Health inspection·January 25, 2024

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. 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 obtain informed consent prior to initiation and administration of psychotropics (medications that affect the mind, emotions, and behavior) to five of seven sampled residents (Residents 43, 52, 64, and 84, and 67). Residents Affected - Some The above failure put Residents 43, 52, 64, 84, and 67 at risk for avoidable harm from unwanted adverse effects (a harmful and undesired effect resulting from a medication or intervention) related to psychotropic medication use. The above failure also removed the Residents' rights to make decisions about the care and treatments they received in the facility. Cross Reference: F-tag F561 Findings: 1. During a review of Resident 67's admission Record, the record indicated the facility originally admitted Resident 67 on 2/3/2023. Resident 67's admitting diagnoses included metabolic encephalopathy (when another health condition makes it hard for the brain to work), psychosis (a collection of symptoms that affect the mind, with some loss of contact with reality), and major depressive disorder (a distinct type of depressive illness accompanied by either delusions, hallucinations, or both). During a review of Resident 67's History and Physical (H&P), dated 2/6/2023, the H&P indicated Resident 67 had fluctuating capacity to understand and make decisions. During a review of Resident 67's medical record titled [Skilled Nursing Facility (SNF)] Follow Up Note, dated 6/14/2023, the record indicated Psychiatric-Mental Health Nurse Practitioner (PMHNP) 1 evaluated Resident 67 for anxiety (feeling of unease, excessive worry), delusion (false belief or judgement about external reality), depression (feeling of sadness), and confusion. The record indicated Resident 67 had a disorganized thought process, poor insight and judgement, and poor fund of knowledge (orientation to reality). The record indicated Resident 67 had been refusing medication and would continue to be off psychotropic medication due to [Resident 67] refusing medication. During a review of Resident 67's social services progress note, dated 6/14/2023, the progress note indicated [Resident 67] stated [he] will not take any medication from any doctor other than his primary physician that has been seeing .for over 15 years. Resident stated does not trust any other doctor. Resident stated, 'It's my choice if I decide to take medication.' During a review of Resident 67's electronic medical record (EMR), the record indicated Resident 67 was hospitalized on [DATE] and was re-admitted to the facility on [DATE]. Page 1 of 52 056415 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 67's medical record titled, SNF Initial Evaluation, dated 7/19/2023, the record indicated PMHNP 1 evaluated Resident 67 following his 5150 hospitalization (the involuntarily detainment/hospitalization of an adult experiencing a mental health crisis, who has been evaluated as a danger to others, themselves, or gravely disabled). The record indicated that at the time of the evaluation, Resident 67 had a disorganized thought process, paranoid delusions (feelings that someone or some group is out to mistreat, harm, and sabotage you), and poor insight and judgement. The note indicated Resident 67 would be started on 0.5 milligrams (mg, a unit of measuring medication dosage) of Risperidone (a medication used to improve mood, thoughts, and behaviors in people with schizophrenia, bipolar disorder, and autism). The note indicated PMHNP 1 discussed the treatment plan with Resident 67 and facility staff and indicated benefits of these medications outweigh the risks for this patient given the patient's degree of mental illness. During a review of Resident 67's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 7/26/2023, the MDS indicated a Brief Interview For Mental Status (BIMS) score of 10, which indicated Resident 67 had moderately impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday). During a review of Resident 67's discontinued physician orders, dated 7/19/2023, the orders indicated Resident 67 was started on 0.5 mg of Risperidone, twice a day, for manic disorder on 7/20/2023. During a review of Resident 67's Medication Administration Records (MAR), dated 7/2023, 8/2023, 9/2023, 10/2023, and 11/2023, the MARs indicated Resident 67 received Risperidone from 7/2023 to 11/2023. During a review of Resident 67's Multidisciplinary Care Conference (MCC) notes, dated 10/17/2023, the notes indicated Resident 67 was unable to make medical decisions, and indicated per primary physician [Resident 67] able to make needs known, but unable to make medical decisions. During a review of Resident 67's EMR, the EMR indicated Resident 67 was hospitalized on [DATE] and was re-admitted to the facility on [DATE]. During a review of Resident 67's discontinued physician orders, dated 11/24/2023, the orders indicated Resident 67 was started on 0.5 mg of Risperidone, twice a day, for manic disorder on 11/24/2023, and indicated consent obtained by [physician] from [Resident 67]. During a review of Resident 67's medical record titled, Facility Verification of Informed Consent, dated 11/24/2023, the record indicated consent obtained by [physician] from [Resident 67]. During a review of Resident 67's MARs, dated 11/2023 and 12/2023, the MARs indicated Resident 67 received 0.5 mg of Risperidone, twice a day, from 11/2023 to 12/2023. During a review of Resident 67's MDS, dated [DATE], the MDS indicated a BIMS score of 9, indicating moderate cognitive impairment. During a review of Resident 67's medical record titled, [Interdisciplinary Team (IDT, group of different disciplines working together towards a common goal of a resident)] Behavior Management, dated 12/8/2023, the record indicated Resident 67 was having increased erratic behavior (behavior that is 056415 Page 2 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some unpredictable, or may be considered irregular or illogical for the situation, or not keeping with the standards of behavior for a given set of circumstances). The record further indicated the IDT reviewed Resident 67's medications and recommended an increase in his psychotropic medication dose. During a review of Resident 67's active physician orders, dated 12/8/2023, the orders indicated Resident 67 was now on 0.5 mg of Risperidone, once a day, for psychosis, and started on 0.75 mg of Risperidone at bedtime for psychosis. During a review of Resident 67's medical record titled, SNF Initial Evaluation, dated 12/11/2023, the record indicated PMHNP 2 evaluated Resident 67 and indicated that at the time of the evaluation, Resident 67 had paranoia and delusion, poor insight, and poor judgement. The note indicated Resident 67 would be continued on 0.5 mg of Risperidone once a day in the morning and reflected the new order of 0.75 mg once a day at bedtime. The note indicated PMHNP 1 discussed the treatment plan, including the medications, with Resident 67 and facility staff. During a review of Resident 67's medical records titled, Facility Verification of Informed Consent, dated 12/8/2023, the documents indicated that informed consent for Risperidone 0.5 mg once a day, and Risperidone 0.75 mg at bedtime, were obtained from [Resident 67]. During an interview, on 1/25/2024 at 12:50 PM, with Medical Doctor (MD) 1, MD 1 stated he was Resident 67's primary physician in the facility and was familiar with the resident. MD 1 stated Resident 67 had fluctuating capacity to make medical decisions, and stated Resident 67 was not capable of providing informed consent. MD 1 stated potential side effects of Risperidone included worsening psychosis, mood disorders, and hallucinations. During a concurrent record review and interview, on 1/26/2024 at 11:10 AM, with the Director of Social Services (DSS), Resident 67's EMR, including multidisciplinary care conference (MCC) notes, IDT conference notes were reviewed. The DSS stated there was supposed to be someone with medical decision-making capacity present on Resident 67's behalf during the conferences because Resident 67 did not have medical decision-making capacity. The DSS stated Resident 67 was able to independently make decisions or speak for himself due to his cognitive impairment. The DSS stated Resident 67 should have been referred to the Office of Representatives to appoint a responsible party to make medical decisions on his behalf, including informed consent. The DSS stated that not appointing a responsible party was a violation of Resident 67's rights. The DSS stated there was no documentation in Resident 67's medical record to indicate the facility had attempted to identify a responsible party for Resident 67. 