Health inspection·May 2, 2024

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure seven sampled residents (Residents 28, 61, 3, and 7) were treated with dignity and respect, and staff did not refer to the residents as feeders. This deficient practice had the potential for Residents 28, 61, 3, and 7 to suffer humiliation, embarrassment, shame, and lowered self-esteem when referred to a feeders. Findings: A review of Resident 28's admission Record indicated the resident was admitted to the facility on [DATE], with medical diagnoses that included hemiplegia (an inability to move one side of the body), hemiparesis (an inability to move the arm, leg and sometimes face on one side of the body) following a cerebral infarction (lack of blood flow resulting in severe damage to part of the brain) affecting the left non-dominant side of the body, and Type 2 Diabetes Mellitus (A condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). A review of Resident 28's Minimum Data Set (MDS - a standardized assessment and care screening tool), indicated Resident 28's cognition (the mental ability to make decisions of daily living) was severely impaired. Resident 28 requires moderate to maximal assistance from staff for feeding, personal hygiene, bathing, upper and lower body dressing, and toileting). During observation on 4/29/2024 at 8:20 a.m., Resident 28 was lying in bed, awake and asking for something to eat. During an interview on 4/29/2024 at 8:21 a.m., with Resident 28. Resident 28 stated that she was hungry and needed something to eat. During an observation and interview on 4/29/24 at 8:22 a.m., in the presence of two surveyors, Certified Nurse Assistant 2 (CNA 2) was heard saying Resident 28 called the staff to help feed the resident. CNA 2 was also heard saying that Resident 28, is a feeder. During a concurrent interview, when asked to clarify what CNA 2 meant by calling Resident 28 is a feeder, CNA 2 stated again Resident 28, is a feeder, because she cannot eat on her own . and needs staff assistance to eat. During a dinning observation on 4/29/24 at 12:24 p.m., Residents 61, 3 and 7 required feeding assistance and were being fed by staff. During an interview on 4/29/24 at 12:37 p.m., Assistant Director of Staff Development (ADSD) Page 1 of 29 056321 056321 05/02/2024 Olympia Convalescent Hospital 1100 S. Alvarado St Los Angeles, CA 90006

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated, we (facility) have three residents (Residents 61, 3, and 7) here in the dining area. they are feeders. The ADSD stated Residents 61, 3, and 7 could not eat independently and at times needed encouragement to eat. They are called Feeders because, they are losing weight and need help eating. When asked if ADSD had other words to identify the residents that need feeding assistance, other than feeder, ADSD stated, No. That is what we call them. Do you have any suggestion on what else we should call them? When asked if every resident that needs assistance with feeding is called a feeder, ADSD stated, Yes. During an observation and interview on 4/29/24 at 1:57 p.m., Director of Staff Development (DSD) stated, for the residents that need assistant with eating we call them feeders. The DSD stated that we know who needs feeding assistance by the list of feeders. All the staff know who the feeders are; if they are new staff, then they need to refer to the list to find out who the feeders are. DSD left to obtain a copy of the list of residents that required assistance with feeding. DSD was then heard yelling in a loud voice down the hallway to ADSD asking ADSD, do you have the list of feeders? DSD provided a copy of the list of residents that required assistance with feeding to the surveyors. The DSD then stated, there is a list posted in the dining area so that new staff, and the RNA staff know who the feeders are in the dining area so they can help them with eating. The DSD escorted the surveyors to the dining hall and presented the list of residents labelled, RNA FEEDERS. Residents 61, 3, and 7 names and room numbers were on that list. During an interview on 5/01/24 at 9:28 a.m., Director of Nursing (DON) stated, residents should not be called feeders, under any circumstance. The DON stated that the staff will be trained to respect the residents and not call the residents derogatory names such as feeders. DON removed the list of residents posted in the resident dining hall labelling Residents 61, 3, and 7 as feeders. 056321 Page 2 of 29 056321 05/02/2024 Olympia Convalescent Hospital 1100 S. Alvarado St Los Angeles, CA 90006

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor signs (something found during a physical exam or as a result of a laboratory or imaging test that shows that a person may have a condition or disease) and symptoms (Something that a person feels or experiences that may indicate that they have a disease or condition) of urinary tract infection (UTI; an infection involving any part of the urinary system, including urethra, bladder, and kidney) and indwelling catheter (a flexible tube inserted in the bladder to drain out urine) was irrigated as per treatment administration record (TAR) for one of 6 residents (Resident 48). This deficient practice resulted in Resident 48 developing cloudy urine with sediment and a potential UTI and blocked indwelling catheter. Findings: A review of Resident 48's Face Sheet indicated the Resident 48 was admitted to the facility on [DATE], with diagnoses that included bladder neck obstruction, UTI, and Benign Prostatic Hyperplasia (BPH; non-cancerous enlargement of prostate). A review of Resident 48's History and Physical (undated) indicated, Resident 48 had fluctuating capacity to understand and make decisions. A review of Resident 48's Minimum Data Set (MDS; a standardized assessment and care screening tool) dated 3/31/24, indicated Resident 48 did not have intact cognition (capable of remembering, learning new things, concentrating, or making decisions that affect everyday life) and was dependent on staff for eating, hygiene (oral and physical), dressing and toileting. A review of Resident 48's Clinical Physician Orders dated 3/28/24, the Clinical Physician Orders indicated an order for indwelling foley catheter. A review of Resident 48's Care Plan titled The resident has indwelling catheter for bladder neck obstruction initiated on 4/2/2024, indicated Resident 48 will show no signs and symptoms of urinary infection through review date. During a review of Progress Notes dated 4/27/24 to 4/29/24, the Progress Notes did not indicate a medical doctor (MD) was notified of Resident 48 having cloudy urine with sediment. During a review of Resident 48's TAR dated 4/1/24 to 4/30/24, indicated Resident 48's foley catheter was not irrigated as needed for cloudy urine with sediment on 4/29/24 and 4/30/24. During an observation on 4/29/24 at 9:45 AM in Resident 48's room, Resident 48's foley catheter tubing was observed with cloudy looking urine. During a concurrent interview and observation on 4/29/24 at 10:01 a.m. with Licensed Vocational Nurse 3 (LVN 3), Resident 48's indwelling catheter was observed. LVN 3 stated, indwelling catheters are checked every day. We check if the tube is clean, on the right side, kinked or not, if it has a strap, if bag has cover or not, if irrigation order, irrigate. This [indwelling catheter] looks cloudy 056321 Page 3 of 29 056321 05/02/2024 Olympia Convalescent Hospital 1100 S. Alvarado St Los Angeles, CA 90006

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and has sediment in the tubing. If there is too much sediment, we notify medical doctor (MD). The consequences of having too much sediment are the tubing can get blocked, resident will not be able to urinate, distended bladder and resident can get a UTI. During an interview on 4/29/24 at 8:26 a.m., licensed vocational nurse 4 (LVN 4) stated, We look for sedimentation and cloudiness in the [indwelling] catheter tubing. We call the MD if we find it. The resident could experience pain in abdomen and a urinary tract infection if we do not report it to the doctor. During an interview on 5/1/24 at 10:01 a.m., Director of Nursing (DON stated, we check on the patency and the drainage of [indwelling] catheters. If there are signs and symptoms of infection such as sediment, we report it to the MD, then the MD orders to flush the catheter if necessary or any labs. It can cause UTI if not reported to MD or sepsis, bleeding, A review of the facility's policy and procedures titled, Catheter Care of dated 6/1/17, indicated, A resident, with or without a catheter, receives the appropriate care and services to prevent infections to the extent possible. Report the following signs and symptoms to the attending physician: any sign or symptom of UTI: such as cloudy appearance. 056321 Page 4 of 29 056321 05/02/2024 Olympia Convalescent Hospital 1100 S. Alvarado St Los Angeles, CA 90006

