Health inspection·January 10, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide privacy to four of seven residents (Resident 54, 35, 58 and 3) observed during medication administration. This deficient practice violated the resident`s right to be treated with dignity and respect which could affect the residents' sense of self-worth and sense of well-being. Findings: a. During a review of Resident 54's admission Record, the admission Record indicated that the facility admitted the resident on 10/31/2024 with diagnoses that included dysphagia (difficulty swallowing) and type 2 diabetes mellitus (DM-a chronic condition that affects how the body uses sugar [glucose] for energy). During a review of Resident 54's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/07/2024, the MDS indicated that the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making intact and the resident was dependent on staff for toileting hygiene, shower, upper and lower body dressing, and personal hygiene. During a medication administration observation on 01/07/25 at 12:08 p.m., observed Licensed Vocational Nurse 1 (LVN1) check Resident 54's blood sugar (glucose) using a glucometer (measures the amount of glucose in your blood) in the resident's room while the resident was in a wheelchair and the privacy curtain was open. b. During a review of Resident 35's admission Record, the admission Record indicated that the facility originally admitted the resident on 11/16/2021 and readmitted on [DATE] with diagnoses that included seizures (abnormal electrical activity in your brain that temporarily affects your consciousness, muscle control and behavior) and type 2 diabetes mellitus (DM-a chronic condition that affects how the body uses sugar [glucose] for energy). During a review of Resident 35's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/18/2024, the MDS indicated that the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was impaired and the resident required maximal assistance from staff for toileting hygiene, shower, lower body dressing and personal hygiene. Page 1 of 30 056412 056412 01/10/2025 Northridge Care Center 7836 Reseda Blvd Reseda, CA 91335

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a medication administration observation on 01/07/25 at 12:15 p.m., observed Licensed Vocational Nurse 1 (LVN 1) check Resident 35's blood sugar (glucose) using a glucometer (measures the amount of glucose in your blood) in the resident's room while the resident was in bed and the privacy curtain was open. c. During review of Resident 58's admission Record, the admission Record indicated that the facility originally admitted the resident on 12/08/2021 and readmitted on [DATE] with diagnoses that included muscle weakness and history of falling. During a review of Resident 58's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 02/08/2024, the MDS indicated that the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was intact and the resident was dependent on staff for toileting hygiene, shower, upper body dressing, lower body dressing and personal hygiene. During a medication administration observation on 01/07/25 at 12:22 p.m., observed Licensed Vocational Nurse 1 (LVN1) check Resident 58's blood sugar (glucose) using a glucometer (measures the amount of glucose in your blood) in the resident's room while the resident was in bed and the privacy curtain was open. LVN 1 stated Resident 58's blood sugar was 156 mg/dl. LVN 1 prepared 1 unit of insulin and administered the insulin without closing the curtain to ensure the resident's privacy. d. During a review of Resident 3's admission Record, the admission Record indicated that the facility admitted the resident on 11/20/2023 with diagnoses that included shortness of breath and type 2 diabetes mellitus (DM-a chronic condition that affects how the body uses sugar [glucose] for energy). During a review of Resident 3's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/20/2024, the MDS indicated that the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely impaired and the resident was dependent on staff for toileting hygiene, shower, lower body dressing and personal hygiene. During a medication administration observation on 01/07/25 at 12:26 p.m., observed Licensed Vocational Nurse 1 (LVN1) check Resident 3's blood sugar (glucose) using a glucometer (measures the amount of glucose in your blood) in the resident's room while the resident was in bed and the privacy curtain was open. LVN 1 stated Resident 3's blood sugar was 216 mg/dl. LVN1 then prepared 4 units of insulin and administered the insulin without closing the curtain to ensure the resident's privacy. During an interview on 1/07/2025 at 12:30 p.m., with LVN 1, LVN 1 stated that he should have ensured privacy was provided to the four residents when he (LVN 1) was checking their blood sugar and giving the insulin. LVN 1 stated that resident should not be put in a situation that could cause them to feel embarrassed about their condition. LVN 1 stated the residents should be treated with respect and dignity by providing privacy during medication administration. During a review of the facility`s policy and procedure titled Dignity, last reviewed on 3/15/2024, the policy indicated that each resident shall be cared for in a manner that promotes and enhances his or her well-being, level of satisfaction with life, and feeling of self-worth and self-esteem .residents are treated with respect and dignity at all times . 056412 Page 2 of 30 056412 01/10/2025 Northridge Care Center 7836 Reseda Blvd Reseda, CA 91335

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. 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 resident's Quarterly Minimum Data Set (MDS - a standardized assessment and care screening tool) was completed timely for one (Resident 37) out of 1 sampled resident. Residents Affected - Few This deficient practice had the potential to negatively affect the provision of necessary care and services for Resident 37. Findings: During a review of Resident 37's admission Record, the admission Record indicated the facility admitted the resident on 8/24/2024 with diagnoses including asthma (a chronic lung disease that causes inflammation in the airways, making it difficult to breathe) and Parkinson`s disease (a chronic brain disorder that causes movement problems, and can also impact mental health, sleep, and pain). During a review of Resident 37's MDS, dated [DATE], the MDS indicated the resident had intact cognition (thought processes) and dependent on staff for most activities of daily living (ADLs - fundamental skills that people need to care for themselves independently). On 01/08/2025 at 3:31 p.m., during a concurrent interview and record review with Minimum Data Set Nurse 1 (MDS Nurse 1), reviewed the Centers for Medicare and Medicaid Services (CMS - a federal agency that manages Medicare, Medicaid, the Children's Health Insurance Program [CHIP], and the Affordable Care Act [ACA] health insurance marketplaces) Submission Report, dated 01/02/2025. The record indicated that the assessment was completed more than 14 days after assessment reference date (ARD). MDS Nurse 1 stated the ARD was 11/29/2024, so the assessment should have been completed by 12/12/2024. On 01/10/2025 at 8:03 a.m., during a concurrent interview and record review, with MDS Nurse 1, reviewed the Resident Assessment Instrument (RAI - a public document that provides guidance on how to use the RAI to assess residents in long-term care facilities) Omnibus Budget Reconciliation Act of 1987 (OBRA - a federal law that reformed nursing homes and improved the quality of care for residents) required Assessment Summary with MDS Nurse 1. MDS Nurse 1 stated according to the guidelines, the Quarterly what date Resident 37's Quarterly MDS assessment was actually completed, MDS Nurse 1 stated it was completed on 12/26/2024. MDS Nurse 1 stated it should have been completed on 12/12/2024. 056412 Page 3 of 30 056412 01/10/2025 Northridge Care Center 7836 Reseda Blvd Reseda, CA 91335

