Health inspection·November 19, 2023

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS, an assessment and screening tool) was coded correctly for two of two sampled residents (Resident 36 and Resident 32). Residents Affected - Few a.Resident 36 was discharged to home and the Minimum Data Set (MDS, an assessment and screening tool) dated 10/11/23 was coded as Resident 36 being discharged to the hospital. b. Resident 32's primary language was Thai and was documented as English in the MDS dated [DATE]. This failure resulted in inaccuracy of Resident 36 and 32's MDS clinical status and had the potential to result in both residents to not receive the necessary care and services. Findings: a.During a review of Resident 36's admission Record, the AR indicated Resident 36 was admitted to the facility on [DATE] with diagnoses that included hypertension (increased blood pressure) and dysphagia (difficulty swallowing). During a review of Resident 36's Transfer/Discharge Report, signed 10/11/23, the Transfer/Discharge Report indicated Resident 36 was discharged to Resident 36's son's house on 10/11/23. During a review of Resident 36's MDS, dated [DATE], the MDS indicated Resident 36 was discharged to the hospital. During an interview on 11/18/23 at 5:07 pm., the MDS coordinator (MDSC) stated Resident 36 was discharged home on [DATE]. The MDSC stated the MDSC made a mistake when coding Resident 36 as being discharged to the hospital in Resident 36's MDS. The MDSC stated Resident 36's MDS should have been coded as discharged home. The MDSC stated it was important to code Resident 36's MDS correctly to make sure Resident 36 received necessary care and services. b. During a review of Resident 32's AR, the AR indicated Resident 32 was admitted to the facility on [DATE] with diagnoses that included glaucoma (group of eye conditions that can cause blindness) and type II diabetes mellitus (DM2- a disease that results in elevated levels of sugar in the blood). The AR indicated Resident 32's primary language was Thai. During a review of Resident 32's MDS, dated [DATE], the MDS indicated Resident 32's preferred language was English. The MDS indicated Resident 32 had moderately impaired cognition (ability to understand and process information). Resident 32 required substantial/maximal assistance (helper does more Page 1 of 19 056331 056331 11/19/2023 Beacon Healthcare Center 919 N Sunset Ave West Covina, CA 91790

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few than half the effort. Helper lifts or holds trunk or limbs and provides more than half effort) with eating, oral hygiene, and upper body dressing. Resident 32 was dependent (helper does all the effort) with toileting hygiene, showers/bathing self, lower body dressing, putting on/taking off footwear, and personal hygiene. During an interview on 11/17/2023 at 3:48 pm., with Resident 32's responsible party (RP 1), RP 1 stated Resident 32 could not speak enough English to communicate in clear sentences. During an interview on 11/18/2023 at 3:31 pm., with Resident 32 (the Los Angeles County Interpreter Services was used), Resident 32 stated Resident 32 only understood a little English and could not communicate Resident 32's needs well to the facility staff. Resident 32 stated staff did not speak Thai or use a Thai interpreter when communicating with Resident 32. Resident 32 stated this situation made it hard to tell staff what was wrong with Resident 32. During a concurrent interview and record review on 11/19/2023 at 9:27 am., with the MDSC, the MDSC reviewed Section A of Resident 32's MDS dated [DATE]. The MDSC stated Resident 32's primary language was documented as English in the MDS. The MDSC stated Resident 32's primary language was not English, but was Thai. The MDSC stated the MDSC was not sure if Resident 32 understood the MDSC. The MDSC stated it was important to make an accurate assessment in Resident 32's MDS so Resident 32 could be cared for the way Resident 32 wanted and needed. During an interview on 11/19/2023 at 11:01 am., with the Director of Staffing Development (DSD), the DSD stated it was possible Resident 32's needs were not being met because Resident 32 could not effectively speak English to staff. During a review of the facility's policy and procedure (P&P), titled, Comprehensive Assessments, revised March 2022, the P&P indicated, a significant error is an error in an assessment where the resident's overall clinical status is not accurately represented (i.e., miscoded) on the erroneous assessment and/or results in an inappropriate plan of care. 056331 Page 2 of 19 056331 11/19/2023 Beacon Healthcare Center 919 N Sunset Ave West Covina, CA 91790

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 implement care plans (CP) that met the needs of two of two sampled residents (Residents 17 and 32) as indicated in the facility's policy and procedure, titled, Care Plans, Comprehensive Person-Centered. a. The facility did not follow interventions inidicated in Resident 17's Pressure Injury CP. Resident 17 was not repositioned every two hours as indicated in Resident 17's CP. b. b. Resident 32's CP for communication skills did not include appropriate interventions that addressed Resident 32's problem areas. Resident 32 did not speak English only spoke Thai and Resident 32 could not see the communication board indicated in the CP due to glaucoma (a group of eye conditions that can cause blindness). These failures had the potential to result in a psychosocial and physical decline to Residents 17 and Resident 32. Cross Reference F676 Findings: a. During a review of Resident 32's admission Record (AR), the AR indicated Resident 17 was admitted to the facility on [DATE] at 8:21 pm., with diagnoses including generalized muscle weakness (weakness of the muscles) and pressure ulcer (an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure) of sacral ((portion of the spine between the lower back and tailbone) stage 1, and glaucoma. During a review of Resident 17's Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 9/7/2023, the MDS indicated Resident 17 had moderately impaired cognition (ability to understand and process information). Resident 17 required supervision (oversight, encouragement, or cueing) with eating. Resident 17 required extensive assistance (resident involved activity, staff provide weight-bearing support) with bed mobility, dressing, toilet use, and personal hygiene. During a review of Resident 17's care plan dated 7/17/2023, the CP indicated Resident 17 was at high risk for developing pressure injuries (PIs, localized damage to the skin and underlying tissue, primarily caused by prolonged pressure on the skin, shear (mechanical force that causes skin to break of), or friction [surfaces rub against each other]), bruising and other types of skin breakdown related to reduced mobility, thin and fragile skin. The interventions included to assess Resident 17's skin during care, use pressure relieving devices as needed and turn and reposition every two hours and as needed when in bed or using the wheelchair. During a concurrent observation and interview on 11/17/2023 at 5:31 pm., Resident 17 was observed 056331 Page 3 of 19 056331 11/19/2023 Beacon Healthcare Center 919 N Sunset Ave West Covina, CA 91790