2. During a review of Resident 43's admission Record, the admission record indicated Resident 43 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions) and Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves). During a review of Resident 43's History and Physical (H&P) dated 12/27/2023, the H&P indicated Resident 43 had the capacity to understand and make decisions. The H&P indicated Resident 43 had a diagnosis of seizures (burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements [stiffness, twitching or limpness], behaviors, sensations, or states of awareness). 056415 Page 3 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0552 Level of Harm - Minimal harm or potential for actual harm During a review of Resident 43's Minimum Data, dated 1/15/2024, the MDS indicated that Resident 43's cognitive skills for daily decision was intact. The MDS indicated Resident 43 needed supervision for activities of daily living. The MDS indicated Resident had a history of dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). Residents Affected - Some During a review of Resident 43's Order Summary, dated 7/20/2022, the order summary indicated Resident 43 was to receive Quetiapine fumarate tablet 400 mg, 1 tablet at bedtime for psychosis. During a review of Resident 43's MAR, dated 7/1/2022 to 7/31/2022, the MAR indicated Resident 43's received 1 tablet of Quetiapine fumarate 400mg at bedtime from 7/20/2022 to 7/31/2022. During a review of Resident 43's informed consent for Quetiapine fumarate tablet 300 mg, 2 times a day, dated 12/10/2023, the form indicated Resident 43 gave consent to receive quetiapine fumarate. 3. During a review of Resident 52's admission Record, the admission record indicated Resident 52 was originally admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of schizophrenia and angina pectoris (severe pain in the chest, often also spreading to the shoulders, arms, and neck, caused by an inadequate blood supply to the heart). During a review of Resident 52's H&P dated 1/19/2024, the H&P indicated Resident 52 had the capacity to understand and make decisions. The H&P indicated Resident 52 had a diagnosis of left femur fracture (a break in the thighbone). During a review of Resident 52's MDS, dated [DATE], the MDS indicated that Resident 52's cognitive skills for daily decision was intact. The MDS indicated Resident 52 required supervision for activities of daily living (ADLs, self-care activities performed daily such as grooming, dressing, and personal hygiene). During a review of Resident 52's Order Summary, dated 6/1/2022, the order summary indicated Resident 52 was to receive Escitalopram oxalate tablet 5mg one time day for anxiety. During a review of Resident 52's MAR, dated 6/1/2022 to 6/30/2022, the MAR indicated Resident 52 received 1 tablet of Escitalopram oxalate 5 mg on 6/2/2022, and 6/4/2022 to 6/9/2022 and from 6/15/2022 to 6/30/2022. During a review of Resident 52's medical records, unable to locate a consent for Escitalopram oxalate 5 mg. During a review of Resident 52's medical records, the records indicated a consent form for Escitalopram oxalate 10 mg, dated 6/1/2023, given by Resident 52. During a review of Resident 52's MAR, dated 11/1/2023 to 11/30/2023, the MAR indicated Resident 52 received Lorazepam injection 2mg/milliliter (ml, unit of measurement) for agitation on 11/2/2023. During a review of Resident 52's medical records, unable to locate a consent for Lorazepam injection 2mg/ml. During a review of Resident 52's medical records, the records indicated informed consent for 056415 Page 4 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0552 Lorazepam, dated 4/27/2023, given by Resident 52 to receive Lorazepam 1mg by mouth. Level of Harm - Minimal harm or potential for actual harm 4. During a review of Resident 64's admission Record, the admission record indicated Resident 64 was originally admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of dementia and psychosis. Residents Affected - Some During a review of Resident 64's H&P dated 12/27/2023, the H&P indicated Resident 64 did not have the capacity to understand and make decisions. The H&P indicated Resident 64 had a diagnosis of supra pubic catheter (a medical device that helps drain urine from the bladder, enters the body through a small incision in the abdomen). During a review of Resident 64's MDS, dated [DATE], the MDS indicated that Resident 64's cognitive skills for daily decision was impaired. The MDS indicated Resident 64 needed substantial assistance for ADLs. The MDS indicated Resident 64 had a history of obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow and can be either structural or functional). During a review of Resident 64's Order Summary, dated 6/15/2023, the order summary indicated Resident 64 was to receive Quetiapine fumarate tablet 50 mg, two times day. During a review of Resident 64's MAR, dated 6/1/2023 to 6/30/2023, the MAR indicated Resident 64 received 2 tablets of Quetiapine fumarate 50 mg daily from 6/15/2023 to 6/30/2023. During a review of Resident 64's medical records, unable to locate a consent form for Quetiapine fumarate 50 mg. During a review of Resident 64's medical records, the records indicated Resident 64's responsible party (RP) gave consent for Quetiapine fumarate 25 mg two times a day on 12/6/2023. 5. During a review of Resident 84's admission Record, the admission record indicated Resident 84 was originally admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of psychosis and obstructive uropathy. During a review of Resident 84's H&P dated 12/23/2023, the H&P indicated Resident 84 had fluctuating capacity to understand and make decisions. The H&P indicated Resident 84 had a diagnosis of hypertension (high blood pressure). During a review of Resident 84's MDS, dated [DATE], the MDS indicated that Resident 84's cognitive skills for daily decision was moderately impaired and Resident 84's BIMS was 8. The MDS indicated Resident 84 required moderate assistance for personal hygiene and oral hygiene. The MDS indicated Resident 84 had a history of heart failure (progressive heart disease that affects pumping action of the heart muscle). During a review of Resident 84's Order Summary, dated 10/14/2023, the order summary indicated Resident 84 was to receive Remeron oral tablet, 15 mg, 1 tablet at bedtime for depression. During a review of Resident 84's MAR, dated 10/1/2023 to 10/31/2023, the MAR indicated Resident 84 received 1 tablet of Remeron oral tablet, 15 mg daily from 10/14/2023 to 10/23/2023. During a review of Resident 84's medical records, unable to locate consent for Remeron oral tablet 056415 Page 5 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0552 15 mg. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 84's medical records, the records indicated Resident 84's RP gave consent for Remeron 15 mg at bedtime on 12/20/2023. Residents Affected - Some During a review of Resident 84's informed consent for Buspirone HCI oral tablet 5 mg, 2 times a day for depression, dated 12/20/2023, the informed consent indicated the doctor obtained consent from Resident 84 for administration of Buspirone HCI medication. During a review of Resident 84's Baseline Care Plan, dated 12/20/2023, the care plan indicated Resident 84 was cognitively impaired. During a review of Resident 84's BIMS Evaluation, dated 12/26/2023, the BIMS evaluation indicated Resident 84 had a BIMS score of 7 (severe cognitive impairment). During an interview on 1/25/2024 at 2:12 p.m. with Registered Nurse (RN) 1, RN 1 stated all residents needed an informed consent for a medication before administering the medication. RN 1 stated all informed consents should be in the resident's paper chart and if they were not in the chart, it meant the resident did not have an informed consent. During an interview on 1/25/2024 at 3:25 p.m. with the Director of Nursing (DON), the DON stated all residents or their responsible parties must give their authorization to administer antipsychotic medications. The DON stated they determine whether the resident has the capacity to provide informed consent based on the MDS and the H&P. The DON stated a resident could authorize the administration of an antipsychotic medication if they had a BIMs score of 12 or higher and if a resident had the mental capacity to make medical decisions. The DON stated if a resident had a responsible party, the doctor must explain the medication to the responsible party and get their consent to administer the medication. The DON stated all parties sign the consent indicating they understood the use of the medication. The DON stated informed consent was obtained from the resident or responsible party upon admission or re-admission to the facility, even if the resident received the medication in the hospital. During an interview on 1/25/2023 at 4:19 p.m. with Medical Records Staff 1, Medical Records Staff 1 stated they did not have the initial medication informed consent for Resident 43, 52, 64 and 84. During a review of facility's policy and procedure (P&P) titled, Health, Medical Condition and Treatment Options, Informing Residents of, dated 2001, the P&P indicated each resident is informed of his/her total health status and medical condition, including diagnosis, treatment recommendation and prognosis, in advance of treatment and on - going basis. If a resident has an appointed representative, the representative is also informed. During a review of the facility's P&P titled, Psychotropic Medication Use, dated 10/2017, the P&P indicated facility staff should inform the resident and/or resident representative of the initiation, reason for use, and the risks associated with the use of psychotropic medications. 056415 Page 6 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to appoint a responsible party and/or representative for one of 18 sampled residents (Resident 67), who did not have medical decision-making capacity. The above failure put Residents 67 at risk for avoidable harm from unwanted adverse effects (a harmful and undesired effect resulting from a medication or intervention) related to psychotropic medication use. The above failure also prevented Resident 67's from exercising his rights to make decisions about the care and treatments they received in the facility. Cross Reference: F-tag F552 Findings: During a review of Resident 67's admission Record, the record indicated the facility originally admitted Resident 67 on 2/3/2023. Resident 67's admitting diagnoses included metabolic encephalopathy (when another health condition makes it hard for the brain to work), psychosis (a collection of symptoms that affect the mind, with some loss of contact with reality), and major depressive disorder (a distinct type of depressive illness accompanied by either delusions [a false belief or judgement], hallucinations [seeing things that are not real], or both). During a review of Resident 67's History and Physical (H&P), dated 2/6/2023, the H&P indicated Resident 67 had fluctuating capacity to understand and make decisions. During a review of Resident 67's medical record titled [Skilled Nursing Facility (SNF)] Follow Up Note, dated 6/14/2023, the record indicated Psychiatric-Mental Health Nurse Practitioner (PMHNP) 1 evaluated Resident 67 for anxiety (feeling of unease, excessive worry), delusion, depression, and confusion. The record indicated Resident 67 had a disorganized thought process, poor insight and judgement, and poor fund of knowledge (orientation to reality). The record indicated Resident 67 had been refusing medication and would continue to be off psychotropic medication due to [Resident 67] refusing medication. During a review of Resident 67's social services progress note, dated 6/14/2023, the progress note indicated [Resident 67] stated [he] will not take any medication from any doctor other than his primary physician that has been seeing .for over 15 years. Resident stated does not trust any other doctor. Resident stated, 'It's my choice if I decide to take medication.' During a review of Resident 67's electronic medical record (EMR), the EMR indicated Resident 67 was hospitalized on [DATE] and was re-admitted to the facility on [DATE]. During a review of Resident 67's medical record titled SNF Initial Evaluation, dated 7/19/2023, the record indicated PMHNP 1 evaluated Resident 67 following his 5150 hospitalization (the involuntarily detainment/hospitalization of an adult experiencing a mental health crisis, who has been evaluated as a danger to others, themselves, or gravely disabled). The record indicated that at the time of the evaluation, Resident 67 had a disorganized thought process, paranoid delusions (feelings that someone or some group is out to mistreat, harm, and sabotage you), and poor insight and judgement. The note indicated Resident 67 would be started on 0.5 milligrams (mg, a unit of measuring medication 056415 Page 7 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dosage) of Risperidone (a medication used to improve mood, thoughts, and behaviors in people with schizophrenia, bipolar disorder, and autism). The note indicated PMHNP 1 discussed the treatment plan with Resident 67 and facility staff and indicated benefits of these medications outweigh the risks for this patient given the patient's degree of mental illness. During a review of Resident 67's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 7/26/2023, the MDS indicated a Brief Interview For Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents) score of 10, which indicated Resident 67 had moderately impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday). During a review of Resident 67's discontinued physician orders, dated 7/19/2023, the orders indicated Resident 67 was started on 0.5 mg of Risperidone, twice a day, for manic disorder on 7/20/2023. During a review of Resident 67's Medication Administration Records (MAR), dated 7/2023, 8/2023, 9/2023, 10/2023, and 11/2023, the MARs indicated Resident 67 received the Risperidone from 7/2023 to 11/2023. During a review of Resident 67's Multidisciplinary Care Conference (MCC) notes, dated 10/17/2023, the notes indicated Resident 67 was unable to make medical decisions, and indicated per primary physician [Resident 67] able to make needs known, but unable to make medical decisions. During a review of Resident 67's EMR, the EMR indicated Resident 67 was hospitalized on [DATE] and was re-admitted to the facility on [DATE]. During a review of Resident 67's discontinued physician orders, dated 11/24/2023, the orders indicated Resident 67 was started on 0.5 mg of Risperidone, twice a day, for manic disorder on 11/24/2023, and indicated consent obtained by [physician] from [Resident 67]. During a review of Resident 67's medical record titled Facility Verification of Informed Consent, dated 11/24/2023, the record indicated consent obtained by [physician] from [Resident 67]. During a review of Resident 67's MARs, dated 11/2023 and 12/2023, the MARs indicated Resident 67 received 0.5 mg of Risperidone, twice a day, from 11/2023 to 12/2023. During a review of Resident 67's MDS, dated [DATE], the MDS indicated a BIMS score of 9, indicating moderate cognitive impairment. During a review of Resident 67's medical record titled [Interdisciplinary Team (IDT)] Behavior Management, dated 12/8/2023, the record indicated Resident 67 was having increased erratic behavior (behavior that is unpredictable, or may be considered irregular or illogical for the situation, or not keeping with the standards of behavior for a given set of circumstances). The record further indicated the IDT (professionals from various disciplines who work in collaboration to address a patient's needs) reviewed Resident 67's medications and recommended an increase in his psychotropic medication dose. During a review of Resident 67's active physician orders, dated 12/8/2023, the orders indicated 056415 Page 8 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 67 was now on 0.5 mg of Risperidone, once a day, for psychosis, and started on 0.75 mg of Risperidone at bedtime for psychosis. During a review of Resident 67's medical record titled SNF Initial Evaluation, dated 