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 interview and record review, the facility failed to develop a comprehensive person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) for one of four sampled resident (Resident 58) investigated under accidents. This deficient practice had the potential for Resident 58 to not receive the necessary care and services to prevent potential injury caused by the use of bed rails (adjustable metal or rigid plastic bars that attach to the bed that are available in a variety of types, shapes, and sizes) Findings: During review of Resident 58's admission Record, the admission Record indicated the facility originally admitted the resident on 12/08/2021 and readmitted on [DATE] with diagnoses including muscle weakness and history of falling. During a review of Resident 58's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 02/08/2024, the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was intact and the resident was dependent on staff for toileting hygiene, shower, upper body dressing, lower body dressing and personal hygiene. During a concurrent record review and interview with the Director of Nursing (DON) on 01/08/2025 at 10:31 a.m., reviewed Resident 58`s assessments records. The DON stated the resident did not have a safety assessment for the use of the bed side rails. The DON checked the resident`s room and verified that a quarter bed side rail is attached to the resident`s bed. The DON stated every resident using a bed side rail must be assessed for safety and risk for entrapment to prevent potential injury to the resident. The DON stated that Resident 58 could suffer an injury in the event that a part of her body is entrapped within the gaps of the bed side rails. The DON stated that the use of bed rails should be care planned to ensure that there is an identified problem in which its use is warranted. The DON stated that care plan must have a timeframe for evaluating the effectiveness of the intervention, determining if treatment goals are met, and ensuring that the ongoing use of the bed rails does not put the resident's safety at risk. During a review of the facility`s policy and procedures titled The Resident Care Plan, last reviewed on 03/15/2024, the policy and procedure indicated an objective to provide an individualized nursing care plan and to promote continuity of resident care .the care plan generally includes identification of medical, nursing, and psychosocial needs; goals stated in measurable/observable terms; approaches (staff action to meet the above goals . 056412 Page 4 of 30 056412 01/10/2025 Northridge Care Center 7836 Reseda Blvd Reseda, CA 91335

F 0657 Level of Harm - Minimal harm or potential for actual harm Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: Residents Affected - Some 1. Revise the comprehensive person-centered care plan (a care plan is a form where you can summarize a person's health conditions, specific care needs, and current treatments) addressing the residents activity needs for two of three (Resident 15 and 69) residents investigated under the activity care area. This deficient practice had the potential for the residents to not receive the necessary care and services related to their activity needs. 2. Revise the comprehensive person-centered care plan addressing nutritional needs of one of three (Resident 25) residents investigated under the nutrition care area. This deficient practice had the potential for Resident 25 to not receive the necessary care and services related to his nutritional needs. Findings: 1.a. During a review of Resident 15's admission Record, the admission Record indicated that the resident was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE], with diagnoses including anxiety disorder (mental health conditions that involve persistent feelings of fear or worry that can significantly impair a person`s life) and Parkinson's disease (a chronic brain disorder that causes movement problems, and can also impact mental health, sleep, and other health issues). During a review of Resident 15`s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/11/2024, the MDS indicated the resident`s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was intact and was totally dependent on staff for eating, oral hygiene, toileting hygiene, shower, dressing and personal hygiene. During a concurrent interview and record review on 01/08/2025 at 08:34 a.m., with the Director of Nursing (DON), reviewed Resident 15`s care plan for activity which indicated a target date of a 11/10/2024. The DON stated that the care plan is not active care plan and should have been evaluated on the target date of 11/10/2024 and renewed for another quarter. The DON stated that the resident's care plans should be evaluated quarterly to determine if the goals of the resident related to activity needs are met. The DON stated that quarterly revision of the care plan ensures that there is an ongoing activity provided to Resident 15 to address his psychosocial needs. The DON stated that without a care plan in place addressing Resident 15's activity needs, the resident could experience emotional distress, potentially leading to depression. During a review of the facility`s policy and procedures titled The Resident Care Plan, last reviewed on 3/15/2024, the policy and procedure indicated that the resident care plan shall be implemented for each resident on admission and developed throughout the assessment process .the resident`s plan of care shall be reviewed at least quarterly . 056412 Page 5 of 30 056412 01/10/2025 Northridge Care Center 7836 Reseda Blvd Reseda, CA 91335

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of the facility`s policy and procedures titled Activity Program, last reviewed on 3/15/2024, the policy and procedure indicated that the Activity Coordinator shall interview the resident and develop an individual activity plan based on the resident`s needs and interests. The initial assessment shall be on the basis for activity plan that is part of the resident care plan . 1.b. During a review of Resident 69's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE], with diagnoses including quadriplegia (paralysis of all four limbs) and epilepsy (a chronic brain disorder that causes seizures, which are brief episodes of abnormal electrical activity in the brain). During a review of Resident 69`s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/20/2024, the MDS indicated that the resident`s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely impaired and was totally dependent on staff for eating, oral hygiene, toileting hygiene, shower, dressing and personal hygiene. During a concurrent interview and record review on 01/08/2025 at 08:34 a.m., with the Director of Nursing (DON), reviewed Resident 69`s care plan for activity which indicated a target date of 11/19/2024. The DON stated that the care plan is not active care plan and should have been evaluated on the target date of 11/19/2024 and renewed for another quarter. The DON stated that the resident's care plans should be evaluated quarterly to determine if the goals of the resident related to activity needs are met. The DON stated that quarterly revision of the care plan ensures that there is an ongoing activity provided to Resident 69 to address her psychosocial needs. The DON stated that without a care plan in place addressing Resident 69's activity needs, the resident could experience emotional distress, potentially leading to depression. During a review of the facility`s policy and procedures titled The Resident Care Plan, last reviewed on 3/15/2024, the policy and procedure indicated that the resident care plan shall be implemented for each resident on admission and developed throughout the assessment process .the resident`s plan of care shall be reviewed at least quarterly . During a review of the facility`s policy and procedures titled Activity Program, last reviewed on 3/15/2024, the policy and procedure indicated that the Activity Coordinator shall interview the resident and develop an individual activity plan based on the resident`s needs and interests. The initial assessment shall be on the basis for activity plan that is part of the resident care plan . 2. During a review of Resident 25's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE], with diagnoses including acute respiratory failure (a condition in which your blood doesn't have enough oxygen causing shortness of breath and difficulty breathing, often caused by a disease or injury), type 2 diabetes (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly), end stage renal disease (final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own). During a review of Resident 25`s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/18/2024, the MDS indicated the resident`s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was moderately impaired and resident required moderate assistance from staff for 056412 Page 6 of 30 056412 01/10/2025 Northridge Care Center 7836 Reseda Blvd Reseda, CA 91335