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some sitting on the wheelchair in the dining room, waiting for dinner and the wheelchair was reclined. Resident 17 stated Resident 17's bottom (buttocks) hurt because Resident 17 had been in the same position all day. Resident 17 stated Resident 17 had been on Resident 17's back all day. During a concurrent observation and interview on 11/18/2023 at 4:25 pm., with Licensed Vocational Nurse (LVN) 3, LVN 3 observed Resident 17. LVN 3 stated Resident 17 was in supine position in bed. LVN 3 stated there was no pillow under Resident 17's buttock. LVN 3 observed Resident 17's sacral pressure and stated the pressure ulcer was a healing wound. LVN 3 stated Resident 17 was supposed to be turned and repositioned every two hours so Resident 17 did not develop a new pressure injury and for healing of the PIs. LVN 3 stated repositioning for residents was supposed to take place during the odd hours of the day. LVN 3 stated Resident 17 was on the wheelchair for at least four hours during earlier that morning. LVN 3 stated LVN 3 was not sure how to reposition a resident who was in a wheelchair for an extended period of time. LVN 3 stated Resident 17 should have been repositioned at 11 am, 1 pm and 3 pm today. LVN 1 stated it was important to follow Resident 17's care plan for safety of residents. During an interview on 11/18/2023 at 4:46 pm, with Certified Nurse Assistant (CNA) 1, CNA 1 stated CNA 1 repositioned the residents (in general) every two to three hours. CNA 1 stated between 9:00 am and 11 am, all residents were repositioned to the right side. CNA 1 stated all residents were put on their backs at 11 am so they could eat lunch. CNA 1 stated when residents were in a wheelchair, CNA 1 put a pillow under their arms, shoulders, or knees, but not under back or bottom. CNA 1 stated Resident 17 was already in the wheelchair at 11 am that morning and CNA 1 did not reposition Resident 17. CNA 1 stated it was important to make sure the residents were repositioned appropriately to ensure they did not get pressure injuries and remained safe. During an interview on 11/19/2023 at 10:12 am., with the Director of Staffing Development (DSD), the DSD stated residents were supposed to be repositioned every two hours and as needed every day. The DSD stated if a CP indicated to reposition a resident every two hours, the CP needed to be followed. The DSD stated not following the CP could result in Resident 17 to develop new pressure injuries. During a concurrent observation and interview on 11/18/2023 at 10:26 am., Resident 17 was observed sitting on the wheelchair. The wheelchair was reclined. Resident 17 was in the dining room watching a movie. Resident 17 stated Resident 17's bottom hurt. During a concurrent observation and interview on 11/18/2023 at 3:15 pm., Resident 17 was observed lying in bed and in supine (back of body to the bed) position. Resident 17 stated staff put Resident 17 on one side after lunch but Resident 17 could not remember what side. Resident 17 stated other than one repositioning, Resident 17 had been laying on Resident 17's back or sitting on the wheelchair. b. During a review of Resident 32's AR, the AR indicated Resident 32 was admitted to the facility on [DATE], with diagnoses that included glaucoma (group of eye diseases that can vision and blindness by damaging the optic nerve) and type II diabetes mellitus (DM2- A condition that happens because of a problem in the way the body regulates and uses sugar as fuel). The AR indicated Resident 32's primary language was Thai. During a review of Resident 32's MDS, dated [DATE], the MDS indicated Resident 32 had moderately impaired cognition. Resident 32 required substantial/maximal assistance (helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half effort) with eating, oral 056331 Page 4 of 19 056331 11/19/2023 Beacon Healthcare Center 919 N Sunset Ave West Covina, CA 91790