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure one of one sampled resident (Resident 64), had a documented date for the Isosource bag (a form of liquid nutrition) hung for the gastronomy tube feeding (G-tube, a tube that is inserted through the belly to deliver nutrition, medication, and or hydration directly to the stomach). Residents Affected - Few The failure has the potential to cause the bag to be infused past the manufacture's 48-hour guidelines resulting in potential growth of food borne illness. Findings: A review of Resident 64's Medical Data Set (MDS - a standardized assessment and care screening tool), dated 09/02/2023, indicates swallowing disorder and weight loss of 5% or more in the last month or loss of 10% or more in last six months. During an observation on 4/29/2024 at 08:01 a.m., in Resident 64's room, Resident 64's Isosource bag was not dated to indicate the open date. During an observation on 4/29/24 at 10:57 a.m., in Resident's 64's room, Resident 64's Isosource bag still not dated to indicate the open date. During a concurrent observation and interview on 4/29/24 at 01:14 PM, with Licensed Vocational Nurse 2 (LVN 2) in Resident 64's room, the Isosource bag was not dated. LVN 2 stated all three bags, flush bag, Enteral bag and Isosource bag needed to be dated. LVN 2 stated LVN 2 got all three bags out on 4/28/2024 but did not date the Isosource bag. During an observation on 4/30/24 at 8:30 a.m., in Resident 64's room, Resident 64's Isosource bag was timed but not dated. During a concurrent observation and interview on 4/30/24 at 10:36 a.m. with LVN 2 in Resident 64's room, Resident 64's Isosource bag was not dated. LVN 2 stated, if bag was not dated it would be bad for the resident. LVN 2 stated feeding bags should be changed every 24 hours. A review of the facility's policy and procedures (P&P) titled, Gastronomy Placement, Nursing Manual Nursing Care, dated June 2017, indicated, equipment and products are labeled with the date and time they were first used or opened. A review of the Isosource manufacturer's instructions, dated June 2017, indicated .sterile, non-air dependent container that may hang up to 48 hours once spiked . 056321 Page 5 of 29 056321 05/02/2024 Olympia Convalescent Hospital 1100 S. Alvarado St Los Angeles, CA 90006

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 interview and record review, the facility failed to: Residents Affected - Some 1. Keep usage record of the emergency medication supplies. 2. Keep record of inventory discrepancies for their automated dispensing cabinet (STATSAFE, a computer-controlled system that stores and dispense medications). 3. Ensure the administration of a controlled substance was documented in the resident's electronic medication administration record for one of 32 sampled residents (Resident 70). These deficient practices had the potentials of medication errors and/or drug diversions. Findings: A review of Resident 70's physician order, dated 4/19/2024 at 4:29 PM, indicated to give Ativan 1 mg 1 tablet by mouth every 8 hours as needed (PRN) for anxiety disorder. A concurrent review of STATSAFE activity report from 4/21/24 to 4/30/24, generated by the pharmacy, indicated the discrepancy occurred on 4/23/24 at 10:51 AM. The report also indicated DON resolved the discrepancy on 4/26/2024 at 1:32 PM. During an inspection of the medication (med) room on 4/30/24 at 2:05 p.m., with the licensed vocational nurse 5 (LVN 5), there was an automated dispensing cabinet (STATSAFE, a computer-controlled system that stores and dispense medications) at the far end of the med room. LVN 5 stated the STATSAFE was used for access to emergency medication supplies and first doses. LVN 5 stated she did not know of a logbook that keep the activity record. During an observation and concurrent interview on 4/30/2024 at 2:17 p.m., the director of nursing (DON) demonstrated the functions of the STATSAFE. DON confirmed the STATSAFE did not have a printer attached. DON stated the facility did not keep a record of the STATSAFE activities and the DON had not received an report from the pharmacy. DON stated if there is discrepancy, the pharmacy will contact the facility. During an interview on 4/30/2024 at 2: 45 p.m., DON stated any controlled substances activity at the STATSAFE would require a call to the pharmacy to verify the order and obtain a code for the facility to enter into the STATSAFE, in order to gain access to the medications. During an observation on 4/30/2024 at 2:50 p.m., DON selected Resident 42 from the STATSAFE computer. DON stated Resident 42 did not have an active order of Norco (a potent opioid to treat pain) 10/325 milligrams (mg, an unit to measure mass); however, DON was able to gain access to STATSAFE without the aforementioned prompt to enter a code to be obtained by calling the pharmacy. DON stated the facility would not know who had accessed the STATSAFE without asking the staff or the pharmacy. DON also stated she had not received any STATSAFE report sent from the pharmacy. During an interview on 4/30/2024 at 3:06 p.m., the Regional Clinical Operation (RCO) stated the pharmacy had been sending the STATSAFE daily activity report to the former administrator. The current 056321 Page 6 of 29 056321 05/02/2024 Olympia Convalescent Hospital 1100 S. Alvarado St Los Angeles, CA 90006

F 0755 administration (ADM) stated he started working at the facility since 11/20/2023. Level of Harm - Minimal harm or potential for actual harm A review of Resident 70's lorazepam (Ativan, a controlled substance used to treat anxiety) count (accountability) sheet indicated a dose was removed from the inventory on 4/30/24 at 4:20 PM. Residents Affected - Some A review of the STATSAFE inventory list indicated there were 218 types of medications stored in the STATSAFE. The quantity for each type of medications ranged from one (1) to 25 counts. During an observation on 5/1/24 at 9:05 a.m., DON reviewed the process of resolving STATSAFE discrepancy report. During a concurrent interview, DON stated the STATSAFE station monitor would have a banner alert indicating a discrepancy had been detected and needed to be resolved, when there was a discrepancy. DON stated the facility could not print the discrepancy report. DON stated she recently resolved a STATSAFE discrepancy that involved a nurse who made an error when entering the remaining inventory count for a controlled substance. However, she did not keep a record of the resolved discrepancy. On 5/1/24 at 10:20 AM during an interview, DON stated the facility's emergency pharmacy service and emergency kits policy did not denote the current process observed at the facility. On 5/1/24 at 11:20 AM, during an interview and a concurrent review of Resident 70's electronic medication administration record (eMAR), RCO stated the eMAR did not indicate a medication administration documenting the aforementioned lorazepam on 4/30/24. At 11:28 AM, DON spoke to the nurse on the phone who confirmed the administration of the lorazepam to Resident 70. The nurse stated she forgot to document the administration in the eMAR. A review of the facility's policy and procedures, Medication Administration (dated 6/2017), indicated, . When a PRN medication is given, it will be documented on the Medication Administration Record. The nurse will document the date, time, and reason for giving the medication. The result or effectiveness of the PRN medication will be charted by the responsible nurse on the back of the MAR or in the nursing notes . A review of the facility's policy and procedures, STATSAFE policy and procedures (dated 5/2019), indicated, . an activities report will be printed or emailed daily . This report identifies all non-controlled and controlled substance activities performed on the STATSAFE station . The Activities reports will be retained for ten (10) years at the Facility and the Pharmacy . 056321 Page 7 of 29 056321 05/02/2024 Olympia Convalescent Hospital 1100 S. Alvarado St Los Angeles, CA 90006