F 0657 eating, oral hygiene, toileting hygiene, shower, dressing and personal hygiene. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 25's History and Physical, dated 11/22/2024, the History and Physical indicated that Resident 25 had a capacity to make needs known, but cannot make decisions. Residents Affected - Some During a review of Resident 25 Nutritional Assessment, dated 01/07/2025 , the Nutritional Assessment indicated that Resident 25 was at risk for malnutrition. During a review of Resident 25 Nutritional Dietary Note, dated 01/07/2025, the Nutritional Dietary Note indicated that Resident 25 had weight loss due to fluid shift (the movements of fluid within the body, specifically from tissues and cells into the bloodstream during a dialysis treatment) related to end stage renal disease. During a concurrent interview and review on 01/09/2025 at 2:47 p.m., with the Director of Dietary Services (DDS), Resident 25`s care plan for alteration in nutritional status on 01/09/2025 at 2:47 p.m., indicated that the care plan was initiated on 10/22/2024, revised on 12/13/2024 and had a target date of 4/24/2025. The DDS stated that the care plan for alteration in nutritional status is an active care plan. The DDS stated that care plans are evaluated quarterly to determine if the goals of the resident related to nutritional needs are met. The DDS reviewed the care plan and stated that current care plan indicated that Resident 25 had a risk for malnutrition due to broken teeth and leaves 25% of food uneaten on therapeutic diet. The DDS stated that the care plan did not indicate that the resident is undergoing dialysis which could significantly contribute to weight fluctuation. The DDS stated that Resident 25's care plan should be person centered and address all nutritional risk factors to meet the resident's needs, preventing nutritional distress and potential weight loss. During a concurrent interview and review of Resident 25`s care plan for nutritional status with the Director of Nursing (DON) on 1/9/2025 at 4:43 p.m., the DON stated that the care plan has to be person-centered and based on current assessment to meet the resident's needs. The DON stated that missing nutritional risk factors in care plan had the potential for Resident 25 to not receive the necessary care and services related to his nutritional needs. During a review of the facility`s policy and procedures titled The Resident Care Plan, last reviewed on 3/15/2024, the policy and procedure indicated that the resident care plan shall be implemented for each resident on admission, and developed throughout the assessment process .the president's plan of care shall be reviewed at least quarterly . 056412 Page 7 of 30 056412 01/10/2025 Northridge Care Center 7836 Reseda Blvd Reseda, CA 91335

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review the facility failed to provide appropriate and consistent activities for one of 21 sampled residents (Resident 52). Residents Affected - Few This deficient practice had the potential to negatively affect Resident 52's physical, cognitive, sense of belonging, and emotional health. Findings: During a review of Resident 52's admission Record (Face sheet) , the admission Record indicated the resident was initially admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including paraplegia (a chronic condition that involves the loss of muscle control in the lower half of the body), anxiety (a feeling of fear, dread, and uneasiness), and depression (an illness characterized by persistent sadness and a loss of interest in activities, accompanied by an inability to carry out daily activities). During a review of Resident 52's Minimum Data Set (MDS, a standardized assessment tool and care screening tool) dated 11/1/2024, the MDS indicated the resident had intact cognition (ability to make decisions, understand, learn). The MDS indicated the resident required maximal - to- moderate assistance from staff for most activities of daily living (transfer, bed mobility, locomotion on unit and off unit, dressing, eating, toilet use, and personal hygiene). During a review of Resident 52's History and Physical (H&P) dated 8/14/2023, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 52's activity care plan initiated on 8/14/2023 and revised on 10/30/2024, the care plan interventions indicated that Resident 52 will be encouraged to participate in activities of interest like special event and spiritual events. During a concurrent observation and interview on 1/6/2025, at 9:44 a.m., with Resident 52 in his room, observed the resident sitting in the wheelchair. Resident 52 stated that he likes to participate in bible studies on Sunday afternoons. However, the facility has recently discontinued this activity without providing any explanation to the residents. Resident 52 stated that is his right to attend a religious activity. During a review of the Activities Calendar for the year 2024 and 2025, the calendar indicated religious services are scheduled every Sunday at 9 a.m., with Bible study taking place at 2 p.m. During an interview and record review with the Activity Director (AD) on 1/6/2025, at 11:40 a.m., the AD stated that religious services and bible studies were provided to residents every Sunday. The AD stated that that bible studies where not provided to the residents for last 3-4weeks resident because of possible COVID-19 outbreak in the religious institution providing the bible services to the facility. The AD was unable to provide a list of participants in the bible studies or contact information of the religious organization providing the bible studies in the facility. The AD stated that it is important to provide to Resident 52 the activities of his choice to promote emotional health and sense of belonging. 056412 Page 8 of 30 056412 01/10/2025 Northridge Care Center 7836 Reseda Blvd Reseda, CA 91335

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with the Director of Nursing (DON), on 1/9/2025 at 4:43 p.m., the DON stated that facility should provide Resident 52 his activities of choice. The DON stated not providing Resident 52 his activities of choice may increase the resident's anxiety and depression. The DON stated that it is the AD responsibility to contact a religion organization and organize bible studies for the residents. During a review of the facility policy titled Spiritual and Religious Activities, reviewed on 3/15/2024, the policy indicated Spiritual and religious activities are provided for resident population. A variety of spiritual and religious activities are available and scheduled through local religious organizations. Residents are encouraged to attend religious activities of their choice. 056412 Page 9 of 30 056412 01/10/2025 Northridge Care Center 7836 Reseda Blvd Reseda, CA 91335

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 provide an environment free from accidents and hazards for one of eight sampled residents (Resident 50) reviewed under the accidents care area by failing to ensure Resident 50 did not store medications at bedside readily accessible to other residents. This deficient practice had the potential to result in residents obtaining medication without staff knowledge resulting in accidental ingestion causing harm to residents. Findings: During a review of Resident 50's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility admitted the resident on 12/30/2022 and readmitted the resident on 5/31/2024 with diagnoses including diabetes mellites type 2 (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly), myalgia (muscle aches and pain), and essential hypertension (high blood pressure). During a review of Resident 50's Minimum Data Set (MDS - a resident assessment tool), dated 10/7/2024, the MDS indicated the resident had intact cognition (the mental process of acquiring knowledge and understanding through thought, experience, and the senses) and required supervision-to- moderate assistance from staff for most activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 50's Order Summary Report , the Order Summary Report indicated an order dated 6/18/2024 for self-administration of over the counter (OTC) medications at bedside per patient ordered via online and requested to keep it: Endopeak (supplement) Relion glucose tabs (supplement that helps to support blood sugar) BPS-5 (supplement), Visiblue (vision supplement) Ocuprime (supplement) cranberry extract (supplement), zinc 50 mg (supplement that helps the body fight off infection and for wound healing), Nervogen pro (supplement) , Advance Amino (supplement), Cinnachroma (supplement), Vitamin A, Eye pressure support, B 12 (vitamin), Fenugreek (supplement), Glucosamine (supplement), Ginko (supplement). During a review of Resident 50's self-administration of drug assessment, the self-administration drug assessment dated [DATE] indicated Resident 50 is safe to self-administer OTC medications but requires assistance with eyedrops as needed. During an observation on 1/6/2024 at 9:20 a.m., observed Resident 50 in the bed in his room. Observed three clear plastic drawers next to the resident's bed containing the following: 1. Heal (supplement)-six (6) bottles. 2. Ocuprime (supplement)-five (5) bottles 056412 Page 10 of 30 056412 01/10/2025 Northridge Care Center 7836 Reseda Blvd Reseda, CA 91335