12/11/2023, the record indicated PMHNP 2 evaluated Resident 67 and indicated that at the time of the evaluation, Resident 67 had paranoia and delusion, poor insight, and poor judgement. The note indicated Resident 67 would be continued on 0.5 mg of Risperidone once a day in the morning and reflected the new order of 0.75 mg once a day at bedtime. The note indicated PMHNP 1 discussed the treatment plan, including the medications, with Resident 67 and facility staff. During a review of Resident 67's medical records titled Facility Verification of Informed Consent, both dated 12/8/2023, the documents indicated that informed consent for Risperidone 0.5 mg once a day, and Risperidone 0.75 mg at bedtime, were obtained from [Resident 67]. During an interview, on 1/25/2024 at 12:50 PM, with Medical Doctor (MD) 1, MD 1 stated he was Resident 67's primary physician in the facility and was familiar with the resident. MD 1 stated Resident 67 had fluctuating capacity to make medical decisions, and stated Resident 67 was not capable to provide informed consent. MD 1 stated potential side effects of Risperidone included worsening psychosis, mood disorders, and hallucinations. During a review of Resident 67's care plans, the care plans indicated [Resident 67] has impaired cognitive function or impaired thought processes [related to history of] metabolic encephalopathy and psychosis. The care plans further indicated Resident 67 was at risk for movement disorder, discomfort, low blood pressure, gait disturbance, constipation, or cognitive/behavioral impairment from use of Risperidone. During a review of Resident 67's Multidisciplinary Care Conference (MCC) notes, dated 1/5/2024, the notes were documented by the Social Services Director (SSD) and indicated per primary physician [Resident 67] able to make needs known, but unable to make medical decisions. During an interview on 1/25/2024 at 3:23 PM, with the Director of Nursing (DON), the DON stated informed consent was supposed to be obtained from the resident or responsible party/representative upon admission or re-admission to the facility, even if the resident received the medication in the hospital. The DON stated determination of whether the resident has capacity to provide informed consent based on the MDS and the H&P. The DON stated the resident should have an MDS BIMS score of 12 or higher, which indicated a resident had no cognitive impairments, and stated the H&P should specify the resident had capacity to make medical decisions. During a concurrent record review and interview, on 1/26/2024 at 11:10 AM, with the Social Services Director (SSD), the SSD reviewed Resident 67's EMR, including multidisciplinary care conference (MCC) notes, IDT conference notes. The SSD stated there was supposed to be someone with medical decision-making capacity present on Resident 67's behalf during the conferences because Resident 67 did not have medical decision-making capacity. The SSD stated Resident 67 was able to independently make decisions or speak for himself due to his cognitive impairment. The SSD stated Resident 67 should have been referred to the Office of Representatives to appoint a resident representative to make medical decisions on Resident 67's behalf, including informed consent. The SSD stated that not appointing a responsible party was a violation of Resident 67's rights. The SSD stated there was no documentation in Resident 67's medical record to indicate the facility had attempted to identify a resident representative or make the necessary referrals for Resident 67. 056415 Page 9 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of the undated facility job description document titled Director of Social Services, the document indicated that responsibilities of the SSD included to implement policies and procedures for the identification of medically related social and emotional needs of the residents and refer resident/families to appropriate social service agencies when the facility does not provide the services or needs of the resident. During a review of the facility policy and procedure (P&P) titled Resident Rights, dated 2/2021, the P&P indicated resident rights included: appointing a legal representative of his or her choice, in accordance with state law, being informed of, and participating in, his or her care planning and treatment, and participating in decision-making regarding his or her care. During a review of the facility P&P titled Health, Medical Condition and Treatment Options, Informing Residents of), dated 2/2021, the P&P indicated each resident is informed of his/her total health status and medical condition, including diagnosis, treatment recommendation and prognosis, in advance of treatment and on - going basis. If a resident has an appointed representative, the representative is also informed. During a review of the facility P&P titled Resident Representative, dated 2/2021, the P&P defined a resident representative as: a. an individual chosen by the resident to act on behalf of the resident in order to support the resident in decision-making; access medical, social, or other personal information of the resident; manage financial matters; or receive notifications; b. a person authorized by state or federal law (including but not limited to agents under power of attorney, representative payees, and other fiduciaries) to act on behalf of the resident in order to support the resident in decision-making; access medical, social, or other personal information of the resident; manage financial matters; or receive notifications; c. legal representative, as used in section 712 of the Older Americans Act; or d. the court-appointed guardian or conservator of a resident. The P&P further indicated If the resident is determined to be incompetent under the laws of the state by a court of competent jurisdiction, the rights of the resident will devolve to and will be exercised by the resident representative appointed to act on the resident's behalf and The court-appointed resident representative will exercise the resident's rights to the extent judged necessary by a court of competent jurisdiction, in accordance with state law. During a review of the facility P&P titled Psychotropic Medication Use, dated 10/2017, the P&P indicated facility staff should inform the resident and/or resident representative of the initiation, reason for use, and the risks associated with the use of psychotropic medications. 056415 Page 10 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

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 interview and record review, the facility failed to develop and/or implement the care plans (document that assists nurses and other team care members organize aspects of resident care) for four of 46 sampled residents (Resident 23, Resident 11, Resident 51, and Resident 45) when facility staff failed to: 1. Develop a care plan for Resident 23 who had fungal dermatitis (a skin infection that causes red, irritated, or scaly rash) to her lower back. 2. Implement Resident 51's care plans for skin breakdown and pressure ulcers (PU, an injury that breaks down the skin and underlying tissue, caused when an area of skin is placed under prolonged pressure). 3. Implement Resident 11's care plans for skin breakdown and pressure ulcers. 4. Implement Resident 45's care plan for her impaired vision. These failures had the potential to negatively affect the delivery of necessary care and services for Residents 23, 11, and 45. Resident 23 was at risk for worsening fungal dermatitis; Resident 11 and Resident 51 were at risk for a worsening condition of existing PUs, or development of new PUs; and Resident 45 was at risk for suffering from an avoidable inability to see, and inability to participate in her preferred activities. Cross Reference: F-tag 685 and F-tag 686 Findings: 1. During a review of Resident 23's admission Record (Face Sheet), the admission Record indicated Resident 23 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses included but not limited to chronic obstructive pulmonary disease (a lung disease characterized by long-term poor airflow), atrial fibrillation (an irregular, often rapid heart rate that can cause poor blood flow), and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). During a review of Resident 23's History and Physical Examination (H&P), dated 11/23/23, the H&P indicated Resident 23 had the capacity to understand and make decisions). During a review of Resident 23's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 11/14/2023, the MDS indicated Resident 23 was able to make herself understood and understood others. The MDS indicated Resident 23's cognition (process of thinking) was intact. The MDS indicated Resident 23 had cellulitis (skin infection that spreads rapidly) and moisture associated skin damage (MASD, inflammation and erosion of the skin that resulted from prolonged exposure to different sources of moisture such as feces or urine). During a review of Resident 23's Progress Notes, dated 1/25/2024, the Progress Notes indicated fungal dermatitis was found on Resident 23's lower back on 1/3/2024 and the physician was notified. 