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation, interview, and record review, the facility failed to provide effective dietetic service oversight when the dietary manager did not meet the state and federal requirements for the position and the registered dietitian worked on a consulting basis, as evidenced by lapses in the delivery of food services associated with staff competency (cross reference F802), safe and sanitary food storage and food preparation practices (F812) and therapeutic diet texture accuracy, wrong portion sizes and not following the menu (cross reference F805 and F803). This deficient practice could result in compromising the safety and nutritional status of residents through the potential for cross contamination, decreased nutrient intake and choking or aspiration risk. Findings: During the annual recertification survey from 4/29/2024 to 5/2/2024, multiple issues surrounding the delivery of dietetic services were unmet in relation to: 1.The oversight of food safety, sanitation, and storage of food in the kitchen (cross reference F812) 2.The evaluation of dietary staff competency (cross reference F802) 3.The overall evaluation of food production in relation to therapeutic diet, puree diets, portion control and following the menu (F803 and F805). During an interview with the Dietary manager (DM) on 4/29/2024 at 8:30a.m. regarding kitchen supervision, DM stated DM is full time and works every day in the facility kitchen. DM stated DM oversees supervising kitchen staff, attending meetings and interviewing residents for food preferences. A review of the kitchen manager credentials indicated that DM had a certification from an accredited certified dietary manager program effective from 8/2/2023 to 8/31/2024. However, DM did not receive at least six hours of in-service training on the specific California dietary service requirements contained in CCR title 22 (health and safety Code 1265.4) During an interview with Registered Dietitian (RD) on 4/29/2024 at 12:45p.m. RD stated RD is in the facility once a week and was mainly addressing resident care and clinical nutrition issues. RD stated DM is mainly managing the kitchen. During an interview with RD on 4/29/2024 at 1:50p.m. RD stated RD is new to the facility and did not know about the identified concerns in the kitchen regarding serving the incorrect portions, following the menu, and serving the incorrect therapeutic diet texture. RD stated kitchen staff changed the menu and didn't follow recipe, RD stated RD was not informed to approve the changed menu. During an interview with DM on 4/29/2024 at 2:00p.m DM stated that DM used to work as a cook in the facility until DM completed Certified Dietary Manager trainings. DM stated DM did not know that DM needed to complete 6 hour of California state dietary service requirements. DM agreed that ingredients were missing from inventory for the cooks to prepare lunch. When asked why the lunch menu was 056321 Page 8 of 29 056321 05/02/2024 Olympia Convalescent Hospital 1100 S. Alvarado St Los Angeles, CA 90006

F 0801 different for pureed diets, DM did not answer. Level of Harm - Minimal harm or potential for actual harm A review of facility job description for Supervisor of Food Service undated, indicated, Assist in planning regular and special diet menus as prescribed by the attending physician. Assure that food is available for preparation by cooks .Work with the facility's dietitian as necessary and implement recommended changes are required .Meet with food services personnel, as necessary, to assist in identifying and correcting problem areas, and or the improvement of services. Residents Affected - Some A review of the California Health and Safety Code (HSC) 1265.4, the HSC indicated, .a) A licensed health facility . shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations. (b) The dietetic services supervisor shall have completed at least one of the following educational requirements: (1) A baccalaureate degree with major studies in food and nutrition, dietetics, or food management and has one year of experience in the dietetic service of a licensed health facility. (2) A graduate of a dietetic technician training program approved by the American Dietetic Association, accredited by the Commission on Accreditation for Dietetics Education, or currently registered by the Commission on Dietetic Registration. (3) A graduate of a dietetic assistant training program approved by the American Dietetic Association. (4) Is a graduate of a dietetic services training program approved by the Dietary Managers Association and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility . 056321 Page 9 of 29 056321 05/02/2024 Olympia Convalescent Hospital 1100 S. Alvarado St Los Angeles, CA 90006

F 0802 Level of Harm - Minimal harm or potential for actual harm Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency related to their duties when: Residents Affected - Some 1.Dishwasher 1 (DW1) and Dietary Aide 1 (DA1) did not know the proper sanitizer test strip to use for dish machine sanitizer. Both DW1 and DA1 were testing the dish machine sanitizer using the wrong test strip. 2.Cook 1 did not follow the menu and the standardized recipes when preparing pureed diet and was not evaluated for competency related to pureed diet preparation. 3. Dietary Manager (DM) did not have documented routine staff competency evaluation to ensure all kitchen staff were competent in their job-related duties. These deficient practices had the potential: 1. To result in unsafe and unsanitary food production that could place 88 out of 92 residents in the facility who received food at risk for food borne illness. 2. Not following the menu and recipe for the pureed diet had the potential for decreased meal satisfaction, decreased nutrient intake and risk for choking for 15 residents who receive the incorrect texture of pureed diet. Findings: 1. During an observation and concurrent interview in the kitchen on 4/29/2024, at 9 a.m. Dishwasher 1 (DW1) was rinsing dishes and loading dirty dishes in the dish machine. Dietary Aide 1 (DA1) was removing the clean and sanitize dishes for storage. During a concurrent interview with DW1, DW1 stated DW1 checked the dish machine sanitizer effectiveness before he started washing dishes. DW1 stated DW1 documented in the dish machine log. During the same observation and interview DA1 was requested to check the dish machine sanitizer concentration. DA1 attempted to use the QUAT (quaternary ammonium-QUAT, a type of sanitizing solution used to sanitize food contact surfaces) sanitizer test strip to test the sanitizer concertation in the dish machine. DA1 stated, the test strip is not working. The normal range for the sanitizer is 200PPM. DA1 stated DA1 used to be the dishwasher but now DW1 is the dishwasher who was hired two weeks ago. During the same observation and interview DW1 stated DW1 will get another test strip that works. DW1 returned and stated, there is no other test stirp to check the dish machine sanitizer. DW1 stated that he used the same test strip as the DA1 to check the sanitizer before starting to wash the dishes. During an observation and interview with Dietary Manager (DM) on 4/29/2024, at 9:10a.m., DM stated, they (kitchen staff) are using the wrong test strip, that is not the correct test strip for the dish machine. DM stated DA1 and DW1 should have used a chlorine test strip to test the dish machine sanitizer and not the QUAT test strip. DM stated these are two different chemicals and test strips. DM 056321 Page 10 of 29 056321 05/02/2024 Olympia Convalescent Hospital 1100 S. Alvarado St Los Angeles, CA 90006

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated sanitizer is checked before each wash and normal range is 50ppm. DM stated there were no recent training and in-services pertaining to checking dish machine sanitizer effectiveness and test strips. During a concurrent interview and review of the dish machine sanitizer log with DM on 4/29/2024, at 9:15 a.m., there was no documentation that the dish machine sanitizer was checked in the morning. DM stated, if they don't check the sanitizer correctly then the dishes can be potentially contaminated and not sanitized. A review of facility competency checklist for Food Service Worker indicated to be able to demonstrate correct sanitation of equipment, utensils and state proper sanitizer solution range-correctly prepare sanitizer solution and tests concentrations. 2. During an observation of the noon meal food production on 4/29/2024 at 8:30a.m, Cook1 was boiling tofu with vegetables in a large pot of water. Cook1 was also boiling rice for the pureed diet. During a concurrent observation and interview, Cook1 stated Cook1 was preparing the meal for the pureed diet. Cook1 stated the residents on the pureed diet will receive pureed tofu and vegetables, pureed rice, and pureed green peas. During a concurrent review of the menu and spreadsheet (food production and serving guide), Bean Dregs Stew (Pork and Kimchi stew) with blanched zucchini and steam rice was on the menu for pureed diet. Cook1 stated she is not following the menu and the recipe because she doesn't have the ingredients. During the same observation and interview on 4/29/2024 at 8:45a.m, Cook1 removed the rice from the pot and poured the rice with the boiling water in the blender. Cook1 stated Cook1 doesn't add thickener because the residents complain if the puree rice is thick. During an observation of the tray line service for lunch on 4/29/2024 at 11:50a.m, residents who were on puree diet received rice that was soupy and thin liquid consistency. During an interview with Registered Dietitian (RD) on 4/29/2024 at 12:45 p.m., RD said that the pureed rice looked like milk or soup. RD said puree food should be smooth and like mashed potato and not like soup. During a concurrent interview with Dietary Manager (DM) and Speech Therapist (ST) on 4/29/2024 at 1:30p.m. ST stated puree food should hold its shape and not be runny or watery and should have pudding like consistency. During a concurrent interview DM said the puree rice was thin like soup and was not served at the correct texture. DM said she will provide in-service to the cooks on diet textures. DM said she has not heard of any residents complaining about thick puree consistency. A review of facility policy and procedures titled Puree (dated 2018) indicated, Puree diet provides foods that do not require chewing and are easily swallowed. All foods should be smooth and pureed to the consistency of pudding. Foods should be prepared using a food processor or blender. Blenderized foods that are liquid may need to be thickened to the consistency of mashed potatoes depending on the individuals' swallowing abilities. This diet is for individuals who have no teeth lack a gag 056321 Page 11 of 29 056321 05/02/2024 Olympia Convalescent Hospital 1100 S. Alvarado St Los Angeles, CA 90006