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some hygiene, and upper body dressing. Resident 32 was dependent (helper does all of the effort. Resident 32 did none of the effort. Helper lifts or holds trunk or limbs and provides less than half the effort) toileting hygiene, showers/bathing self, lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 32's CP dated 10/21/2023, the CP indicated Resident 32 was at risk for decline in communication skills. The CP indicated Resident 32 had impaired/altered communication pattern due to a language barrier, Resident 32's native language was Thai. The goal indicated Resident 32's needs would be attended to and met accordingly through the next review date. The interventions included the use of a communication board as needed, involve in activities that which did not depend on Resident 32's ability to communicate like music, parties, and movies, monitor for understanding and repeat as needed, and use short phrases and questions which required yes/no answers. During an interview on 11/17/2023 at 3:48 pm., with Resident 32's responsible party (RP 1), RP 1 stated Resident 32 could not speak enough English to communicate in clear sentences and RP 1 felt concerned for Resident 32. RP 1 stated Resident 32 could not use a communication board to communicate because Resident 32 had glaucoma and could not see. RP 1 stated RP 1 was worried staff would miss information because of the language barrier. During an observation on 11/17/2023 at 4:42 pm., of Resident 32 and Certified Nurse Assistant (CNA) 1, CNA 1 was observed speaking to Resident 32 in English. CNA 1 asked Resident 32, Do you need anything? How are you? Do you need to 'peepee'? Resident 32 nodded head once in up and down motion. Resident 32 did not answer the questions orally. CNA 1 exited the room without receiving answers to the questions asked. The use of a phone was not used to translate from English to Thai. During an interview on 11/17/2023 at 4:49 pm., CNA 1 stated CNA 1 did not speak English well. CNA 1 stated Resident 32 understood English just fine. CNA 1 stated CNA 1 was unsure what Resident 32's primary language was. CNA 1 stated when caring for Resident 32, Resident 32 was always spoken to in English. CNA 1 stated CNA 1 could only translate for Spanish-speaking residents. CNA 1 stated CNA 1 did not use a phone to translate when speaking to Resident 32. CNA 1 stated the use of a communication board was not used for Resident 32 because Resident 32 could not see. During a concurrent observation and interview on 11/18/2023 at 3:31 pm., with Resident 32, Using Los Angeles County Interpreter Services, Identification Number 14320, Thai translation, Resident 32 stated Resident 32 could only understand a little English and could not communicate Resident 32's needs to staff well. Resident 32 stated staff did not speak Thai or use a Thai interpreter when communicating, and this made it hard to tell staff what was really wrong with Resident 32. Resident 32 stated, I feel like I am not being heard correctly. Resident 32 stated all of the activities provided to Resident 32 were in English, not in Thai. Resident 32 stated that none of the staff asked Resident 32 if Resident 32 understood what was being told to Resident 32. Resident 32 stated staff assume Resident 32 understands as much as is spoken to Resident 32 by staff. CNA 1 entered the Resident 32's room. CNA 1 asked in English if Resident 32, How are you, do you need anything? Resident 32 looked at CNA 1 but did not answer the questions. CNA 1 walked away. Resident 32 stated Resident 32 did not understand CNA 1. During a concurrent observation and interview on 11/18/2023 at 3:57 pm, with Licensed Vocational Nurse (LVN) 2, LVN 2 was observed speaking to Resident 32 in English. LVN 2 asked Resident 32, Are you in pain? Where is your pain? Resident 32 replied with the word, pain. LVN 2 stated Resident 32 could communicate English in very simple terms, not in full sentences. LVN 1 stated if a resident's 056331 Page 5 of 19 056331 11/19/2023 Beacon Healthcare Center 919 N Sunset Ave West Covina, CA 91790

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some primary language was not English, staff were supposed to call family or many use Google (translation service on phone) Translate. LVN 2 stated LVN 2 was not 100% (percent) sure Resident 32 could understand LVN 2 when speaking English to Resident 32. During a concurrent observation and interview on 11/18/2023 at 4:09 pm., LVN 3 was observed speaking to Resident 32 about medications. LVN 3 asked Resident 32 if Resident 32 wanted Tylenol (pain medication used to treat mild pain). LVN 3 asked Resident 32 if Resident 32 was agreeable to being given blood pressure medication (medications used to treated elevated blood pressure). LVN 3 stated when speaking to Resident 32, LVN 3 spoke slowly in English. LVN 3 stated the protocol for limited English Proficiency (LEP) residents like Resident 32 was to use family to translate or google translate. LVN 3 stated LVN 3 was not sure if the facility had translation services for staff. LVN 3 stated Resident 32's primary language was Thai and could not be fully sure that Resident 32 understood LVN 3 when speaking to Resident 32 in English. LVN 3 stated LVN 3 did not use family or Google translate to speak to Resident 32 when discussing medication being given to Resident 32. During a concurrent interview and record review on 11/19/2023 at 11:01 am., the DSD reviewed Resident 32's CP. The DSD stated Resident 32's primary language was Thai and that a communication board that was indicated in the CP was not effective because of Resident 32's medical condition. The DSD stated the CP did not indicate to use of translation or interpreter services when communicating with Resident 32 but should have. The DSD stated staff were supposed to follow Resident 32's CP for communication. The DSD stated staff were supposed to use their personal phones to communicate with residents who were LEP. The DSD stated it was possible that Resident 32's needs were not being met because staff were not using Google translate when speaking to Resident 32. The DSD stated not using google translate would make Resident 32 not feel heard. The DSD stated the facility did not use an official translation or interpretation service. During an interview on 11/19/2023 at 1:45 pm., with the Director of Nursing, the DON stated all CP needed to meet the needs of residents and if they were not effective, they needed to be reevaluated and revised. The DON stated that use of a communication board as an intervention for a resident who could not see was not effective. The DON stated care plan interventions needed to ensure residents were receiving the most updated care and that the interventions maintained or improved the residents' quality of life. During a review of the facility's policy and procedure (PP) titled, Care Plans, Comprehensive Person-Centered, Revised 3/2022, indicated a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the residents' physical, psychosocial, and functional needs is developed and implemented for each resident. The PP indicated care plans were derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The PP indicated care plan interventions are chosen only after data gathering, proper sequencing of events, careful considerations of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. The PP indicated when possible, interventions addressed the underlying sources of the problem areas, not just the symptoms or triggers. 056331 Page 6 of 19 056331 11/19/2023 Beacon Healthcare Center 919 N Sunset Ave West Covina, CA 91790

