another or while walking) after completing RNA walking exercises with Resident 96. These deficient practices had the potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and place residents at risk for the spread of infection. 056308 Page 42 of 43 056308 06/13/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0880 3.Ensure Resident 3's nephrostomy tube (a drainage tube placed into the kidney to drain urine directly from the kidney) drainage should be below the level of the kidneys. Level of Harm - Minimal harm or potential for actual harm This deficient practice had the potential for backflow of urine that can lead to infection. Residents Affected - Many Findings: 1.During an observation on 6/13/2024 at 12:40 p.m., in the hallway, Certified Nursing Assistant (CNA) 1 and 2, were observed not performing hand hygiene while passing meal trays to the residents. During an interview on 6/13/2024 at 12:50 p.m., with CNA 1, CNA 1 stated she did not perform hand hygiene between residents while passing out their lunch trays. CNA 1 stated she should be performing hand hygiene when passing trays to prevent the spread of infection. During an interview on 6/13/2024 at 12:50 p.m., with CNA 2, CNA 2 stated she was rushing when passing out the lunch trays and forgot to perform hand hygiene. CNA 2 stated she should have performed hand hygiene because it was important in the prevention of spreading germs and infection to the residents. During an interview on 6/13/2024 at 1:04 p.m., with the Infection Prevention Nurse (IP), the IP Nurse stated the staff should be performing hand hygiene when passing lunch trays to prevent the spread of infection which could potentially cause the residents to get sick. During a record review of the facility's policy and procedure (P&P), titled Handwashing/Hand Hygiene, revised August 2019, indicated, All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitor. 056308 Page 43 of 43