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some reflex .Individuals who have the potential for aspiration should be further evaluated by a speech therapist to determine their ability to tolerate liquids. Liquids may need to be thickened to a specified level of thickness. A review of cook's job description not dated indicated, Work with facility's dietitian as necessary and implement recommended changes as required. Prepare meal in accordance with planned menus. Prepares and serve meals that are palatable and appetizing appearance, serve food in accordance with established portion control procedures. Prepare food for therapeutic diets in accordance with planned menus. Prepare food in accordance with standardized recipes and special diet orders. 3. During an interview with DM on 4/29/2024 at 9:15a.m., DM stated there were no recent training and in-services pertaining to checking dish machine sanitizer effectiveness and test strips. During an interview with DM on 4/29/2024 at 1:50p.m, DM stated the puree consistency was too thin, and the cooks did not follow the menu and recipe. DM said DM will provide in service to the cooks. A review of facility in-service records for year 2024, indicated there was no in-service documentation on puree diet preparation or following the recipe and the menu. A review of in-service record dated 1/11/24 indicated in-service on use of sanitizer strips but no record of the method of in-service presentation or lesson plan related to the in-service and there was no attendance signature from dishwasher DW1 on the in-service training report for the sanitizer strips. 056321 Page 12 of 29 056321 05/02/2024 Olympia Convalescent Hospital 1100 S. Alvarado St Los Angeles, CA 90006

F 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to ensure the standardized recipes and portion sizes for lunch menu was followed on 4/29/24 when: Residents Affected - Some 1.facility failed to ensure staff followed food production recipes for the puree diet (food that is blended to a pudding consistency, no chewing required) during lunch preparation and tray line observation. 15 Residents on puree diet did not receive the puree pork and kimchi stew and the zucchini, they received pureed tofu and pureed peas. 2.Cook used small scoop size to serve pork and kimchi for residents on regular and mechanical soft diet. 24 Residents on regular diet and 18 residents on mechanical soft diet received 3oz of pork and kimchi stew instead of 6 oz per menu and 15 residents on puree diet received 4 oz of pureed tofu instead of 6 ounces. This deficient practice had the potential to result in meal dissatisfaction, decreased nutritional intake and weight loss in residents who received food from the kitchen. Findings: According to the facility lunch menu for regular and mechanical soft diet on 4/29/2024, the following items will served on regular diet: Bean Dregs Stew (Pork and Kimchi stew) (kimchi is Korean pickled cabbage and radish) 6 ounces(oz.); Blanched zucchini strips (3oz.); Steamed rice #8 scoop yielding (4oz.) or ½ cup; green onion soup, side of kimchi; dessert, milk and beverage of choice. Mechanical soft diet: Chopped/Mashable Bean Dregs Stew (Pork and Kimchi stew)6oz.; soft chopped blanched zucchini strips (3 oz); steams rice; green onion soup; minced side of Kimchi; dessert, milk, and beverage. Puree Diet: Pureed Bean Dregs Stew (Pork and Kimchi stew) #6 scoop yielding (5 1/3 oz); pureed blanched zucchini stirps #12 scoop yielding (2 2/3 oz); Pureed steamed rice (4oz.) or ½ cup; pureed green onion soup; Pureed side of kimchi or kimchi juice; pureed dessert; milk and beverage of choice. During an observation in the kitchen on 4/29/2024 at 8:30 a.m. Cook1 placed tofu in a large pot, added water, onions, seasonings, green and red bell peppers and began to cook. There was also another pot with white rice, and it was boiling, the consistency of the mixture of the white rice was soupy and liquid in the pot. [NAME] was covered with a lot of boiling water. During a concurrent interview with [NAME] 1 on 4/29/2024 at 8:30 a.m. cook1 stated she makes the breakfast every day. Cook1 stated there are two sets of menus in the facility, a regular American food menu and a Korean food menu. Cook1 stated majority of residents are on the Korean food menu by preference and only four to six residents request the American food menu. Cook1 stated she is preparing pureed tofu with vegetables and pureed peas for the pureed Korean diet. During a concurrent interview and review of the Korean diet menu and production sheet (food portion and serving guide) with Cook1, cook1 said residents on puree should receive Bean Dregs Stew (Pork and Kimchi stew) (kimchi a type of Korean pickled cabbage and radish with spices), blanched zucchini 056321 Page 13 of 29 056321 05/02/2024 Olympia Convalescent Hospital 1100 S. Alvarado St Los Angeles, CA 90006

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stripes and white rice. Cook1 stated she is not following the recipe for the pork and kimchi stew and the blanched zucchini because she is not responsible for the Korean food menu and does not have the ingredients for the Korean diet. Cook1 said there is another cook who prepares the Korean food menu and comes in later to prepare for lunch. Cook1 stated she is assigned to make the pureed diet for lunch and she makes something different everyday with Korean seasonings and flavors. Cook1 stated Dietary Manager (DM) agree for her to make the tofu for the pureed Korean diet. When asked if she is assigned for making pureed food for the Korean food menu and the American food menu, cook 1 responded yes, she is assigned to make puree for both Korean menu and the American menu. Cook1 stated DM is aware that I am not following the menu for the Korean pureed diet, and she said its ok. During an observation in the kitchen on 4/29/2024 at 10:20 a.m., Cook2 was cutting sliced pork across into wide strips. During a concurrent observation and interview with cook2, cook2 stated she is responsible for the regular and mechanical soft diet on the Korean food menu. Cook2 stated that cook1 is making the pureed diet for both Korean menu and the American menu. Cook2 stated she is aware that cook1 is not following the recipe for the Korean food menu. Cook2 stated we are working with ingredients available and there is not enough pork or kimchi; Cook2 stated DM is aware that menu is not followed for the pureed diet. [NAME] 2 stated she does not have enough Kimchi which is part of the ingredient for the stew, and she will use less than what the recipe is asking for. Cook2 also said she is omitting the soybean ingredient from the stew recipe. During an interview with Cook1 on 4/29/2024 at 10:30a.m. cook1 stated she is making pureed peas instead of pureed zucchini per Korean menu and she is making tofu with vegetables instead of pork and kimchi stew per the Korean Menu. Cook1 said she does not have the ingredients to make the Korean menu. During an observation of the tray line service for lunch on 4/29/2024 at 11:50 a.m. residents who were on pureed texture diet cook1 served pureed tofu, pureed peas, and soupy rice. During a test tray on 4/29/2024 at 12:50p.m. Dietary Manager (DM) said the pureed food is not the same as the regular menu. DM said the main entrée is puree tofu instead of pureed pork and kimchi stew, and the vegetable is pureed peas instead of pureed zucchini. DM said the pureed rice is liquid and soupy. DM said cooks should always follow the menu and recipes. DM said the facility is transitioning to a new menu and some ingredients have been low inventory. DM said they have hired a Korean cook to manage the Korean menu. When asked why cook1 is preparing different food for the pureed diet, she did not answer. During an interview with registered Dietitian (RD)on 4/29/2024 at 1:50p.m. RD stated the puree food had different color and was a different food from the regular diet. RD stated the lunch menu and ingredients were changed and she was not informed to approve the changes on the menu. RD stated the cook should always follow the menu. A review of facility spreadsheet (portion and serving guide) dated 4/30/24 for Monday Lunch indicated, For the pureed diet for lunch serve with 6 scoop (5 1/3 oz.) of pureed Bean Dregs Stew (pork and kimchi stew), pureed Blanched Zucchini strips and puree rice. A review of facility recipe for Bean Dregs Stew indicated the ingredients are pork, kimchi, soybeans, and seasonings. 056321 Page 14 of 29 056321 05/02/2024 Olympia Convalescent Hospital 1100 S. Alvarado St Los Angeles, CA 90006