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 32), who had limited English proficiency (LEP), received translation support and services by the facility according to the facility's policy and procedure (PP) titled, Translation and/or interpretation of Facility Services, by failing to when Resident 32's primary language was Thai (language of Thailand) and the facility spoke English to Resident 32. Residents Affected - Some This failure had the potential in Resident 32 not to be able to communicate basic needs and had the potential to result in Resident 32 to suffer a physcial and psychosocial decline. Cross Reference F656 Findings: a. During a review of Resident 32's AR, the AR indicated Resident 32 was admitted to the facility on [DATE], with diagnoses that included glaucoma (group of eye diseases that can vision and blindness by damaging the optic nerve) and type II diabetes mellitus (DM2- A condition that happens because of a problem in the way the body regulates and uses sugar as fuel). The AR indicated Resident 32's primary language was Thai. During a review of Resident 32's MDS, dated [DATE], the MDS indicated Resident 32 had moderately impaired cognition. Resident 32 required substantial/maximal assistance (helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half effort) with eating, oral hygiene, and upper body dressing. Resident 32 was dependent (helper does all of the effort. Resident 32 did none of the effort. Helper lifts or holds trunk or limbs and provides less than half the effort) toileting hygiene, showers/bathing self, lower body dressing, putting on/taking off footwear, and personal hygiene. During a concurrent observation and interview on 11/18/2023 at 3:31 pm., with Resident 32, Using Los Angeles County Interpreter Services, Identification Number 14320, Thai translation, Resident 32 stated Resident 32 could only understand a little English and could not communicate Resident 32's needs to staff well. Resident 32 stated staff did not speak Thai or use a Thai interpreter when communicating, and this made it hard to tell staff what was wrong with Resident 32. Resident 32 stated, I feel like I am not being heard correctly. Resident 32 stated all the activities provided to Resident 32 were in English, not in Thai. Resident 32 stated that none of the staff asked Resident 32 if Resident 32 understood what was being told to Resident 32. Resident 32 stated staff assumed Resident 32 understood as much as was spoken to Resident 32 by staff. CNA 1 entered the Resident 32's room. CNA 1 asked in English if Resident 32, How are you, do you need anything? Resident 32 looked at CNA 1 but did not answer the questions. CNA 1 walked away. Resident 32 stated Resident 32 did not understand CNA 1. During an interview on 11/17/2023 at 3:48 pm., with Resident 32's responsible party (RP 1), RP 1 stated Resident 32 could not speak enough English to communicate in clear sentences and RP 1 felt concerned for Resident 32. During an observation on 11/17/2023 at 4:42 pm., of Resident 32 and Certified Nurse Assistant (CNA) 056331 Page 7 of 19 056331 11/19/2023 Beacon Healthcare Center 919 N Sunset Ave West Covina, CA 91790

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1, CNA 1 was observed speaking to Resident 32 in English. CNA 1 asked Resident 32, Do you need anything? How are you? Do you need to 'peepee'? Resident 32 nodded head once in up and down motion. Resident 32 did not answer the questions orally. CNA 1 exited the room without receiving answers to the questions asked. The use of a phone was not used to translate from English to Thai. During an interview on 11/17/2023 at 4:49 pm., CNA 1 stated CNA 1 did not speak English well. CNA 1 stated Resident 32 understood English just fine. CNA 1 stated CNA 1 was unsure what Resident 32's primary language was. CNA 1 stated when caring for Resident 32, Resident 32 was always spoken to in English. CNA 1 stated CNA 1 could only translate for Spanish-speaking residents. CNA 1 stated CNA 1 did not use a phone to translate when speaking to Resident 32. During a concurrent observation and interview on 11/18/2023 at 3:31 pm., with Resident 32, Using Los Angeles County Interpreter Services, Identification Number 14320, Thai translation, Resident 32 stated Resident 32 could only understand a little English and could not communicate Resident 32's needs to staff well. Resident 32 stated staff did not speak Thai or use a Thai interpreter when communicating, and this made it hard to tell staff what was wrong with Resident 32. Resident 32 stated, I feel like I am not being heard correctly. Resident 32 stated all the activities provided to Resident 32 were in English, not in Thai. Resident 32 stated that none of the staff asked Resident 32 if Resident 32 understood what was being told to Resident 32. Resident 32 stated staff assume Resident 32 understands as much as is spoken to Resident 32 by staff. CNA 1 entered the Resident 32's room. CNA 1 asked in English if Resident 32, How are you, do you need anything? Resident 32 looked at CNA 1 but did not answer the questions. CNA 1 walked away. Resident 32 stated Resident 32 did not understand CNA 1. During a concurrent observation and interview on 11/18/2023 at 3:57 pm, with Licensed Vocational Nurse (LVN) 2, LVN 2 was observed speaking to Resident 32 in English. LVN 2 asked Resident 32, Are you in pain? Where is your pain? Resident 32 replied with the word, pain. LVN 2 stated Resident 32 could communicate English in very simple terms, not in full sentences. LVN 1 stated if a resident's primary language was not English, staff were supposed to call family or many use Google (translation service on phone) Translate. LVN 2 stated LVN 2 was not 100% (percent) sure Resident 32 could understand LVN 2 when speaking English to Resident 32. During a concurrent observation and interview on 11/18/2023 at 4:09 pm., LVN 3 was observed speaking to Resident 32 about medications. LVN 3 asked Resident 32 if Resident 32 wanted Tylenol (pain medication used to treat mild pain). LVN 3 asked Resident 32 if Resident 32 was agreeable to being given blood pressure medication (medications used to treated elevated blood pressure). LVN 3 stated when speaking to Resident 32, LVN 3 spoke slowly in English. LVN 3 stated the protocol for limited English Proficiency (LEP) residents like Resident 32 was to use family to translate or google translate. LVN 3 stated LVN 3 was not sure if the facility had translation services for staff. LVN 3 stated Resident 32's primary language was Thai and could not be fully sure that Resident 32 understood LVN 3 when speaking to Resident 32 in English. LVN 3 stated LVN 3 did not use family or Google translate to speak to Resident 32 when discussing medication being given to Resident 32. During an interview on 11/19/2023 at 11:01 am, with the DSD, The DSD stated staff were supposed to use their personal phones to communicate with residents who were LEP. The DSD stated it was possible that Resident 32's needs were not being met because staff were not using Google translate when speaking to Resident 32. The DSD stated not using google translate would make Resident 32 not feel heard. The DSD stated the facility did not use an official translation or interpretation service. 056331 Page 8 of 19 056331 11/19/2023 Beacon Healthcare Center 919 N Sunset Ave West Covina, CA 91790