F 0689 3. Level of Harm - Minimal harm or potential for actual harm Visi-Clear (vision supplement)-five (5) bottles 4. Residents Affected - Few Sight care (vision supplement) -six (6) bottles 5. Visi-blue advance (vision supplement)-five (5) bottles 6. Advance Amino Formula (supplement) -five (5) bottles 7. Niacin 500 mg (Vitamin B 3)-three (3) bottles 8. Glucosamine (supplement) -two (2) bottles 9. Vitamin C 1000 mg (vitamin) -two (2 )bottles 10. Vitamin E 3 bottles (vitamin) - three (3) bottles 11. Cleanse supplement (supplement)- five (5) bottles 12. Centrum 50 + (vitamins) - two(2) bottles 13. Vitamin D3 (vitamin)-three (3 )bottles 14. Vitamin B12(vitamin) - five (5) bottles Resident 50 stated that all the medications in the plastic containers next to his bed are his 056412 Page 11 of 30 056412 01/10/2025 Northridge Care Center 7836 Reseda Blvd Reseda, CA 91335

F 0689 supplements and that he takes these medications by himself all the time. Level of Harm - Minimal harm or potential for actual harm During an interview on 1/6/2024 at 9:25 a.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated that Resident 50 did not want to comply with facility policy about not storing medication at bedside. LVN 3 stated Resident 50 had an assessment for self-administration of medications. LVN 3 stated keeping medication at the bedside of Resident 50 create a risk to allow other residents to consume the medications, who are confused and may enter Resident 50's room. Residents Affected - Few During an interview on 1/9/202 at 4:43 p.m., with the Director of Nursing (DON), the DON stated it was important not to leave medications accessible to other residents at bedside because the residents may take the medications and consume it, and it could lead to the residents experiencing adverse side effects. During a review of the facility's policy and procedure titled, Self-Administration of Medication, last reviewed and revised on 3/15/2024, the policy and procedure indicated that bedside medications storage is permitted only when it does not present a risk to confused residents who wander into the rooms of, or room with, residents who self-administer. During a review of the facility's policy and procedure titled, Storage of Medication, last reviewed and revised on 3/15/2024, the policy and procedure indicated: The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized. 056412 Page 12 of 30 056412 01/10/2025 Northridge Care Center 7836 Reseda Blvd Reseda, CA 91335

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and record review the facility failed to ensure residents receiving enteral feeding (EF, also known as tube feeding, a method of supplying nutrients directly in to the gastrointestinal [the body's system for processing liquids and foods] tract) received appropriate care and services to prevent complications of enteral feeding for one out of three sampled residents (Resident 47) by failing to cover the enteral feeding tube with a cap after disconnecting the tubing from Resident 47 once the enteral feeding had been completed. The deficient practice had the potential to contaminate the enteral feeding system and placed the resident at risk for infection. Findings: During a review of Resident 47's admission Record, the admission Record indicated that the facility admitted Resident 47 on 6/14/2024 with diagnoses including cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked), acute respiratory failure with hypoxia (a serious condition that occurs when the air sacs of the lungs cannot release enough oxygen into the blood), gastrostomy malfunction (when a gastrostomy [ G- Tube, a feeding tube that delivers nutrition, fluids and medication directly into the stomach)] is blocked, dislodged, or has other issues), and schizophrenia(a mental health problem where you experience psychosis [a mental disorder characterized by a disconnection from reality] as well as mood symptoms). During a review of Resident 4's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 12/19/2024, the MDS indicated that the resident had moderately impaired cognition (a moderate damaged mental abilities, including remembering things, making decisions, concentrating, or learning). The MDS further indicated that Resident 47 was totally dependent on staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During the review of Resident 47's History and Physical, dated 6/18/2024, the History and Physical indicated that Resident 47 had a capacity to make needs known, but cannot make decisions. During a review of Resident 47's Order Summary Report, the Order Summary Report indicated an order dated 12/09/2024 for Jevity 1.2 (feeding formula) at 50 cc/hours (rate of infusion of feeding formula) for 20 hours via pump off at 8 a.m. and start on 12 p.m. During a review of Resident 47's care plan (a document that outlines the actions and interventions needed to address a resident's health and care needs) regarding gastrostomy status initiated on 6/19/2024, and revised on 9/12/2024, the care plan indicated a goal to minimize risk of infection at G-Tube site. During an observation on 1/6/2025 at 11:51 a.m. in Resident 47's room, observed a bottle of Jevity 1.2 on the pole (a device that holds a bag of feeding formula in place), with the tubing disconnected from Resident 47 and hanging on the pole. The tip of the tubing was not covered with a cap. During an interview on 1/6/2025 at 11:52 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 confirmed that the tip of the tubing was not capped. LVN 2 stated that the tubing should be covered with 056412 Page 13 of 30 056412 01/10/2025 Northridge Care Center 7836 Reseda Blvd Reseda, CA 91335

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cap once it is disconnected from the resident to prevent cross contamination and decrease risk of healthcare acquired infection to Resident 47. During an interview on 1/8/2025 at 10 a.m. with the Infection Preventionist (IP), the IP stated that the tubing tip should be covered with a cap once it is disconnected from the resident to prevent microbial growths. LVN 2 stated that failing to cap the tip of the tubing increased the risk of infection for Resident 47. During an interview on 1/9/2024 at 4:34 p.m. with the Director of Nursing (DON), the DON stated that the tip of the formula tubing should be covered with a cap once it is disconnected from the resident to prevent microbial growths. The DON stated that failing to cap the tip of the tubing increased the risk of healthcare acquired infections for Resident 47. During a review of the facility policy named Enteral Feeding - Safety Precautions, last reviewed on 3/15/2024, the policy stated: The facility will remain current in and follow accepted best practices in enteral nutrition. 056412 Page 14 of 30 056412 01/10/2025 Northridge Care Center 7836 Reseda Blvd Reseda, CA 91335