056415 Page 11 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 23's Order Summary Report, dated 1/24/2024, the Order Summary Report indicated to cleanse with normal saline (NS, solution made of salt and water), pat dry, apply Nystatin-Triamcinolone External Cream (medicated cream to treat fungal skin infections) 100000-0.1 unit per gram (GM, unit of measurement) to the lower back, and keep open to air, once a day for 21 days. During a current interview and record review on 1/25/2024 at 8:25 AM, with Treatment Nurse (TN 1), Resident 23's Care Plans were reviewed. Resident 23 did not have a care plan that addressed her fungal dermatitis. TN 1 stated once the fungal dermatitis was assessed and treatment was ordered by the physician, a care plan should have been developed. TN 1 stated care plans were developed when there was any change to the residents' condition or status. TN 1 stated care plans allowed the staff to be updated with the residents' conditions and their interventions. TN 1 stated since Resident 23 did not have a care plan that addressed her fungal dermatitis, there was the potential that the condition could worsen because the staff would be unaware of Resident 23's treatment plan and required monitoring. During an interview on 1/25/2024 at 9:14 AM, with the Minimum Data Set Nurse (MDSN), the MDSN stated care plans were developed based on the condition of the resident when they were first admitted to the facility and any changes thereafter. The MDSN stated he would audit the residents' medical record to ensure they have care plans developed based on their conditions, medications, and physician orders. The MDSN stated care plans were essential for the staff to be aware of the residents' goals and how to treat them properly. The MDSN stated Resident 23 did not have a care plan for her fungal dermatitis and there was the potential that Resident 23's skin condition would not be communicated to all the staff who provided care to her. During an interview on 1/25/2024 at 4:23 PM, with the Director of Nursing (DON), the DON stated care plans were developed to create a goal for the residents and to communicate the interventions to be implemented to meet their goal. The DON stated Resident 23 should have had a care plan developed that addressed her fungal dermatitis which would have had a measurable goal and the interventions the staff would implement to rectify the issue. The DON stated there was the potential that Resident 23's treatment could be missed, and her skin condition could worsen. 2. During a review of Resident 51's admission Record, the record indicated the facility originally admitted Resident 51 on 12/22/2020 and re-admitted Resident 51 on 11/28/2022, and again on 6/6/2023. Resident 51's admitting diagnoses included: hemiplegia and hemiparesis (weakness and/or inability to move one side of the body) following a stroke (when the blood supply to part of the brain is blocked or reduced), muscle wasting and atrophy (a decrease in size of an organ or tissue), and unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 51's MDS, dated [DATE], the MDS indicated Resident 51 experienced cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 51 had impairment to the upper and lower extremities on one side of her body, which interfered with daily function and placed her at risk of injury. The MDS further indicated Resident 51 was fully dependent on staff to move from side to side in bed, and to transition from a sitting position to lying position, and a lying position to a sitting position. The MDS further indicated Resident 51 was at risk for developing PUs, and used a pressure reducing device in her bed, and was being turned and repositioned while in bed by staff. 056415 Page 12 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 51's medical record titled Braden Scale for Predicting Pressure Sore Risk, dated 12/7/2023, the record indicated Resident 51 was at high risk for skin breakdown. During a review of Resident 51's care plans, the care plans indicated Resident 51 was at risk for developing PUs and experiencing skin breakdown, and goals of care included reducing Resident 51 having intact skin free of breakdown. Staff's interventions included Low Air Loss Mattress (LALM, mattress used to distribute pressure) to prevent wounds and LALM setting according to .weight of resident. During a review of Resident 51's weight measurements, the records indicated Resident 51's most recent documented weight was 112.2 pounds (lbs., unit of measuring weight) on 1/1/2024. During an observation, on 1/22/2024 at 1:42 PM, at Resident 51's bedside, Resident 51 was observed lying on a [NAME] Medical brand Elite LALM. The weight settings on the pump that inflated the LALM indicated the LALM was set for a resident that weighed 210 lbs. During an observation, on 1/23/2024 at 4:25 PM, at Resident 51's bedside, Resident 51 was observed lying on a [NAME] Medical brand Elite LALM. The weight settings on the pump that inflated the LALM indicated the LALM was set for a resident that weighed 210 lbs. During an interview on 1/24/2024 at 8:17 AM, with TN 1, TN 1 stated LALMs were used to prevent a worsening condition of existing PUs, and to prevent the development of PUs in residents who were high risk. TN 1 stated the weight settings were supposed to reflect the resident's current weight. TN 1 stated that incorrect weight settings will prevent the healing of, and potentially cause a worsening in condition of, existing PUs. TN 1 stated incorrect settings could also cause the development of new PUs. TN 1 stated she checked the LALM settings daily for all residents on a LALM, and stated she checked all residents on 1/23/2024, and stated all settings were accurate. During a concurrent observation and interview, on 1/24/2024 at 8:29 a.m., at Resident 51's bedside, TN 1 observed Resident 51's LALM settings. Resident 51 was observed lying on a [NAME] Medical brand Elite LALM, and the weight settings indicated the LALM was set for a resident that weighed 210 lbs. TN 1 stated, That's too high. TN 1 then stated she had not checked Resident 51's LALM settings on 1/23/2024 and stated Resident 51 had a history of PUs and the incorrect settings on the LALM increased her risk at re-developing PUs. 3. During a review of Resident 11's admission Record, the record indicated the facility originally admitted Resident 11 on 10/24/2020 and re-admitted Resident 11 on 7/14/2023. Resident 11's admitting diagnoses included Stage IV PU to the right hip. During a review of Resident 11's MDS, dated [DATE], the MDS indicated Resident 11 had impairment to the upper extremities on one side of her body, and impairment to the lower extremities on both side of her body, which interfered with daily function and placed her at risk of injury. The MDS further indicated Resident 11 had an existing Stage IV PU, was at risk for developing PUs, and used a pressure reducing device in her bed. During a review of Resident 11's medical record titled Skin and Wound Evaluation, dated 1/18/2024, the record indicated Resident 11 had a Stage IV PU with slow wound healing. During a review of Resident 11's medical record titled [Interdisciplinary Team] Wound Management Update, dated 1/18/2024, the record indicated recommendations for continued PU care included a LALM 056415 Page 13 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0656 for wound management. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 11's care plans, the care plans indicated Resident 11 was at risk for developing PUs and goals of care included minimizing the risk for Resident 11 experiencing further skin breakdown. Interventions included LALM setting according to .weight of resident. Residents Affected - Some During a review of Resident 11's weight measurements, the records indicated Resident 11's most recent documented weight was 155.8 lbs. on 1/1/2024. During an interview on 1/24/2024 at 8:17 AM, with TN 1, TN 1 stated her normal practice was to document the resident's current weight by hand onto the pump for reference to ensure the settings were always accurate. TN 1 stated she reviewed the residents' weights on a weekly basis and updated the settings as needed. TN 1 stated she checked the LALM settings daily for all residents on a LALM, and stated she checked all residents on 1/23/2024, and stated all settings were accurate. During a concurrent observation, interview, and record review, on 1/24/2024 at 8:26 AM, at Resident 11's bedside, TN 1 observed Resident 11's LALM settings and reviewed Resident 11's most recent weight measurements. Resident 11 was observed lying on a [NAME] Medical brand Elite LALM. The weight settings on the pump indicated the LALM was set for a resident that weighed 140 lbs., which matched the handwritten weight of 140 that TN 1 documented on the pump itself. TN 1 reviewed Resident 11's most recent weight of 155.8 lbs. and stated it did not match the weight she was using for the LALM settings. TN 1 stated Resident 11 had not weighed 140 lbs. since 10/2023. TN 1 stated incorrect settings could cause a delay in Resident 11's wound healing. 4. During a review of Resident 45's admission Record, the record indicated the facility originally admitted Resident 45 on 6/4/2020 and readmitted Resident 45 on 1/7/2022. Resident 45's admitting diagnoses included hemiplegia and hemiparesis following a stroke and aphasia (language disorder that affects a person's ability to communicate) following a stroke. During a review of Resident 45's MDS, dated [DATE], the MDS indicated Resident 45 had moderately impaired vision, and severely impaired cognition. During a review of Resident 45's care plans, the care plans indicated Resident 45 had impaired visual function, and goals of care included Resident 45 maintaining optimal quality of life. Staff's interventions indicated staff were to arrange consultation with eye care practitioner as required and ensure appropriate visual are available to support the resident's participation in activities. During a review of Resident 45's medical record titled, Optometric Consultation, dated 4/5/2023, the record indicated Resident 45 was seen by an optometrist and the optometrist recommended glasses. During a concurrent observation and interview, on 1/24/2024 at 10:51 AM, with Certified Nursing Assistant (CNA) 2, at Resident 45's bedside, CNA 2 checked Resident 45's bedside belongings for any corrective lenses or glasses. CNA 2 stated Resident 45 did not have any glasses. During a concurrent interview and record review, on 1/24/2024, with Licensed Vocational Nurse (LVN) 2, LVN 2 reviewed Resident 45's undated medical record titled Resident's Clothing and Possessions. LVN 2 stated the document indicated Resident 45 did not have glasses in her possession. LVN 2 stated that if a resident received glasses after initial completion of the record titled Resident's Clothing and Possessions, the document would be updated to reflect any new items in the resident's 056415 Page 14 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0656 possession. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review, on 1/24/2024 at 11:37 AM, with the Director of Social Services (DSS), the DSS reviewed the facility document titled Summary Sheet 2023 and stated Resident 45 was seen by an optometrist on 4/5/2023. The DSS stated the document indicated the optometrist recommended glasses for Resident 45. The DSS stated it would typically take a month for glasses to be delivered to the facility, and stated that upon delivery, the glasses would be documented on the resident's inventory list. Residents Affected - Some During an interview on 1/24/2024 at 2:15 PM, with the optometrist's office, the optometrist's office stated an invoice (a list of goods sent, or services provided, with a statement of the sum due for these) was sent to the facility, which the facility was supposed to provide to Resident 45 or her responsible party. The optometrist's office stated the invoice indicated the remaining payment due for the glasses to be made and delivered to Resident 45. The optometrist's office stated the invoice was sent to the DSS directly via email. During an interview on 1/24/2024 at 2:36 PM, with Resident 45's family member (FM) 2, FM 2 stated the facility did not send her an invoice for glasses. During an interview on 1/24/2024 at 2:40 PM, with Resident 45's FM 1, and responsible party, FM 1 stated the facility did not send him an invoice for glasses. FM 1 stated he communicated multiple times with facility staff to inform them that Resident 45 needed glasses. FM 1 stated that if an invoice had been sent, he would have paid, stating that he really wanted Resident 45 to be able to see. During a concurrent interview and record review, on 1/24/2024 at 3:14 PM, with the DSS, the DSS reviewed her emails and located the invoice from the optometrist's office. The DSS stated she received the invoice on 4/25/2023 and stated she did not send it to FM 1 or FM 2. The DSS stated this failure to send the email to Resident 45's responsible parties for completion of payment led to a delay in Resident 45 receiving the glasses she needed. During an interview on 1/24/2024 at 3:26 PM, with the Activity Director (AD), the AD stated it was important for residents to participate in activities that they enjoy to increase their quality of life and comfort in the facility. The AD stated Resident 45 enjoyed watching television, and stated Resident 45 would not be able to watch TV and participate in her preferred activity if she was unable to see. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated the comprehensive, person-centered care plan reflects currently recognized standards of practice for problem areas and conditions, and further indicated that services provided for or arranged .and outlined in the comprehensive care plan are provided by qualified persons. 056415 Page 15 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an observation, interview, and record review, the facility failed to ensure staff provided the necessary care and services for three of 18 sampled residents (Resident 36, 47, and 84) when: Residents Affected - Few 1. Certified Nurse Assistant (CNA) 3 did not change Resident 36's diaper in a timely manner. 2. Resident 47 was not repositioned every 2 hours or as needed per the physician's order. 3. Resident 84 was not repositioned every 2 hours or as needed per the physician's order. These deficient practices had the potential to cause a negative impact on Resident's 36, 47, and 84's health and psychosocial well-being by not meeting resident's needs. Findings: 1. During a review of Resident 36's admission Record, the admission record indicated Resident 36 was admitted to the facility on [DATE] with diagnoses including Parkinson's (a progressive disorder that affects the parts of the body controlled by the nerves) and generalized muscle weakness (lack of muscle strength). During a review of Resident 36's History and Physical (H&P), dated 12/28/2023, the H&P indicated Resident 36 had the capacity to understand and make decisions. The H&P indicated Resident 36 had a history of dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). During a review of Resident 36's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/21/2023, the MDS indicated Resident 36's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact. The MDS indicated Resident 36 required partial/moderate assistance with oral hygiene and personal hygiene. The MDS indicated Resident 36 was dependent on staff for toileting hygiene. During an observation on 1/23/2024 at 8:12 a.m., in Resident 36's room, CNA 3 told Resident 36 she needed to wait to get her diaper changed because CNA 3 was collecting food trays and then had to go get her (CNA 3) linen cart. During an interview on 1/23/2024 at 8:19 a.m. with CNA 3, in Resident 36's room, CNA 3 stated Resident 36 had to wait to get a diaper change because CNA 3 was busy collecting food trays. CNA 3 stated she did not know how long Resident 34 had to wait to get her diaper changed. During an interview on 1/23/2024 at 8:22 a.m. with Resident 36, in Resident 36's room, Resident 36 stated she had been waiting to get her diaper changed since the night shift (11 p.m. to 7 a.m.). Resident 36 stated she kept asking to have her diaper changed but staff kept telling the resident to wait. Resident 36 stated she did not know why the CNAs did not change her diaper. Resident 36 stated she asked the CNAs to change her and to put her on her wheelchair because she did not want to be in bed. Resident 36 stated she felt sad the CNAs had her wait to get her diaper changed. 