F 0803 Level of Harm - Minimal harm or potential for actual harm A review of cook's job description not dated indicated, Work with facility's dietitian as necessary and implement recommended changes as required. Prepare meal in accordance with planned menus. Prepares and serve meals that are palatable and appetizing appearance, serve food in accordance with established portion control procedures. Prepare food for therapeutic diets in accordance with planned menus. Prepare food in accordance with standardized recipes and special diet orders. Residents Affected - Some A review of Dietary Managers job description not dated indicated, assist in planning regular and special diet menus as prescribed by the attending physician. Assure that food is available for preparation by cooks. Work with the facility's dietitian as necessary and implement recommended changes as required. Meet with food services personnel, as necessary, to assist in identifying and correcting problem areas and or the improvement of services. 2.During an observation of the tray line service for lunch on 4/29/2024, at 11:50 a.m., residents who were on regular and mechanical soft diet cook2 served Bean Dregs Stew (pork and kimchi stew) using 3oz ladle instead of 6 oz. per menu and residents on pureed diet the cook1 served pureed tofu using 4oz ladle instead of scoop #6 (5 1/3oz) per menu. During an interview with DM on 4/29/2024, at 12:50p.m. DM stated the portion sizes were incorrect and cooks served less food to residents. DM stated less food can cause less nutrition intake and weight loss. During a concurrent interview with Cook1 and [NAME] 2 on 4/29/2024, at 1:00p.m. cook1 stated she did not use the correct scoop to serve residents the pureed food. Cook2 stated she used smaller 3oz. ladle instead of 6oz. and residents received less food. Cook2 stated she did not follow the spreadsheet (food production and serving guide) for portions when serving the food. During an interview with RD on 4/29/2024, at 1:50p.m. RD stated the residents received less food because they served smaller portion seizes than the menu. RD stated Serving less food can cause weight loss. A review of the recipe for Bean Dregs Stew (pork and kimchi stew), indicated stir fry the pork and the kimchi together, add stock bring to a boil .add blended soybeans, soy sauce, garlic, ginger black pepper and serve 6oz. portion per serving. A review of facility spreadsheet (portion and serving guide) dated 4/30/24 for Monday Lunch indicated, Bean Dregs Stew (pork and kimchi stew) regular portion is 6oz, pureed use #6 scoop (5 1/3oz). 056321 Page 15 of 29 056321 05/02/2024 Olympia Convalescent Hospital 1100 S. Alvarado St Los Angeles, CA 90006

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, and record review, the facility failed to ensure: 1. 12 residents on finely chopped diet (modified diet with food prepared approximately 1/8-1/4-inch inches) and 14 residents on minced diet (modified diet with food prepared approximately 1/8-1/4-inch inches) received meat texture in the forms that meet their needs when cook served regular diet with inconsistent size and large size of meat instead of chopped and minced per resident diet orders. 2. 15 residents on pureed diet received the incorrect pureed diet texture (foods that do not require chewing and are easily swallowed. Food should be smooth .consistency of pudding) when the [NAME] served thin and soupy rice instead of pureed rice that was homogenous, cohesive and had a pudding like consistency. These deficient practice had the potential to result in decreased intake related to inconsistent and large size meats, meal dissatisfaction and increased choking and aspiration risk. Findings: According to the facility lunch menu for minced (finely chopped) diet on 4/29/24, the following items will be served: Ground Bean Dregs Stew (pork and kimchi stew (pork mixed with pickled or fermented seasoned cabbage, onion and radish) 6 ounces (oz.); Minced blanched zucchini stirps 3 oz.; steamed rice moist #8scoop yielding (4oz.); pureed green onion soup; minced fresh fruits, milk, and hot beverage. During an observation of the meal preparation on 4/29/2024 at 10:20a.m., cook (Cook 2) was cutting sliced pork steak into strips with inconsistent size, length, and width. During a concurrent interview, [NAME] 2 said residents on mechanical modified (food that is chopped, ground, or finally chopped and minced) and regular diet will get pork and kimchi stew. Cook2 stated the pork slices are thin and it doesn't need to be further chopped for the mechanical modified diet. During an observation of the tray line service for lunch on 4/29/2024 at 11:50a.m, residents who were on finally chopped diet and minced diet received pork and kimchi stew including inconsistent size of pork strips, large chunks of kimchi (pickled/fermented cabbage and radish) instead of ground pork and kimchi stew per menu. During an interview with Registered Dietitian (RD) on 4/29/2024 at 12:45 p.m., RD said residents on finally chopped and minced diet received the same food texture as residents on regular and mechanical soft diet. RD said some residents complain if they receive minced or finally chopped diets but RD said Serving wrong diet textures can be risk for not able to chew or swallow the food. During a concurrent interview with Dietary Manager (DM) and Speech Therapist (ST) on 4/29/2024 at 1:30p.m. ST said she orders the textures of the diet, and she expects that the kitchen will provide the chopped and minced diet per order. She said examples of different textures are puree, chopped, finally chopped, and minced. ST said puree must hold its shape and not be watery or thin, must be cohesive and pudding consistency. ST said finally chopped should be chopped very small it still requires 056321 Page 16 of 29 056321 05/02/2024 Olympia Convalescent Hospital 1100 S. Alvarado St Los Angeles, CA 90006

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some some chewing and moving in the mouth. ST said the minced should be minimum munching and then swallowing not too much chewing required its more like a ground texture. ST said the pork and kimchi stew served for lunch is not adequate for finally chopped and minced diet texture. During the same interview DM said finally chopped diet size should be the size as the grain of rice for reference and minced is ground. DM said the kitchen didn't serve the right texture diet for the finely chopped and minced diet. DM said this can be risk for choking. 2. During an observation of the tray line service for lunch on 4/29/2024 at 11:50 a.m., residents who were on puree diet received rice that was soupy and thin liquid consistency. During concurrent observation and interview [NAME] 1stated she added liquid because the rice doesn't get blended very well. Cook1 said the residents complain if the puree is too thick. During an interview with Registered Dietitian (RD) on 4/29/2024 at 12:45 p.m., RD said that the pureed rice looked like milk or soup. RD said puree food should be smooth, like mashed potato and not like soup. During a concurrent interview with Dietary Manager (DM) and Speech Therapist (ST) on 4/29/2024 at 1:30p.m. ST stated puree food should hold its shape and not be runny or watery and should have pudding like consistency. ST said some resident on puree diet might be able to tolerate the liquid puree rice that was served but others who are on honey or nectar consistency or on thickened liquids consistency diets would not be able to tolerate the thin puree rice and can be risk for aspiration. During a concurrent interview DM said the puree rice was thin like soup and was not served at the correct texture. DM said she will provide in-service to the cooks on diet textures. DM said she has not heard of any residents complaining about thick puree consistency. A review of facility policy tilted Mechanical or Dental Soft (dated 2018) indicated, The mechanical altered diet provides foods that are easily chewed. It is appropriate for individuals who have chewing problems, poor dentition, and minor swallowing problems, but can tolerate more than pureed texture or blenderized diet . The diet should be planned using ground meats and diced fruits and vegetables. The following terms should be used to describe the desired texture: Finally chopped/Minced: 1/8-1/4-inch pieces. Ground: 1/8 inch or less pieces-consistency of ground meat. Puree: Should be able to go through a sieve for smooth consistency. A review of facility policy titled Finely Chopped (dated 2018) indicated, This diet may be ordered for residents who have difficulty chewing and or swallowing a mechanical Diet. Most foods should be finely chopped to the consistency of coleslaw. Meats should be ground and have gravy or broth served over them to help maintain moisture. A review of facility policy titled Puree (dated 2018) indicated, Puree diet provides foods that do not require chewing and are easily swallowed. All foods should be smooth and pureed to the consistency of pudding. Foods should be prepared using a food processor or blender. Blenderized foods that are liquid may need to be thickened to the consistency of mashed potatoes depending on the individuals' swallowing abilities. This diet is for individuals who have no teeth lack a gag reflex .Individuals who have the potential for aspiration should be further evaluated by a speech therapist to determine their ability to tolerate liquids. Liquids may need to be thickened to a specified level of thickness. 056321 Page 17 of 29 056321 05/02/2024 Olympia Convalescent Hospital 1100 S. Alvarado St Los Angeles, CA 90006