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to label the insertion site (areas where intravenous [IV, into or within a vein] lines are placed such as the forearm) of the intravenous catheter (a device used to provide medications) dressing per facility protocol to one out of three sampled residents (Resident 13) who had an IV access. Residents Affected - Few This deficient practice has the potential to fail to identify the signs and symptoms of intravenous site insertion complications such as swelling and redness in the insertion site. Findings: During a review of Resident 13's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the document indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included hypertension (high blood pressure). During a review of Resident 13's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 10/24/2024, the MDS indicated Resident 13 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact with skills required for daily decision making. The MDS indicated Resident 13 was dependent (helper does all the effort) on staff for personal hygiene. During a review of Resident 13's Physician's Orders, it indicated an order for Ceftriaxone (an antibiotic medication to treat a bacterial infection) Solution 1 gram (gm, metric unit of measurement, used for medication dosage and/or amount) intravenously every 24 hours for Respiratory syncytial virus (RSV, a contagious virus that infects the respiratory tract and lungs) pneumonia (an infection/inflammation in the lungs), every 24 hours for three days, dated 12/26/2024. During a review of Resident 13's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), the MAR indicated Resident 13 received Ceftriaxone by intravenous access on the dates 12/26/2024, 12/27/2024, and 12/28/2024. During a review of Resident 13's Care Plan for Antibiotic Therapy, the care plan, initiated 12/27/2024, indicated Resident 13 was on Ceftriaxone one gm by IV access for RSV pneumonia. The care plan indicated a goal that infection will clear in 14 days through interventions. The care plan indicated to administer antibiotics as ordered. During a concurrent interview and observation on 1/06/2025 at 9:55 a.m., with the Director of Nurses (DON), observed Resident 13's IV site to the left forearm that was undated. Resident 13's Family Member 1 (FM 1) stated Resident 13 had the IV from the GACH before entering the facility. FM 1 could not state the exact date the IV was started. The DON stated if a resident is on IV antibiotics, the doctor is to be notified when the IV medication was complete. The DON stated they would check to see if Resident 13 was still ordered IV antibiotics. During an interview with the DON on 1/07/2025 at 9:55 a.m., the DON stated Resident 13's IV antibiotic medication was completed by 12/29/2024. The DON stated the licensed nurse from the GACH should 056412 Page 15 of 30 056412 01/10/2025 Northridge Care Center 7836 Reseda Blvd Reseda, CA 91335

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few tell when the IV was started in their phone report to the facility but there was no indication in the medical records that there was a start date for the IV. The DON stated Registered Nurse 1 (RN 1) notified Resident 13's physician on 1/06/2025 of the IV site and received an order to discontinue the IV access site. During a concurrent interview and record review with RN 1 on 1/07/2025 at 11:56 a.m., reviewed Resident 13's 12/2024 MAR. RN 1 stated they gave Resident 13, the Ceftriaxone on 12/27/2024. RN 1 stated they discontinued Resident 13's IV access site on 1/06/2025. RN 1 stated they did not know when Resident 13's IV was started but must be at least 11 days since the resident was admitted to the facility from the GACH on 12/26/2024. RN 1 stated the process is for the registered nurse administering the last dose to a resident to call a resident's physician to see if they wanted to keep the IV access or to discontinue it. RN 1 stated a resident can get phlebitis (inflammation of the vein) if left in for too long. During a concurrent interview and record review with the DON on 1/07/2025 at 2:14 p.m., reviewed the facility's policy and procedure titled, Peripheral Catheter Removal, last reviewed 3/15/2024. The policy and procedure indicated peripheral catheters are removed when clinically indicated, at the completion of therapy, or if the site is reddened, swollen, painful, leaking/draining. The policy and procedure indicated a physician order is not required to remove a peripheral catheter. The DON, stated, even though the policy indicated a physician order is not required to remove an IV, the registered nurse should still notify a resident's physician when an antibiotic is completed to ensure a resident is safe and that there is no infection at the IV insertion site. The DON stated the registered nurses failed to notify the doctor of the presence of the IV. The DON stated, according to policy, that indicated peripheral IV catheter sites will be changed when clinically indicated means that the IV antibiotic is finished then it is to be removed unless the doctor wants to continue the IV medication or change to a different one. The DON stated if the physician wants to keep the IV, the registered nurses will obtain an order to keep the IV inserted for another three days. During a phone interview and record with RN 2 on 1/07/2025 at 3:32 p.m., reviewed Resident 13's 12/2024 MAR. RN 2 stated RN 2 gave Resident 13 the IV Ceftriaxone on 12/26/2024. RN 2 stated they gave Resident 13 the IV antibiotic medication but not the last registered nurse to give the medication. RN 2 stated that after the last dose, policy dictates the nurse would remove the IV line after speaking with the doctor in the case he wants to continue the medication. During a phone interview and concurrent record review with RN 3 on 1/07/2025 at 4:14 p.m., reviewed Resident 13's 12/2024 MAR. RN 3 stated RN 3 was the last nurse to administer Resident 13's IV antibiotic medication which was on 12/28/2024. RN 3 stated they gave the medication at 11:40 a.m. and did not notify Resident 13's physician that night that the IV medication was completed but endorsed to the 7 a.m. to 3 p.m. nurse on 12/29/2024 but was unable to remember the registered nurse's name. During a review of the facility's policy and procedure titled, Peripheral Catheter Removal, last reviewed 3/15/2024, the policy indicated peripheral catheters are removed when clinically indicated, at the completion of therapy, or if the site is reddened, swollen, painful, leaking/draining. The policy and procedure indicated a physician order is not required to remove a peripheral catheter. 056412 Page 16 of 30 056412 01/10/2025 Northridge Care Center 7836 Reseda Blvd Reseda, CA 91335

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident was assessed for risk of entrapment from the use of bed side rails (adjustable metal or rigid plastic bars that attach to the bed) as indicated in the facility's policy and procedure for one of one sampled residents (Resident 58). This deficient practice had the potential for inappropriate use of bed rails that could lead to entrapment and result to injury. Findings: During review of Resident 58's admission Record, the admission Record indicated the facility originally admitted the resident on 12/08/2021 and readmitted on [DATE] with diagnoses including muscle weakness and history of falling. During a review of Resident 58's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 02/08/2024, the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was intact and the resident was dependent on staff for toileting hygiene, shower, upper body dressing, lower body dressing and personal hygiene. During an observation on 01/06/2024 at 11:26 a.m., observed Resident 58 lying in bed sleeping with both bed side rails in raised position. During a record review and interview 01/08/2025 at 10:31 a.m., with the Director of Nursing (DON), reviewed Resident 58`s assessments records. The DON stated the resident did not have a safety assessment for the use of the bed side rails. The DON checked the resident`s room and verified that a quarter bed side rail is attached to the resident`s bed. The DON stated every resident using a bed side rail must be assessed for safety and risk for entrapment to prevent potential injury to the resident. The DON stated that Resident 58 could suffer an injury in the event that a part of her body is entrapped within the gaps of the siderails. During a review of the facility`s policy and procedure titled Side Rail Use When Not A Restraint, last reviewed on 03/15/2024, the policy and procedure indicated that the facility shall Complete Physical Restraint Assessment Form .the licensed nurse should obtain an order from the attending physician that may include the ff: 1. Resident may have both side rails up when in bed, resident does not have voluntary or involuntary movement and resident is immobile and cannot voluntarily get out of bed due to physical limitation . 056412 Page 17 of 30 056412 01/10/2025 Northridge Care Center 7836 Reseda Blvd Reseda, CA 91335