F 0676 Level of Harm - Minimal harm or potential for actual harm During an interview on 11/19/2023 at 11:26 am, the Social Services Director (SSD) stated the facility's language access program was the use of Google Translate by staff for residents who required translation. The SSD stated the language access program should be implemented for Resident 32. The SSD stated not using the language access program for Resident 32 could make Resident 32 feel bad and not have needs communicated which could lead to medical decline. Residents Affected - Some During a review of the facility's PP titled, Translation and/or Interpreation of Facility Services, revised 11/8:20 pm, the PP indicated the facility's language access program will ensure that the individuals with LEP shall have meaningful access to information and services provided by the facility. The PP indicated that providing meaningful access to serviced provided by the facility required that LEP residents' needs and questions were accurately communicated to the staff, and that oral interpretation services would therefore include interpretation from the LEP residents' primary language back to English. The PP indicated that in order to provide meaningful access to services provided by the facility, translation and/or interpretation must be provided in a way that is culturally relevant and appropriate to the LEP individual. During a review of the PP titled, Language Barrier, Communication, Revised 11/8:20 pm, the PP indicated the facility will ensure that residents with LEP shall have meaningful access to information and services provided by the facility. The PP indicated to use a phone app for translation. The PP indicated the Activity Director or Social Services would coordinate the language access program when needed. 056331 Page 9 of 19 056331 11/19/2023 Beacon Healthcare Center 919 N Sunset Ave West Covina, CA 91790

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safety measures were implemented, for one of two sampled residents (Resident 26) and as indicated in the facility's policy and procedure (P&P), when Resident 26's bed pad alarm (device that alerts staff when a resident gets out of bed) was turned off. Resident 26 was at high risk for falls and had a history of multiple falls. This failure had the potential to result in injury and a physical decline to Resident 26. Findings: During a review of Resident 26's admission Record (AR), the AR indicated Resident 26 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included urinary tract infection (UTI, an infection in any part of the urinary system, including the kidneys, bladder, or urethra), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and dementia (a group of thinking and social symptoms that interferes with daily functioning). During a review of Resident 26's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/29/23, the MDS indicated Resident 26 was moderately impaired in cognitive skills (the ability to make daily decisions). The MDS indicated Resident 26 required extensive assistance (resident involved in activity, staff provide weight-bearing support) from staff for transfers, dressing, and personal hygiene. During a concurrent interview and record review on 11/18/23 at 2:35 pm., with the MDS Coordinator (MDSC), Resident 26's care plan titled The Resident is at Risk for Fall or Injury Due to: dated 9/27/23 was reviewed. The MDSC stated the care plan indicated Resident 26 should have a bed pad alarm when in bed. During a concurrent observation and interview on 11/18/23 at 2:59 pm., with the MDSC, Resident 26's bed pad alarm was observed. Resident 26 was asleep in Resident 26's bed and the bed pad alarm was turned off. The MDSC confirmed the alarm was turned off. The MDSC stated the alarm needed to be turned on to ensure Resident 26's safety and to prevent falls. The MDSC stated if the facility staff did not follow safety interventions, then Resident 26 could fall again. During a review of Resident 26's Order Summary Report, the Order Summary Report indicated there was an order, dated 10/23/23, for Resident 26 to have a bed alarm when in bed. During a review of Resident 26's IDT-Incident Review, dated 10/23/23, the IDT-Incident Review indicated Resident 26 fell on [DATE]. The review indicated Resident 26 had poor safety judgement, impaired memory, and was at very high risk for falls. The review indicated a recommendation to place an alarm in bed for Resident 26's safety. During a review of the facility's P&P titled, Fall Prevention and Management, revised March 2023, the P&P indicated, the staff and physician will identify pertinent interventions to try to prevent subsequent falls. During a review of the facility's P&P titled, Personal Alarms, revised May 2023, the P&P indicated, 056331 Page 10 of 19 056331 11/19/2023 Beacon Healthcare Center 919 N Sunset Ave West Covina, CA 91790

F 0689 Least restrictive measures will be initiated to promote safety based on known or identified risk factors (i.e. pressure activated alarms). Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 056331 Page 11 of 19 056331 11/19/2023 Beacon Healthcare Center 919 N Sunset Ave West Covina, CA 91790