F 0805 Level of Harm - Minimal harm or potential for actual harm A review of facility spreadsheet (portion and serving guide) dated 4/30/24 for Monday Lunch indicated, For the Minced diet for lunch serve 6oz. of ground pork and kimchi stew, there is no instruction for the finely chopped diet on the spreadsheet and for the mechanical diet serve chopped pork and kimchi stew .all chopped items must be less than ½ inch and Finally Chopped/Diced/Minced are 1/8-1/4-inch size meats and vegetables; Ground is 1/8 inch or less size meat and vegetables. Residents Affected - Some 056321 Page 18 of 29 056321 05/02/2024 Olympia Convalescent Hospital 1100 S. Alvarado St Los Angeles, CA 90006

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and preparation practices when: 1.One small container of previously prepared rice and one small container of previously prepared minced meat with a use by date of 4/28/24 expired were stored in the reach in refrigerator. One gallon milk with open date 4/26/24 exceeding storage period for open container of milk was stored in the reach in refrigerator. Nutritional supplement (milk based high protein and calorie drinks) labeled store frozen with manufactures instruction to use within 14 days of thawing, were not monitored for the date they were thawed to ensure expired shakes were discarded after this time frame. One box containing 75 individual containers of strawberry flavored nutrition supplements with open delivery date of 4/16/24 and two boxes of sugar free vanilla flavored nutrition supplements with delivery dates of 3/29/24 were stored in the refrigerator thawed and no expiration date. This deficient practice had the potential to result in food borne illness in 11 residents who are on nutrition supplement in the facility. 2. Ice machine was not maintained in a sanitary manner and the inside compartment of ice machine was 3. scoops were stored inside bulk food thickener container and non-fat dry milk container with the handle in contact with the food. dirty. 4. Food was not stored in a sanitary manner to prevent growth of microorganisms that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food), as well as toxins in room [ROOM NUMBER]. These deficient practices had the potential to result in pathogen (germ) exposure, to place the residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications, unnecessary hospitalization, and gnat infestation (a disease causing insect) in 88 of 92 residents who received food from the kitchen. Findings: 1.During an observation in the kitchen on 4/29/2024 at 07:45 a.m., there was one small container of previously cooked rice stored in the reach in refrigerator with no date. There was one small container of cooked meat with use by date of 4/28/2024 expired stored in the reach in refrigerator. One container of milk with open date of 4/26/24 exceeding storage period for open container of milk was stored in the reach in refrigerator. During a concurrent observation and interview with Dietary Manager on 4/29/2024 at 07:45 a.m., DM said everything should be dated and discarded before the use by date. DM said once items are open, they are stored for 3 days, DM said the milk is expired and it should be discarded. During an observation in kitchen on 4/29/2024 at 08:00 a.m., One box containing 75 individual 056321 Page 19 of 29 056321 05/02/2024 Olympia Convalescent Hospital 1100 S. Alvarado St Los Angeles, CA 90006

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some containers of strawberry flavored nutrition supplements with delivery date of 4/16/24 was stored in the reach in refrigerator. There were two more boxes each containing 75 individual cartons of sugar free vanilla flavored nutrition supplements stored on the bottom shelf of the reach in refrigerator with delivery date of 3/29/24. During a concurrent interview with Dietary Manager (DM), DM said the nutrition supplements are delivered frozen and then stored in the refrigerator to thaw. DM said the delivery dates are written on the box and they have been stored in the refrigerator since the delivery date. DM said she does not know the expiration dates of the nutrition supplements. During a concurrent interview and review of the nutrition supplements manufactures storage instructions written on the cartons, DM verified that once thawed the product should be used in 14 days. DM said she is not sure when the supplements were thawed and removed the supplements to discard. DM said the supplements are milk based and expired milk products can cause stomachache and its bad. A review of the 2022 U.S. Food and Drug Administration Food Code titled Ready to Eat, Time/Temperature control for safety food, Date Marking Code#3-501.17, indicated, Ready to eat, time temperature control for safety food prepared and packaged by food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed, sold, or discarded. 2. During an observation of the facility ice machine on 4/29/2024 at 8:45 a.m. located in the kitchen, a clean paper towel swipe of the ice storage bin ceiling and sided produced a pink color resident. The residue was located on the corners and under the baffle (plastic board that hold the ice from falling out of the ice storage bin.) During a concurrent interview with DM, she stated that the Maintenance Supervisor cleans the ice machine. DM said the residue could be build up and will contact the maintenance supervisor. During an interview with Maintenance Supervisor (MS) on 4/29/2024 at 9:45a.m. MS stated he cleans the ice machine once a month. He stated that he didn't remove the baffle before cleaning. He said the ice machine is due for cleaning and said the pink color residue should not be in the ice bin. He stated any residue can contaminate the ice. A review of the 2022 U.S. Food and Drug Administration Food Code titled Equipment Food-Contact Surfaces and Utensils Code# 4-602.11, indicated, Surfaces of utensils and equipment contacting food that is not time/temperature control for safety food such as iced tea dispensers, carbonated beverage dispenser nozzles, beverage dispensing circuits or lines, water vending equipment, coffee bean grinders, ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. 3. During an observation and a concurrent interview with the DM in the kitchen dry storage area on 4/29/2024 at 10:00 a.m., there was one container with food thickener and one container with non-fat dry milk powder, the scoop was stored in the container and on the food so that the handle of the scoop was touching the food thickener and the dry milk powder. The DM stated the scoop should not be on the food and removed the scoop. DM said the handles can result in contamination of the food. A review of the 2022 U.S. Food and Drug Administration Food Code titled In-Use utensils, Between-Use Storage Code 3-304.12 indicated, During pauses in Food operation or dispensing, Food preparation 056321 Page 20 of 29 056321 05/02/2024 Olympia Convalescent Hospital 1100 S. Alvarado St Los Angeles, CA 90006

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and dispensing utensils shall be stored: (E) In food that is not time/temperature control for safety food with their handles above the top of the food within containers or equipment that can be closed, such as bins of sugar, flour or cinnamon. 4. During a tour observation of Resident in room [ROOM NUMBER] on 4/29/2024, at 9:12 AM, a banana was observed on top of the Residents closet. During a concurrent interview with CNA1, CNA1 was unable to state how long the banana had been on top of the Residents closet. CNA1 stated a banana is not supposed to be on top of Residents closets, because of risk of infection to Residents and insect infestation. During an interview with Director of Nursing (DON) on 5/2/2024, at 10:02 PM, DON stated Food should not be left at on top of Residents closets, DON further, stated it would be difficult to know who the food belongs to and, a banana if left on top of closet for a long time would be forgotten and could cause residents rooms to have gnat/bugs infestation in the facility, could cause a food safety issue due poor storage, if rotten/spoilt is consumed by a confused Resident it may cause GI complications from pathogens and/or cause affected resident room environmental safety and well-being in the room due to infection control. A review of the facility policy and procedures titled Food brought in by visitors dated, May 1, 2023 indicated, Perishable food requiring refrigeration will be discarded after two (2) hours at bedside . 056321 Page 21 of 29 056321 05/02/2024 Olympia Convalescent Hospital 1100 S. Alvarado St Los Angeles, CA 90006