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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** c. During a review of Resident 13's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the document indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including hypertension (high blood pressure). During a review of Resident 13's Census (a document that lists a resident, their admissions, discharges to hospital, and room changes since admission to the facility), the census indicated the following: 10/17/2024 admitted to the facility into room [ROOM NUMBER]-A. 12/21/2024 transfer out to GACH. 12/26/2024 re-admission to facility into room [ROOM NUMBER]-A During a review of Resident 13's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 10/24/2024, the MDS indicated Resident 13 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact with skills required for daily decision making. The MDS indicated Resident 13 was dependent (helper does all the effort) on staff for personal hygiene. During a review of Resident 13's Physician's Orders, the document indicated the following: -Artificial Tears Ophthalmic Solution 1%, instill 1 drop in left eye every six hours as needed for dry eye, dated 10/17/2024. -Artificial Tears Ophthalmic Solution 1%, instill 1 drop in left eye every six hours as needed for dry eye, dated 12/26/2024. During a review of Resident 13's Care Plan for Increased Eye Dryness, the care plan, initiated 1/07/2025, indicated a goal that eye dryness will be relieved through appropriate interventions daily through the next assessment. The care plan indicated an intervention to administer eye drops as ordered/indicated. d. During a review of Resident 19's Face Sheet, the document indicated the resident was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 19's MDS, dated [DATE], the MDS indicated Resident 19 was severely 056412 Page 18 of 30 056412 01/10/2025 Northridge Care Center 7836 Reseda Blvd Reseda, CA 91335

F 0761 Level of Harm - Minimal harm or potential for actual harm impaired in cognition with skills required for daily decision making. The MDS indicated Resident 19 was dependent on staff for personal hygiene. During a review of Resident 19's Physician's Orders an order for Artificial Tears, the document indicated to instill one drop in both eyes two times a day for eye redness, dated 10/04/2023. Residents Affected - Some During a review of Resident 19's Care Plan for Increased Eye Dryness, the care plan, initiated 1/07/2025, indicated a goal that eye dryness will be relieved through appropriate interventions daily through the next assessment. The care plan indicated an intervention to administer eye drops as ordered/indicated. e. During a review of Resident 33's Face Sheet, the document indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included diabetes mellitus. During a review of Resident 33's MDS, dated [DATE], the MDS indicated Resident 33 was cognitively intact with skills required for daily decision making. The MDS indicated Resident 33 required set-up assistance (helper sets up) with toileting. During a review of Resident 33's Physician's Orders an order for Artificial Tears, the document indicated to instill two drops in both eyes two times a day for dry eyes, dated 8/30/2024. During a review of Resident 33's Care Plan for Impaired Visual Functioning, the care plan, initiated 11/08/2023, indicated a goal that there will be minimization of risk for injury to seeing daily through the next assessment. The care plan indicated an intervention to administer eye drops as ordered. During a medication cart inspection of Medication Cart One with Licensed Vocational Nurse 1 (LVN 1), on 1/07/2025, observed three boxes that contained Artificial Tears with the room and bed number for Resident 13, Resident 19, and Resident 33. There was no name on each of the boxes. LVN 1 stated the name is not required because the licensed nurses change the room and bed number if a resident moves to a new room. LVN 1 stated licensed nurses also move the artificial tears to the new medication cart of that resident if required. During an interview with LVN 3 on 1/07/2025 at 8:30 a.m., LVN 3 stated licensed nurses put the name as well as the room and bed number on a box for residents who have been prescribed Artificial Tears. LVN 3 stated the reason is that if a resident changes room they will know which resident the Artificial Tears are for. LVN 3 stated this is important so the right resident will receive the right medication. During a concurrent interview and record review with the Director of Nursing (DON) on 1/07/2025, reviewed Resident 13's Census and Physician's Orders. The DON confirmed that Resident 13 who had an order for Artificial Tears was in room [ROOM NUMBER]-A, was discharged to the GACH on 12/21/2024 and returned to the facility 12/26/2024 into room [ROOM NUMBER]-A. The DON confirmed that that the Artificial Tears labeled 11-A was not moved to the medication cart for room [ROOM NUMBER]-A and the room number was not changed on the box. The DON stated the importance of labeling a box of Artificial Tears with the resident's name to avoid the wrong resident getting the wrong medication. Reviewed the facility's policy and procedure titled, Disposal of Medications and Medication-Related Supplies, last reviewed 3/15/2024, indicated when a resident is transferred [to the hospital] or discharged and does not take medications with him/her, the medications are marked as discontinued or stored in a 056412 Page 19 of 30 056412 01/10/2025 Northridge Care Center 7836 Reseda Blvd Reseda, CA 91335