F 0692 Provide enough food/fluids to maintain a resident's health. 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 nutritional care and services were provided to one of two sampled Residents (Resident 29). Resident 29, who had experienced weight loss, did not receive his supplement of ice cream with his lunch tray as ordered by the physician. Residents Affected - Few This failure had the potential to result in further weight loss to Resident 29. Findings: During a review of Resident 29's admission Record (AR), the AR indicated Resident 29 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (also called ischemic stroke, occurs as a result of disrupted blood flow to the brain), hypertension (high blood pressure), and dysphagia (difficulty swallowing foods or liquids). During a review of Resident 29's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/19/23, the MDS indicated Resident 26 had no impairment in cognitive skills (the ability to make daily decisions). The MDS indicated Resident 29 required extensive assistance (resident involved in activity, staff provide weight-bearing support) from staff for transfers, dressing, and personal hygiene. During a concurrent observation and interview on 11/18/23 at 12:33 pm., with Resident 29, Resident 29 was lying in bed eating his lunch. Resident 29 stated the facility did not include ice cream in Resident 29's meal. Resident 29's lunch tray was observed, and the tray did not contain ice cream. During a concurrent interview and record review on 11/18/23 at 12:43 pm., with the Dietary Supervisor (DS), Resident 29's diet card (included with the meal tray) was reviewed. The diet card did indicate ice cream should be given with lunch and dinner. The DS stated if Resident 29's diet was changed and ice cream had to be included with lunch and dinner, a diet communication notice (to indicate change) was sent to the kitchen. The DS stated Resident 29's diet card needed to be updated especially if Resident 29 was losing weight. During a review of Resident 29's IDT-Weight Change Review-V2, dated 10/9/23, the IDT-Weight Change Review-V2 indicated Resident 29 experienced weight loss. The IDT-Weight Change Review-V2 indicated there was a recommendation by the interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of the resident) to give Resident 29 ice cream with his lunch and dinner. During a review of Resident 29's physician order, dated 10/11/23, the physician order indicated Resident 29 was to receive ice cream with his lunch and dinner. During a review of the facility's P&P titled, Nutrition Care, reviewed May 2023, the P&P indicated, It is the policy of this facility to ensure the resident receives adequate nutrition by providing the diet and supplements as ordered by the physician, provide assistance with eating as needed. 056331 Page 12 of 19 056331 11/19/2023 Beacon Healthcare Center 919 N Sunset Ave West Covina, CA 91790

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to act upon the pharmacist medication regimen review (MRR, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication.) recommendation to not use insulin sliding scale (a sliding scale varies the dose of insulin based on blood glucose level. The higher the blood glucose the more insulin to take) for one of five sampled residents (Resident 14). This deficient practice had the potential for the resident receiving unnecessary mediations and not maintaining the resident's highest practicable level of physical, mental and psychosocial well-being and prevents or minimizes adverse consequences related to medication therapy to the extent possible. Findings: During a review of Resident 14's admission Record indicated Resident 14 was readmitted on [DATE], with diagnoses that included type 2 diabetes mellitus (high levels of sugar in the blood) and dysphagia (difficulty swallowing). During a review of Resident 14's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 9/13/23, indicated Resident 14 had clear speech, usually understood others and usually made self-understood. During a review of the facility's Consultant Pharmacist's Medication Regimen Review (MRR) dated 9/17/23, indicated Resident 14 was using insulin aspart (a form of rapid acting insulin) sliding scale (scale followed, dose of insulin varies based on blood sugar levels) order frequently. The MMR indicated the continued or long-term need for sliding scale insulin for non-emergency coverage may indicate inadequate blood sugar control. Please request the medical doctor to evaluate for possible medication adjustment in an effort to minimize the need of the sliding scale insulin and potentially discontinue in the future. Per the MRR, the change also decreased nursing touch points to aid in infection control and increased the time that the nursing staff had for other direct patient care activities. During a review of Resident 14's Progress Notes from 9/16/23 to 11/17/23, indicated that there was no documented nurse's notes that indicated Resident 14's medical doctor was notified of the consultant pharmacist's MRR recommendation regarding insulin aspart sliding scale. During a review of Resident 14's Order Summary Report, dated 11/18/23, indicated, Resident 14 had a physician's order, dated 4/11/23, tha indicated insulin aspart sliding scale. During a concurrent interview and Resident 14's medical record review on 11/18/23 at 11:49 am., Director of Nursing (DON) stated, the DON was the responsible person for handling MRRs. The DON stated, consultant pharmacist performed MRRs every month and emailed the MRR reports and recommendations to the DON. The DON stated, there was no documentation in Resident 14's medical record indicating the pharmacist's recommendation regarding insulin aspart sliding scale was reported to Resident 14's medical doctor. The DON stated, it was important to report the pharmacist' recommendation to the Resident 14's doctor to avoid unnecessary medication administration, for Resident 14's safety, and to 056331 Page 13 of 19 056331 11/19/2023 Beacon Healthcare Center 919 N Sunset Ave West Covina, CA 91790

F 0756 prevent or minimize adverse consequences related to medication therapy. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P& P), titled, Consultant Pharmacist Reports, updated January 2022, indicated Findings and recommendations are reported to the director of nursing and the attending physician. Resident-specific irregularities and/or clinically significant risks resulting from or associated with medications are documented in resident's active record and reported to the DON, and/or prescriber as appropriate. Recommendations are acted upon and documented by the facility staff and or the prescriber. Residents Affected - Few 056331 Page 14 of 19 056331 11/19/2023 Beacon Healthcare Center 919 N Sunset Ave West Covina, CA 91790