2. During a review of Resident 47's admission Record, the admission record indicated Resident 47 056415 Page 16 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including left-sided hemiplegia (a condition caused by a brain injury, that results in a varying degrees of weakness, stiffness, and lack of control in one side of the body) and pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) of the sacral region (tailbone). During a review of Resident 47's H&P dated 3/25/2023, the H&P indicated Resident 47 had the capacity to understand and make decisions. The H&P indicated Resident 47 had a diagnosis of cortical blindness (abnormal visual responses not caused by the eyes themselves). During a review of Resident 47's MDS, dated [DATE], the MDS indicated Resident 47's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 47 was dependent on staff for oral and toileting hygiene, and required maximal assistance for eating and personal hygiene, and with rolling from lying on the back to the left and right side and return to lying on back on the bed. During a review of Resident 47's order summary dated 10/18/2023, the order summary indicated there was an order for Resident 47 to be repositioned and offloaded as needed every shift. The order summary indicated to monitor and report to the physician any skin changes. During a review of Resident 47's Interdisciplinary Team (IDT, group of different disciplines working together towards a common goal of a resident) Wound Management note, dated 12/26/2023, the IDT note indicated Resident 47's plan for pressure management was with the specialized turning program and off-loading. During an observation on 1/22/2024 at 9:16 a.m. in Resident 47's room, Resident 47 was observed lying on his back, with the right side of the body leaning against the wall. During an observation on 1/22/2024 at 12:35 p.m. in Resident 47's room, Resident 47 was observed lying on his back, with the right side of the body leaning against the wall. During an observation on 1/23/2024 at 8:56 a.m. in Resident 47's room, Resident 47 was observed lying on his back, with the right side of the body leaning against the wall. During an observation on 1/23/2024 at 9:50 a.m. in Resident 47's room, Resident 47 was observed lying on his back, with the right side of the body leaning against the wall. During an observation on 1/23/2024 at 2:08 p.m. in Resident 47's room, Resident 47 was observed lying on his back, with the right side of the body leaning against the wall. During an observation on 1/23/2024 at 3:49 p.m. in Resident 47's room, Resident 47 was observed lying on his back, with the right side of the body leaning against the wall. During an observation on 1/24/2024 at 7:58 a.m. in Resident 47's room, CNA 6 was observed standing over Resident 47 and feeding him. Resident 47 was on his bed, head of the bed up and with his body leaning to the right against the wall. During an interview on 1/24/2024 at 8:00 a.m. with CNA 6, in Resident 47's room, CNA 6 stated she did not sit to feed Resident 47 because it was easier for her to feed him in this position. CNA 6 056415 Page 17 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0684 Level of Harm - Minimal harm or potential for actual harm stated she knew she was supposed to sit while feeding the residents but could not find a chair. CNA 6 stated she was supposed to sit during mealtimes for the comfort of the resident and her comfort. CNA 6 stated she did receive an in-service about feeding residents and she was told that she could sit or stand while feeding. CNA 6 stated she did not reposition Resident 47 in bed because the resident had arthritis and it would hurt to reposition the resident. Residents Affected - Few During an observation on 1/24/2024 at 8:22 a.m. in Resident 47's room, Resident 47 was lying on his back, right side of body leaning against the wall. During an observation on 1/24/2024 at 10:40 a.m. in Resident 47's room, Resident 47 was observed lying on his back, with the right side of his body leaning against the wall. Resident 47 did not have a pillow under his head. Resident 47's call light was under a pillow. Resident 47 was screaming out for a nurse. Resident 47 did not stop scratching his right side of his stomach and back. Observed Resident 47 attempt to straighten himself out in bed. During an interview on 1/24/2024 at 10:44 a.m. with Resident 47, in Resident 47's room, Resident 47 stated the right side of his body was hurting and itching. Resident 47 stated he was screamed for a nurse but no one helped him. Resident 47 stated he did not use the call light because he was blind and did not know where the call light was. Resident 47 stated the right side of his body hurt and felt sweaty. During an observation on 1/24//2024 at 10:48 a.m. in Resident 47's room, observed CNA 7 changing Resident 47's gown and drying off the sweat from the resident's body. CNA 7 attempted to straighten out Resident 47's body in the bed. During an interview on 1/24/2024 at 11:00 a.m. with CNA 7, in Resident 47's room, CNA 7 stated Resident 47 stayed in bed all day. CNA 7 stated Resident 47 got repositioned in bed but that Resident 47 liked to lay on his right side. CNA 7 stated she did not know why Resident 47 liked to lay on his right side and liked to lean against the wall. CNA 7 stated she repositioned Resident 47 that morning (1/24/2024). CNA 7 stated resident 47 did not have a pillow behind his back to keep him in position because CNA 7 did not have a pillow. CNA 7 stated she repositioned Resident 47 on his left side facing the door. CNA 7 stated if she did not put a pillow behind the resident, to keep the resident in that position, it was not considered positioning the resident because he needed a pillow behind his back and between his legs. CNA 7 stated Resident 47 did not have skin issues and repositioning him often would prevent skin breakdown. CNA 7 stated Resident 47's call light was not assessable because it was under the pillow and if he needed help, he would not be able to call for help. During an observation on 1/24/2024 at 3:09 p.m. in Resident 47's room, Resident 47 was observed lying on his back, with the right side of the body leaning against the wall. 3. During a review of Resident 84's admission Record, the admission record indicated Resident 84 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including psychosis (severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality) and obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow and can be either structural or functional). During a review of Resident 84's H&P dated 12/23/2023, the H&P indicated Resident 84 had fluctuating capacity to understand and make decisions. 