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some separate location and later destroyed. The DON stated the policy does not indicate what the time frame is for discontinued medications to be removed from the medication cart, but the licensed nurses would conduct this action within three days. The DON stated this was important to prevent another resident from receiving the wrong medication. During a review of the facility's policy and procedure titled, Medication Ordering and Receiving from Pharmacy, last reviewed 3/15/2024, the policy indicated the following: labels are permanently affixed to the outside of the prescription container. If a label does not fit directly onto the product, e.g., eye drops, the label may be affixed to an outside container or cartoon, but the resident's name, at least, must be maintained directly on the actual product container. Based on observation, interview and record review, the facility failed to: a. Ensure a multi-dose vial (contain more than one dose of medication) of Aplisol (used in a skin test to help diagnose tuberculosis [TB, a contagious bacterial infection that can affect the lungs and other parts of the body)] infection) found in one of three medication rooms (Medication Room A), was labeled with an open date. This deficient practice increased the risk that residents could have received the medication that had become ineffective or toxic and result in health complications and inaccurate test results. b. Ensure one unopened insulin (a medication to treat diabetes mellitus [a chronic condition that affects the way the body processes blood sugar]) pen (an injection device with a needle that delivers insulin) was not stored in Medication Cart 2 for one of one sampled resident (Resident 8). This deficient practice had the potential to compromise the therapeutic effectiveness of insulin and result in mismanagement of Resident 8`s Type 2 Diabetes Mellitus (DM-a chronic condition that affects how the body uses sugar [glucose] for energy). c. Ensure that all drugs and biologicals used in the facility were labeled in accordance with professional standards by failing to label a box of Artificial Tears (eye drops that moisten dry eyes) with a resident's name but instead used a room number, during the investigation of one of the facility's six medication carts. d. Ensure Resident 13's medications were removed from Medication Cart One when the resident was discharge to the General Acute Care Hospital (GACH, or simply, hospital). These deficient practices had the potential for a resident to receive a medication not intended for that resident. Findings: a. During a concurrent medication cart inspection and interview on 01/07/2025 at 10:37 a.m., with the Director of Nursing (DON), observed in Medication Room A an opened Aplisol multi-dose vial without an open date. The DON stated that upon opening a multi-dose vial of Aplisol, licensed nurses should have to labeled it with an open date and discard after 28 or 30 days. The DON stated that the purpose of dating is to ensure the multi-dose vial is not used beyond its discard date which if unknown and is still being used, could lead to inaccurate skin test result/s and may not detect infection with Mycobacterium tuberculosis (bacteria that causes tuberculosis) 056412 Page 20 of 30 056412 01/10/2025 Northridge Care Center 7836 Reseda Blvd Reseda, CA 91335

F 0761 Level of Harm - Minimal harm or potential for actual harm During a review of the facility`s policy and procedure titled Vials and Ampules of Injectable Medications, last reviewed on 3/15/2024, the policy indicated that vials and ampules of injectable medications are used in accordance with the manufacturer`s recommendations or the provider pharmacy`s directions for storage, use, and disposal .the date opened and initials of the first person to use the vial are recorded on multi-dose vials . Residents Affected - Some During a review of the Aplisol package insert/manufacturer`s instructions (a document included in the package of a medication that provides information about that drug and its use), dated 3/2016, the document indicated under section Dosage and Administration, that vials in use for more than 30 days should be discarded. b. During a review of Resident 8's admission Record, the admission Record indicated the facility originally admitted the resident on 12/06/2024 and readmitted the resident on 01/01/2025 with diagnoses that included diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]), long term use of insulin, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 8's Minimum Data Set (MDS - a resident assessment tool), dated 12/13/2024, the MDS indicated that the resident has the ability to sometimes makes self-understood and the ability to sometimes understand others. The MDS indicate that Resident 8 is totally dependent on staff for oral hygiene, toileting hygiene, shower, upper and lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 8's Order Summary Report, the report indicated a physician's order dated 01/09/2025 to administer Insulin Lispro Injection Solution (Humalog- a fast-acting insulin) 100 unit per milliliters (U/ml, a unit of measurement) 4 units subcutaneously (administering medication where a short needle is used to inject a medication into the tissue layer between the skin and the muscle) before meals. During a medication cart inspection on 01/09/2025 at 10:04 a.m. with Licensed Vocational Nurse 2 (LVN 2), inspected Medication Cart 2 and found an unopened Insulin Lispro pen without an open date. The Insulin Lispro pen was placed in a plastic bag with a sticker that indicated Refrigerate until used, once in use, store at room temperature. LVN2 stated that the Insulin Lispro pen is new and should have been placed in the refrigerator upon receipt. LVN 2 stated that to maintain the integrity and efficacy of the Insulin Lispro pen it should be stored in room temperature or in the medication cart once opened and marked the date it was used and discard after 28 days. During an interview with the Director of Nursing (DON) 01/09/25 at 11:28 a.m., the DON stated that insulin is used for 28 days per manufacturer`s instruction and if unopened it should be stored in the refrigerator to maintain its efficacy. The DON stated if an insulin lost its efficacy, it will not be effective in managing diabetes and can potentially place Resident 8 at risk for hyperglycemia (a condition where the blood sugar levels are abnormally high) with symptoms such as dizziness, headache, nausea and vomiting. During a review of the manufacturer`s guidelines for Insulin Lispro (Humalog) provided by the facility, indicated that an unopened 3 mL Insulin Lispro should be stored in the refrigerator between 36 to 46 degrees Fahrenheit (unit of temperature) until expiration date. 056412 Page 21 of 30 056412 01/10/2025 Northridge Care Center 7836 Reseda Blvd Reseda, CA 91335

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. 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 leftover food brought from outside by resident`s family and visitors was labeled with resident identifier and use by date for one of one (Resident 141) sampled resident. Residents Affected - Few This deficient practice had the potential to result in foodborne illness (also called food poisoning, illness caused by eating contaminated food) among the residents. Findings: During a review of Resident 141's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including muscle weakness and history of falling. During a review of Resident 141`s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/26/2024, the MDS indicated the resident`s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was intact. The MDS also indicated that the resident was dependent on staff for toileting hygiene, shower, lower body dressing and putting on/taking off footwear. During a concurrent observation and interview with Resident 14 on 01/06/25 at 09:28 a.m., observed Resident 141 in bed. Observed a plastic a plastic bag containing a food item and placed on top of the over-bed table. Resident 141 stated the plastic bag contained two pieces of tamales that were brought by a family member the day before. During an interview and follow up observation of Resident 141, with the Director of Nursing (DON) on 01/06/25 at 09:35 a.m., the DON confirmed that the plastic bag containing two pieces of tamales was on top of the resident`s over-bed table. The DON stated that any left-over food brought by visitors should be refrigerated, labeled with resident`s name and use by date. The DON stated that labeling the food with the date it was brought in will ensure that food is discarded after three days. The DON stated that anyone who consumes an undated food can potentially be at risk for acquiring foodborne illnesses which can result to food poisoning and diarrhea. During a review of the facility`s policy and procedures titled Food Brought by Family/Visitors, last reviewed on 3/15/2024, the policy and procedures indicated that .food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that is clearly distinguishable from facility-prepared food .perishable foods are stored in re-sealable continers with tightly fitting lids in a refrigerator. Containers are labeled with resident`s name, the item and the use by date. 056412 Page 22 of 30 056412 01/10/2025 Northridge Care Center 7836 Reseda Blvd Reseda, CA 91335