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to discard a Lantus insulin (long-acting medication used to regulate blood sugar levels) vial, for one of four sampled residents (Resident 18), during medication administration observation and according to the facility's policies and procedures (P&P). This failure had the potential to result in Resident 18 to experience adverse reactions (any unexpected or dangerous reaction to a medication) due to the administration of the expired medication. Findings: During a review of Resident 18's admission Record (AR), the AR indicated Resident 18 was admitted to the facility on [DATE] with multiple diagnoses including type 2 diabetes mellitus (DM, a chronic condition that affects the way the body processes blood sugar) and dementia (a group of thinking and social symptoms that interferes with daily functioning). During a review of Resident 18's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated [DATE], the MDS indicated Resident 18 was moderately impaired in cognitive skills (the ability to make daily decisions). The MDS indicated Resident 18 required assistance from staff for eating, dressing, and personal hygiene. During a concurrent observation and interview on [DATE] at 8:08 am., with LVN 1, Resident 18's medication administration was observed. LVN 1 drew up 26 units, (unit of measurement) from a multi-dose Lantus insulin vial. The insulin vial had an open date of [DATE]. LVN 1 took the insulin into Resident 18's room along with Resident 18's other medications. Before LVN 1 could give Resident 18 the Lantus insulin injection, the surveyor stopped LVN 1 from administering the medication and asked how long the insulin was good for once the vial was opened. LVN 1 stated the insulin was good for 28 days after the vial was opened. LVN 1 stated Resident 18 could have an adverse reaction, or the medication might not be effective if LVN 1 had given the expired medication. During a concurrent interview and record review on [DATE] at 9:27 am with the Director of Nursing (DON), the facility's P&P titled, Appendix 3: Requirements for Specific medications & Reagents, revised [DATE]. The DON confirmed the P&P indicated Lantus Insulin vials expired 28 days after the vial was opened. During a review of Resident 18's Order Summary Report, the Order Summary Report indicated Resident 18 had a physician order, dated [DATE], for Lantus solution 100 unit per milliliter (ML, unit of measurement), 26-units administered by injection subcutaneously (SQ, injection to the layer between skin and muscle) one time a day. During a review of the facility's P&P titled, Administering Medication, revised [DATE], the P&P indicated, The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. 056331 Page 15 of 19 056331 11/19/2023 Beacon Healthcare Center 919 N Sunset Ave West Covina, CA 91790

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and, record review, the facility failed to prepare meals that met resident preferences and allergy status for one of four sampled residents (Resident 2)as inicated in the facility's policy and procedure (P&P), titled, Nutrition Care. This failure had the potential to affect Resident 2's dietary intake and result in Resident 2 to experience an allergic response and cause a physical decline to Resident 2. Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was readmitted on [DATE], with diagnoses that included fracture of superior rim of left pubis (edge of hip bones) and hypertension (increased blood pressure). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 11/3/23, indicated Resident 2 had clear speech, ability to understand others and make self-understood. Resident 2 had intact cognition (ability to think, remember and reasoning). During an interview on 11/17/23, at 2:27 pm., Resident 2 stated Resident 2 had lactose intolerance (a common digestive problem where the body is unable to digest lactose, a type of sugar mainly found in milk and dairy products) and Resident 2 did not like citrus juice. Resident 2 stated Resident 2 had diarrhea and abdominal pain if Resident 2 consumed dairy products. Resident 2 stated Resident 2 made the dietary supervisor aware of Resident 2'd food allergies and preferences, but the kitchen still provided meals that contained dairy ingredients and sometimes milk. During an observation on 11/17/23, at 5:53 pm., in Resident 2's room, Resident 2's dinner tray was on Resident 2's bedside table. Resident 2's tray card (a card on the food tray with detailed food information) indicated, Resident 2 was on mechanic soft (designed for people who have trouble chewing and swallowing), no added salt, and controlled carbohydrate diet (CCHO, consistent carbohydrate, keeps carb consumption at a steady level, through every meal and snack to prevent blood sugar spikes or falls.) Resident 2's tray card indicated, Resident 2 had eight ounces of juice and disliked milk. Resident 2's tray card was for breakfast, lunch, and dinner. During a record review of Resident 2's nutrition assessment dated [DATE], indicated Resident 2 had lactose intolerance and preferred no citrus. During an interview on 11/17/23, at 6 pm., the Dietary Supervisor (DS) stated the DS performed Resident 2's nutrition assessment on 11/2/23. The DS stated the DS forgot the assessment, so the DS did not write Resident 2's food preferences on Resident 2's meal card. The DS stated, not carrying out the Resident 2's food preferences could affect the Resident 2's dietary intake and cause a change in the resident's health condition. During a review of the facility's P&P, titled, Nutrition Care, dated 2022, indicated The resident's food allergy and food preferences should be placed on the profile care and identified on the tray card. 056331 Page 16 of 19 056331 11/19/2023 Beacon Healthcare Center 919 N Sunset Ave West Covina, CA 91790