F 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 64), range of motion was documented. Residents Affected - Few This deficient practice had the potential to negatively reflect Resident 64's range of motion treatment. Findings: A review of Resident 64's Medical Data Set (MDS - a standardized assessment and care screening tool), dated 09/02/2023, indicated the resident needed some help with self-care, indoor mobility (ambulation), and functional cognition. During a concurrent interview and record review on 5/01/24 at 08:45 AM with Director of Staff Development (DSD), Resident 64's Administrative Record Restorative Nursing, dated April 2024 was reviewed. The Administrative Restorative Nursing Assistant Log did not indicate Resident 64 received range of motion treatment on 4/2, 4/3, 4/4, 4/5, 4/11, 4/13, 4/20, 4/24, and 4/27. DSD stated she could not explain why Resident 64 did not receive range of motion treatment on those dates. During a concurrent interview and record review on 5/01/24 at 09:00 AM with Restorative Nursing Assistant (RNA) 1 and 2, Restorative Nursing Assistant (RNA) Log dated April 2024 was reviewed. The RNA Log indicated on 4/3 and 4/4 for the morning treatment, there were no staff initials in the box for RNA services provided. RNA 1, was scheduled on 4/3 and 4/4, stated she started on 4/2, and she probably forgot. RNA 1 stated she had training on documentation. RNA 2 stated if the RNAs are busy they can go back and sign as a late entry. RNA 2 indicated that X means not assigned and 9 is used for further documentation in progress notes. RNA 2 indicated that their charting does not look like the flowsheet the surveyors see. RNA 2 displayed the flow sheet for the RNAs, which looked like the previous screen by the surveyor. RNA 1 showed that they begin documentation by selecting the resident, then click yes to indicate that the resident was seen and then click save, the next screen allows the RNA to click if the resident refused, if the RNA documented additional notes in the progress notes, or if the treatment was administered. During a concurrent interview and record review on 5/1/2024 at 09:00 AM with RNA 2, the facility's policy and procedures (P&P) titled, Documentation Restorative Nursing Program was reviewed. The P&P indicated Daily and Weekly documentation treatment specifics provided to the residents. RNA 2 stated could not show where they document those items. During a concurrent interview and record review on 05/01/24 at 09:36 AM with Assistant Director of Staff Development (ADSD), the facility's P&P titled, Documentation Restorative Nursing Program, was reviewed. The Documentation Restorative Nursing Program policy indicated Daily and Weekly documentation treatment specifics provided for the residents. The ADSD stated medical records could show the documentation. During a concurrent interview and record review on 05/01/24 at 10:03 AM with Medical Records (MR), The audit for Restorative Nursing Assistant dated 4/1/2024 to 4/5/2024 was reviewed. MR stated he audits the RNA documentation. The Restorative Nursing Assistant audit indicated missing signatures. MR stated report is given to DSD and they speak with the RNAs to correct. 056321 Page 22 of 29 056321 05/02/2024 Olympia Convalescent Hospital 1100 S. Alvarado St Los Angeles, CA 90006

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 05/01/24 at 10:55 AM with DSD and ADSD, they stated received the audit report from medical records. They instruct the RNAs to correct the missing documentation. The DSD stated the RNAs go back and make the correction. During a review of the facility's P&P titled, Documentation Nursing Manual - Restorative Nursing Program, dated 6/1/2017 the P&P indicated, Daily and weekly documentation will be done on the RNA Flow Sheet. 056321 Page 23 of 29 056321 05/02/2024 Olympia Convalescent Hospital 1100 S. Alvarado St Los Angeles, CA 90006

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement their policy titled, Hand Hygiene, by failing to ensure: Residents Affected - Few 1. Certified Nursing Assistant 1 (CNA 1) performed hand hygiene between care of Resident 25 and Resident 81. 2. Licensed Vocational Nurse 1 (LVN 1) performed hand hygiene between resident's room's 142 and 143. 3. A urinal was not found in Resident 82's room without being labeled. A review of Resident 25's admission Record indicated Resident 25 was admitted to the facility on [DATE] with medical diagnoses that includes dementia (impaired ability to remember, think or make decisions that interferes with doing everyday activities), depression (a constant feeling of sadness and loss of interest which stops you from doing normal activities), and hypertension (HTN -blood pumping with more force than normal through your arteries). A review of Resident 25's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 1/25/2024, indicated Resident 25 had impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life) and required substantial/maximal and dependency on staff for showering, toilet use, oral hygiene, and personal hygiene. A review of Resident 81's admission Record indicated the Resident 81 was admitted to the facility on [DATE] with medical diagnoses that includes dementia, delusional disorders (one or more firmly held false beliefs that persist for at least one month), and HTN. A review of Resident 81's MDS, dated [DATE], indicated Resident 81 had impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life) and partial/moderate assist on staff for eating, toilet use, oral hygiene, and personal hygiene. During on observation on 4/29/2024, at 9:04 A.M., in room [ROOM NUMBER], CNA 1 was observed assisting Resident 25 with cutting her slice of bread into smaller pieces, did not perform hand hygiene and then proceeded to picking up a glass of milk from Resident 81's tray and handed it to her. During an interview on 4/29/2024, at 9:06 A.M., CNA 1 stated I am supposed to wash or sanitize my hands when I go from one resident to the next to prevent infection. During an interview on 5/2/2024, at 7:41 A.M., the Infection preventionist Nurse (IPN) stated that between resident care or assistance, basic thing is hand hygiene. The IPN stated. We follow what we call five moments of hand hygiene; before and after procedure/treatment, before and after taking care of the resident, after touching the surfaces of the resident's environment or between residents. The IPN further stated, This is done to prevent transmission of harmful organisms that may lead to infections such as sepsis that maybe life threatening to the residents. 056321 Page 24 of 29 056321 05/02/2024 Olympia Convalescent Hospital 1100 S. Alvarado St Los Angeles, CA 90006

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 5/2/2024, at 8:46 A.M., the Director of Nursing (DON), stated staff have to perform hand hygiene between residents to prevent transfer of infectious pathogens from one resident to another. The DON stated, Infection may lead to additional compromise of the already immunocompromised residents and cause illnesses that could possibly lead to death. A review of Resident 82's Face Sheet, indicated Resident 82 was initially admitted to the facility on [DATE] with diagnoses including Fracture of right Femur (A fracture is a broken bone), (The femur is your thigh bone. It is the longest, and strongest bone in your body); Hyperlipidemia (elevated level of fats in the blood), and HTN. A review of Resident 82's MDS indicated Resident 82's cognition (the mental ability to make decisions of daily living) was severely impaired, Resident 82 required supervision or touch assistance (Helper provides verbal cues and or touching/steadying and/ or contact guard assistance as a resident completes the activity) with standing, showers. During observation on 4/29/24 at 9:07 a.m., LVN 1, was observed not using hand sanitizer or washing hands before entering resident's rooms [ROOM NUMBERS]. During an interview on 4/29/24 at 9:15 a.m., LVN 1 stated, when going inside a resident's room he knocks first and asks for permission to enter; then introduces himself to the resident. LVN 1 further stated, next, he explains the reason for the visit to the Resident; if he needs to touch the resident LVN 1 stated then he will wash his hands, or use sanitizer. LVN 1 further stated and confirmed that he did not use hand sanitizer before entering the resident's rooms. Referring to rooms [ROOM NUMBERS]. LVN 1 stated that he was in a hurry and forgot to wash in and wash out of each room. LVN 1 stated that it is critical to perform hand hygiene each time before entering each room in order to prevent the spread of infection and he would not forget to sanitize his hands again. During observation, on 4/29/24 at 9:39 a.m., it was observed that Resident 82's urinal was not labelled with the Resident's initials, room number, bed number or any other identifying label that would indicate the urinal belonged to Resident 82. Neither was there any date that indicated when the urinal was first provided to Resident 82 for his personal use. During an interview on 4/29/24 at 9:39 a.m., CNA 3 stated that normally there are initials, room numbers and bed numbers written in permanent marker on the urinals; to prevent any mix ups of the urinals. CNA 3 stated that the urinal was at bedside before his shift began, however, he did not check to see if it was labelled with the resident's initial, or any other identifying mark to prevent any mix ups involving the ownership of the urinal. CNA 3 stated, that the initials, and bed numbers are placed on the urinals to prevent them from being given to the wrong Resident by mistake after being cleaned by staff. CNA 3 stated that this is done to help prevent cross contamination from urinals and bedpans, between residents. During an interview on 05/01/24 at 9:28 a.m., the DON stated that all staff must wash their hands or use sanitizer before and after entering a resident's room for any reason. The DON stated, the use of hand sanitizer and washing of hands is an infection control measure used to prevent staff from spreading infections from one resident to another through touch. The DON further stated to maintain Infection control, staff must first use sanitizer before entering a resident's room, and after leaving the resident's room. During an interview on 05/01/24 at 09:28 a.m., with the DON stated that staff are expected to label 056321 Page 25 of 29 056321 05/02/2024 Olympia Convalescent Hospital 1100 S. Alvarado St Los Angeles, CA 90006