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 observe infection control guidelines when Registered Nurse 1 (RN 1) was observed leaving a resident's room during a medication pass observation while still wearing an isolation gown and gloves for one (Resident 295) of nine residents who were on enhanced barrier precautions (EBP-a method of using personal protective equipment [PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments] to reduce the spread of pathogens between residents in skilled nursing facilities). Residents Affected - Some This deficient practice had the potential to increase the risk of spreading infection to other residents. Findings: During a review of Resident 295's Face Sheet, the Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included discitis ( an infection or inflammation of the discs in the spine [the backbone, a column of bones that runs from the base of the skull to the tailbone]), urinary tract infection (an infection in any part of the urinary system), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). During a review of Resident 295' s Minimum Data Set (MDS, a resident assessment tool), dated 12/27/2024, the MDS indicated Resident 295 was moderately impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 295 was dependent (helper does all the effort) on staff for eating, dressing, and personal hygiene. During the review of Resident 295's History and Physical , dated 12/23/2024, the History and Physical indicated that Resident 295 had a capacity to make needs known, but cannot make decisions. During a review of Resident 295's Physician's Orders, the physician's orders indicated the following: 1. Cefazolin Sodium (antibiotic used to treat certain infections) injection 2 gram (gm- unit of measurement) intravenously every eight (8) hours for discitis for 56 days. Start day 12/21/2024. 2. On enhanced barrier precaution (EBP-a method of using personal protective equipment). Start day 12/22/2024. During a medication pass observation with RN 1 on 1/07/2025 at 12:55 p.m., observed RN 1 administer Cefazolin 2 gm via central line at 100 ml /hour rate for Resident 295. RN 1 then did not remove his gloves and gown and exited Resident 295's room while still wearing an isolation gown and gloves. RN 1's gowned arms and gloved hands touched the medication cart. When asked why RN 1 was still wearing the isolation gown after exiting a resident's room on EBP precautions, RN 1 stated he should have removed the isolation gown and gloves before exiting the room. RN 1 removed the isolation gown and gloves. RN 1 stated it is important to follow EBP guidelines to prevent the spread of infection. During an interview with the Infection Preventionist (IP) on 1/8/2025 at 10:50 a.m., the IP stated 056412 Page 23 of 30 056412 01/10/2025 Northridge Care Center 7836 Reseda Blvd Reseda, CA 91335

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some staff providing care for residents who are on EBP, the practice is to remove the isolation gown and gloves before leaving a resident's room. The IP stated RN 1 should have removed the gown and gloves before exiting Resident 295's room. The IP stated this was important to prevent the spread of infection. During an interview with the Director of Nursing (DON) on 1/9/2024 at 4:43 p.m., the DON stated RN 1 should have removed the gown and gloves before exiting Resident 295's room. The DON stated this was important to prevent the spread of infection. During a review of the facility's policy and procedure titled, Enhanced Barrier Precautions, revised 3/15/2024, the policy indicated EBP is used in conjunction with standard precautions (a set of infection control practices that are used to prevent the spread of disease in healthcare settings, such as hand washing) and expand the use of PPE during high-contact resident care activities. The policy indicated EBP are to be used for residents with indwelling medical devices, such as a central line, even if the resident is not known to be infected or colonized with a multidrug-resistant organism (MDRO, bacteria that are resistant to three or more classes of antimicrobial drugs). The policy indicated the PPE: gloves and gown, are to be used in maintaining EBP. 056412 Page 24 of 30 056412 01/10/2025 Northridge Care Center 7836 Reseda Blvd Reseda, CA 91335

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. Based on observation, interview, and record review, the facility failed to provide at least 80 square (sq.) feet (ft.) per resident in 27 of 43 resident rooms (Rooms 4, 6, 8, 10, 11, 12, 14, 15, 17, 18, 19, 20, 21, 22, 23, 24, 25, 27, 28, 29, 31, 33, 35, 37, 39, 41, and 42). The room size for these rooms had the potential to have inadequate space for resident care and mobility. Findings: On 01/06/2025, the Administrator (ADM) submitted an application for the Room Variance Waiver, dated 01/06/2025, for 27 resident rooms. The room waiver request indicated the following: Room # Square Footage (sq ft) Bed Capacity Sq Ft per Resident 4 154.64 2 77.32 6 155.25 2 77.625 8 151.20 2 75.6 10 056412 Page 25 of 30 056412 01/10/2025 Northridge Care Center 7836 Reseda Blvd Reseda, CA 91335

F 0912 153.9 Level of Harm - Potential for minimal harm 2 76.95 Residents Affected - Some 11 153.17 2 76.585 12 153.17 2 76.585 14 153.17 2 76.585 15 157.95 2 78.975 17 153.17 2 76.585 18 157.93 056412 Page 26 of 30 056412 01/10/2025 Northridge Care Center 7836 Reseda Blvd Reseda, CA 91335

F 0912 2 Level of Harm - Potential for minimal harm 78.965 19 Residents Affected - Some 153.17 2 76.585 20 157.93 2 78.965 21 157.93 2 78.965 22 155.11 2 77.555 23 157.93 2 78.965 24 158.68 2 056412 Page 27 of 30 056412 01/10/2025 Northridge Care Center 7836 Reseda Blvd Reseda, CA 91335

F 0912 79.34 Level of Harm - Potential for minimal harm 25 155.11 Residents Affected - Some 2 77.555 27 309.54 4 77.385 28 309.54 4 77.385 29 153 2 76.5 31 153 2 76.5 33 154.18 2 77.09 056412 Page 28 of 30 056412 01/10/2025 Northridge Care Center 7836 Reseda Blvd Reseda, CA 91335

F 0912 35 Level of Harm - Potential for minimal harm 154.18 2 Residents Affected - Some 77.09 37 154.18 2 77.09 39 154.18 2 77.09 41 154.18 2 77.09 42 154.18 2 77.09 The minimum requirement for a 2-bed room should be at least 160 sq. ft. The minimum requirement for a 3-bed room should be at least 240 sq. ft. The minimum requirement for a 4-bed room should be at least 320 sq. ft. During the Resident Council meeting on 01/06/2025 at 10:37 a.m., the residents in attendance did not express concerns regarding their room size. During a general observation on 01/09/2025 at 8:30 a.m., residents and staff had enough space to move freely inside the rooms. The nursing staff had enough space to safely provide care to the 056412 Page 29 of 30 056412 01/10/2025 Northridge Care Center 7836 Reseda Blvd Reseda, CA 91335

F 0912 residents with space for the beds, side tables, dressers, and resident care equipment. Level of Harm - Potential for minimal harm During a review of the room waiver letter dated 01/06/2025, the letter indicated each room has adequate space for each resident with his/her own closet space, over bed table and night stand. Cubicle curtains are hung at each bedside, giving each resident privacy when pulled closed. The rooms are also equipped with call lights for each resident. The rooms are in accordance with the special needs of the residents and would not impede the ability of any resident in the room to attain his or her highest practicable well-being. There is adequate space to move around in the rooms for both ambulatory and non-ambulatory residents and adequate space for wheelchair accessibility and medication carts to provide care. Residents Affected - Some 056412 Page 30 of 30