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview, the facility failed to ensure sanitary practices were followed by one of three sampled staff (Dietary Aid, DA 1). On 11/17/23, DA 1 did not wear a hairnet (netting over the hair to keep hair from contacting exposed food, clean equipment and utensils) during the handling and preparation of food. This failure had the potential to result in foodborne illnesses (illness caused by food contaminated with bacteria) from pathogens (organism that cause disease) that could have been on the hair and land on exposed food fed to residents who ate food orally (by mouth). Findings: During an observation on 11/17/2023 at 1:13 pm., DA 1 was observed handing food in the kitchen and at the table located next to the stove. DA 1 was wrapping tortillas in plastic wrap (thin, transparent film that adheres to surfaces and itself used for the storage of food) and was not wearing a hairnet as indicated in the facility's policy and procedure (P&P) titled, Sanitation and Infection Control. During an interview on 11/17/2023 at 11:17 am, DA 1 stated DA 1 was not wearing a hairnet because the tortillas needed to be put away really quick. DA 1 stated hairnets were supposed to be worn so DA 1 would not get hair in the residents' (in general) food. DA 1 stated hairnets were worn as a part of food safety practices. During an interview on 11/17/2023 at 1:20 pm., with the Assistant Dietary Supervisor (ADS), the ADS stated, all staff were supposed to wear the appropriate gear when working in the kitchen for safe food handling and to prevent food-borne illnesses or staff getting hair in the residents' food. During an interview on 11/17/2023 at 1:22 pm., with the Dietary Supervisor (DS), the DS stated hairnets were required to be worn upon entering the kitchen. The DS stated hairnets were worn as a preventative measure to keep residents safe from getting staff hair in the resident's food. The DS stated hairnets aided in the prevention of food-borne illness. During a review of the facility's P&P, titled, Sanitation and Infection Control, dated 2018, the P&P indicated food and nutrition service employees would be instructed on the relationship between personal hygiene and food safety, including the association of hand contact personal habits, behaviors, and food employees' health to food borne illness. The P&P indicated a hairnet and/or head covering, which completely covered all hair, should be worn during meal preparation and service. 056331 Page 17 of 19 056331 11/19/2023 Beacon Healthcare Center 919 N Sunset Ave West Covina, CA 91790

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 follow infection control practices for one of four sample residents (Resident 19) when Resident 19's urine drainage bag (urinary bag, attaches to a catheter [tube] that is inside your bladder to collect urine.) was observed touching the floor on 11/17/23, as indicated by the facility's policy and procedure P&P titled, Catheter Care, Urinary. Residents Affected - Few This failure had the potential to result in a urinary tract infection (UTI, an infection in any part of the urinary system.) to Resident 19. Findings: During a review of Resident 19's admission Record (AR), the AR indicated Resident 19 was readmitted to the facility on [DATE], with diagnoses that included pneumonia (lung inflammation caused by bacterial or viral infection), sepsis (life-threatening complication of an infection) and immunodeficiency (failure of the immune system to protect the body adequately from infection, due to the absence or insufficiency of some component process or substance). During a review of Resident 19's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 10/4/23, indicated Resident 19 had no speech, was rarely or never understood and was rarely or never made self-understood. Resident 19 was dependent (helper does all of the effort to complete the activity, the assistance of 2 or more helpers is required) for eating, toileting hygiene, and chair/bed-to-chair transfers. During a concurrent observation and interview on 11/17/23 at 2:51 pm., Resident 19 was lying in bed with eyes closed. Resident 19 was placed in a transmission-based precautions room by himself for contact precautions (precautions taken for diseases spread by direct or indirect contact). Resident 19 had a urinary bag hanging from the bedrail, and the bag was touching floor. Director of Staff Development (DSD) stated Resident 19 was on contact precaution because Resident 19 had Extended Spectrum Beta-Lactamase (ESBL, Beta-lactamases are enzymes produced by some bacteria that may make them resistant to some antibiotics.), an infection in the urine. The DSD stated Resident 19's urinary bag should not touch the floor to prevent bacteria from entering the urinary track. The DSD stated if that happened, it would casuse Resident 19's health condition to worsen. During a review of the facility's P&P titled, Catheter Care, Urinary, revised September 2022, indicated, the purpose of this procedure is to prevent catheter-associated urinary track infections. Be sure the catheter tubing and drainage bag are kept off the floor. 056331 Page 18 of 19 056331 11/19/2023 Beacon Healthcare Center 919 N Sunset Ave West Covina, CA 91790

F 0947 Level of Harm - Minimal harm or potential for actual harm Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on interview and record review, the facility failed to ensure in-service training was completed for one of one Certified Nursing Assistants (CNA 2). Residents Affected - Some This failure had the potential to result in the residents with diagnoses of Dementia (a decline in mental ability) to not receive proper care and services and result in a decline in physical health. Findings: During a review of the facility's 2023 Annual In-Service Calendar for C.N.A, the calendar indicated, Dementia training or definition was scheduled in January 2023. During a review of the facility's In-Service Meeting Minutes (the Minutes), dated 1/6/23, the minutes indicated the topic for the training was Dementia. The Minutes indicated CNA 2 did not attend the training. During an interview on 11/18/23, at 2:55 pm., Director of Staff Development (DSD) stated the DSD was the person that provided Dementia in-service on 1/6/23. The DSD stated all staff should attend regular scheduled in-service training including Dementia. The DSD stated the DSD did not know CNA 2 did not attend the training. DSD stated he did not have a system in place to check and make sure all staffs attended required training. The DSD stated it was important for staff to receive regular training to promote the resident's (in general) quality of care and safety. During a review of the facility's policy and procedure titled In-Service Training Program, revised 9/2021, indicated All personnel are required to attend regularly to scheduled in-service training classes. 056331 Page 19 of 19