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few urinals with the resident's room numbers, and perhaps their initials in order to prevent urinals from becoming mixed up with other urinals. The urinals also should be labelled with a date to know when they should be changed. During an interview on 05/02/24 8:34 a.m., with IP in the facility hand hygiene is performed before and after entering the room or every resident. IP stated that he performs in service training with staff every week on various infection control subjects. IP stated, for staff and general population, everyone must perform hand hygiene before and after entering a resident's room. IP stated that the staff call the process, Gel in Gel out before going into the resident room. IP stated, that for the urinals and bedpans staff are instructed to label each container with the resident's name, room & bed number. This will prevent any accidental mix ups of urinals, or bedpans between residents, which could cause a spread of infection between residents. A review of the facility's policy and procedures titled, Hand Hygiene revised 6/1/2017, indicated the purpose of the policy is to ensure that all individuals use appropriate hand hygiene while at the facility. The facility considers hand hygiene the primary means to prevent the spread of infections . Wash hands with soap and water: .Before and after assisting residents with dinning if direct contact with food is anticipated or occurs. 056321 Page 26 of 29 056321 05/02/2024 Olympia Convalescent Hospital 1100 S. Alvarado St Los Angeles, CA 90006

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide at least 80 square feet (sq. ft. -unit of measure) per resident in multiple resident bedrooms for 24 out of the 35 resident rooms (Rooms 107, 109, 116, 118, 120, 121, 122, 123, 124, 125, 126, 128, 129, 130, 131, 133, 134, 135, 136, 138, 142, 143, 144, and 145). The 24 Resident rooms consisted of 3 beds in each room. This deficient practice had the potential to result in inadequate useable living space for the residents and working space for the health caregivers. Findings: A review of the Request for Room Size Waiver letter, dated 5/1/2024, submitted by the Administrator, indicated there are 24 rooms not meeting the 80 square feet requirement per resident according to federal regulation. The letter indicated that the room sizes would not interfere with the daily nursing care or safety of the residents. The letter also indicated there would be enough space to provide for each resident's care, dignity and privacy in those rooms which are in accordance with the special needs of the residents. The letter indicated the spaces would not have adverse effect on the residents' health and safety or impede the ability of any resident in the rooms to attain his or her highest practicable well-being. A review of the Client Accommodations Analysis submitted by the facility on 4/30/2024, indicated the following rooms with their corresponding measurements: Rooms # Total Sq. Ft/Resident # Beds Floor Area Sq. Ft/Resident. room [ROOM NUMBER] is 228 square feet with 3 beds (76.2 square feet per resident) room [ROOM NUMBER] is 228 square feet with 3 beds (76.2 square feet per resident) room [ROOM NUMBER] is 224.4 square feet with 3 beds (74.8 square feet per resident) room [ROOM NUMBER] is 224.2 square feet with 3 beds (74.7 square feet per resident) room [ROOM NUMBER] is 219.0 square feet with 3 beds (73.0 square feet per resident) room [ROOM NUMBER] is 228.6 square feet with 3 beds (76.2 square feet per resident) room [ROOM NUMBER] is 225.5 square feet with 2 beds (75.1 square feet per resident) room [ROOM NUMBER] is 236.9 square feet with 2 beds (78.9 square feet per resident) room [ROOM NUMBER] is 223.3 square feet with 2 beds (74.4 square feet per resident) room [ROOM NUMBER] is 227.7 square feet with 3 beds (75.9 square feet per resident) room [ROOM NUMBER] is 227.7 square feet with 3 beds (75.9 square feet per resident) 056321 Page 27 of 29 056321 05/02/2024 Olympia Convalescent Hospital 1100 S. Alvarado St Los Angeles, CA 90006

F 0912 room [ROOM NUMBER] is 227.7 square feet with 3 beds (75.9 square feet per resident) Level of Harm - Potential for minimal harm room [ROOM NUMBER] is 229.9 square feet with 3 beds (76.6square feet per resident) room [ROOM NUMBER] is 224.4 square feet with 3 beds (74.8 square feet per resident) Residents Affected - Some room [ROOM NUMBER] is 229.9square feet with 3 beds (76.6 square feet per resident) room [ROOM NUMBER] is 229.9 square feet with 3 beds (76.6 square feet per resident) room [ROOM NUMBER] is 229.7 square feet with 3 beds (76.5 square feet per resident) room [ROOM NUMBER] is 229.9 square feet with 3 beds (76.6 square feet per resident) room [ROOM NUMBER] is 228.8 square feet with 3 beds (76.2 square feet per resident) room [ROOM NUMBER] is 228.8 square feet with 3 beds (76.5square feet per resident) room [ROOM NUMBER] is 228.2 square feet with 3 beds (76.2 square feet per resident) room [ROOM NUMBER] is 228.8 square feet with 3 beds (76.2 square feet per resident) room [ROOM NUMBER] is 229.7 square feet with 3 beds (76.6 square feet per resident) room [ROOM NUMBER] is 229.7 square feet with 3 beds (76.6 square feet per resident) The minimum square footage for a 2-bed room should be 160 sq. ft. per federal regulation. During the general observations of the residents' rooms on 4/29/2024 to 5/2/2024, the residents had ample space to move freely inside the rooms. There were sufficient spaces to provide freedom of movement for the residents and for nursing staff to provide care to the residents. There was also sufficient space for beds, side tables and resident care equipment. 056321 Page 28 of 29 056321 05/02/2024 Olympia Convalescent Hospital 1100 S. Alvarado St Los Angeles, CA 90006

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the call light for one of six sampled resident's (Resident 28) was within reach. Residents Affected - Few This failure had the potential to result in Resident 28's not receiving assistance when needed from the facility staff. Findings: During review of Resident 28's admission record, it indicated the resident was admitted in the facility on 12/8/23, with the diagnoses including but not limited to hemiplegia (an inability to move one side of body) and hemiparesis (an inability to move the arm, leg and sometimes face on one side of the body) following a cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting left non-dominant side. During a review of Resident 28's Minimum Data Set (MDS - a standardized comprehensive assessment and care screening tool), dated 3/15/24, indicated Resident 28's cognition (the mental ability to make decisions of daily living) was severely impaired. Resident 28 required moderate to maximal assistance from staff for activities of daily living (ADLs - toileting hygiene, shower/bathe, upper and lower body dressing, and personal hygiene). Resident 28's cognitive condition, losing the ability to understand the meaning or importance of something and the ability to talk or write, resulting in the inability to live independently. During a concurrent observation and interview on 4/29/24 at 8:20 AM, inside Resident 28's room, Resident 28's call light was behind bed, hanging on the wall. Certified Nursing Assistant 2 (CNA 2) stated the resident uses the call light a lot and that CNA 2 forgot to check the call light today when CNA 2 came to work in this morning. During an interview on 4/29/24 at 8:22 a.m., CNA 2 stated Resident 28 uses the call light whenever the resident needs help. CNA 2 stated Resident 28 will use the call light to let staff know the resident needed something. CNA 2 stated she was not aware that the call light was not on the bed within reach of Resident 28. CNA 2 stated CNA 2 did not notice that the call light was hanging on the wall, behind Resident 28's bed. CNA 2 stated that it is CNA2's responsibility to see if the call lights are within resident's reach. CNA 2 stated if Resident 28, does not have the call light within reach, she could need help and would not be able to call for assistance. This could be the cause of a fall, or the resident not being able to get help when needed. During an interview on 5/1/24 at 9:28 a.m., Director of Nursing (DON) stated the call light allows the residents to call for help if they need it at any time. DON stated staff must make sure that all residents have continuous access to the call light for safety reasons and it should never be out of reach, even if a resident is using the call light more than usual. A review of the facility's policy and procedures (P&P) titled, Communication - Call System dated 10/24/22, indicated, The Facility will provide a call system to enable residents to alert the nursing staff from their beds and toileting/bathing facilities. Call cords will be placed within the resident's reach in the resident's room. 056321 Page 29 of 29