056415 Page 18 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 84's MDS, dated [DATE], the MDS indicated Resident 84's cognitive skills for daily decision was moderately impaired. The MDS indicated Resident 84 required moderate assistance with personal hygiene and oral hygiene. During a review of Resident 84's IDT Wound Management Note, dated 12/26/2023, the IDT note indicated Resident 84 was bedfast (confined to bed). The IDT note indicated Resident 84's ability to change and control body position was very limited. The IDT note indicated friction and shear was a problem for Resident 84 and the resident was at high risk for developing pressure sores. During an observation on 1/22/2024 at 10:16 a.m., in Resident 84's room, Resident 84 was observed lying on his back. During an observation on 1/22/2024 at 12:13 p.m. with Resident 84, in Resident 84's room, Resident 84 was observed lying on his back. During an observation on 1/23/2024 at 8:43 a.m., in Resident 84's room, Resident 84 was observed lying on his back with no pillows off-loading the body. During an observation on 1/23/2024 at 9:35 a.m., in Resident 84's room, Resident 84 was observed lying on his back with no pillows off-loading the body. During an observation on 1/23/2024 at 1:44 p.m., in Resident 84's room, the Resident 84 was observed lying on his back with no pillows off-loading the body. During an observation on 1/23/2024 at 3:32 p.m., in Resident 84's room, Resident 84 was observed lying on his back with no pillows off-loading the body. During an observation on 1/24/2024 at 8:15 a.m., in Resident 84's room, Resident 84 was observed lying on his back with no pillows off-loading the body. During an observation on 1/24/2024 at 11:18 a.m., in Resident 84's room, Resident 84 was observed lying on his back with no pillows off-loading the body. During an observation on 1/24/2024 at 3:17 p.m., in Resident 84's room, Resident 84 was observed lying on his back with no pillows off-loading the body. During an interview on 1/25/2023 at 1:22 p.m. with Registered Nurse (RN) 1, in Resident 84's room, RN 1 stated all bedridden residents must be repositioned every 2 hours. RN 1 stated Resident 47 and Resident 84 must be repositioned in bed every 2 hours to prevent skin breakdown. RN 1 stated repositioning bedridden residents prevent pressure areas. During an interview on 1/26/2024 at 3:10 p.m. with Treatment Nurse (TN) 1, in the hallway, TN 1 stated Resident 47 and Resident 84 must be repositioned every 2 hours or as needed because they were both bedridden. TN 1 stated it was important to reposition residents to prevent pressure ulcers or sores. TN 1 stated Resident 47 received skin treatments and the repositioning the residents would prevent the residents from getting worse. TN 1 stated she had not noticed that residents were not repositioned throughout the day. During an interview on 1/26/2024 at 3:25 a.m. with the Director of Nursing (DON), in the hallway, 056415 Page 19 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the DON stated residents that do not have proper mobility, needed help with off-loading. The DON stated residents that were bedridden needed to be repositioned in bed every 2 hours or as needed. The DON stated if residents do not get repositioned, it increased the likelihood of a pressure injury. During a review of the facility's policy and procedure (P&P) titled, Repositioning, dated 5/2013, the P&P indicated repositioning was a common, effective, intervention for preventing skin breakdown, promotes circulation, and provides pressure relief. The P&P indicated repositioning was a critical for a resident who is immobile or dependent upon staff for repositioning. During a review of the facility's P&P titled, Activities of Daily Living (ADL), Supporting, dated 3/2018, the P&P indicated care and services would be provided for residents who are unable to carry out ADLs independently. The P&P indicated residents will receive assistance with mobility, elimination (toileting) and with dining. 056415 Page 20 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 45) received glasses as recommended and prescribed by the optometrist (healthcare provider who specializes in caring for the eyes). Residents Affected - Few This failure created the potential for Resident 45 to suffer from avoidable physical harm related to injury from inability to see, and psychosocial harm related to inability to watch television, which was her preferred activity in the facility. Cross Reference: F-tag 656 Findings: During a review of Resident 45's admission Record, the admission record indicated the facility originally admitted Resident 45 on 6/4/2020 and readmitted Resident 45 on 1/7/2022. Resident 45's admitting diagnoses included hemiplegia (paralysis [inability to move] one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following a stroke (damage to the brain from interruption of its blood supply), and aphasia (language disorder that affects a person's ability to communicate) following a stroke. During a review of Resident 45's Minimum Data Set (MDS, comprehensive resident assessment and care screening tool), dated 11/22/2023, the MDS indicated Resident 45 had moderately impaired vision, and severely impaired cognition (ability to think and reason). During a review of Resident 45's care plans, the care plans indicated Resident 45 had impaired visual function. The goals of care included Resident 45 maintaining optimal quality of life. Staff's interventions indicated staff were to arrange consultation with eye care practitioner as required and ensure appropriate visual are available to support the resident's participation in activities. During a review of Resident 45's active physician orders, dated 1/7/2022, the orders indicated optometrist consult per family request. During a review of Resident 45's medical record titled, Optometric Consultation, dated 4/5/2023, the record indicated Resident 45 was seen by an optometrist and the optometrist recommended glasses. During a concurrent observation and interview, on 1/24/2024 at 10:51 AM, with Certified Nursing Assistant (CNA) 2, at Resident 45's bedside, CNA 2 checked Resident 45's bedside belongings for any corrective lenses or glasses. CNA 2 stated Resident 45 did not have any glasses. During a concurrent interview and record review, on 1/24/2024, with Licensed Vocational Nurse (LVN) 2, Resident 45's undated medical record titled, Resident's Clothing and Possessions was reviewed. LVN 2 stated the document indicated Resident 45 did not have glasses in her possession. LVN 2 stated that if a resident received glasses after initial completion of the record titled Resident's Clothing and Possessions, the document would be updated to reflect any new items in the resident's possession. During a concurrent interview and record review, on 1/24/2024 at 11:37 AM, with the Director of Social Services (DSS), the facility document titled, Summary Sheet 2023 was reviewed. The DSS stated 056415 Page 21 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0685 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 45 was seen by an optometrist on 4/5/2023. The DSS stated the document indicated the optometrist recommended glasses for Resident 45. The DSS stated it would typically take a month for glasses to be delivered to the facility, and stated that upon delivery, the glasses would be documented on the resident's inventory list. During an interview on 1/24/2024 at 2:15 PM, with the optometrist's office, the optometrist's office stated an invoice (a list of goods sent, or services provided, with a statement of the sum due for these) was sent to the DSS on 4/25/2023. The office stated the invoice indicated the remaining payment due for the glasses, and stated that once payment was received, the glasses would be delivered to Resident 45. The optometrist's office stated the facility was supposed to provide the invoice to Resident 45 or her family member/responsible party. During an interview on 1/24/2024 at 2:36 PM, with Resident 45's family member (FM) 2, FM 2 stated the facility did not send her an invoice for the glasses. During an interview on 1/24/2024 at 2:40 PM, with Resident 45's responsible party FM 1, FM 1 stated the facility did not send him an invoice for glasses. FM 1 stated he communicated multiple times with the facility staff to inform them Resident 45 needed glasses. FM 1 stated that if the facility had sent the invoice, he would have paid right away, stating he really wanted Resident 45 to be able to see. During a concurrent interview and record review, on 1/24/2024 at 3:14 PM, with the DSS, the DSS reviewed her emails and located the invoice from the optometrist's office. The DSS stated she received the invoice on 4/25/2023 and stated she did not send it to FM 1 or FM 2. The DSS stated this failure to send the invoice to Resident 45's responsible parties for completion of payment led to a delay in Resident 45 receiving the glasses she needed. During a review of Resident 45's medical record titled, Activity Participation Review, dated 12/13/2023, the record indicated [Resident 45] likes to watch TV. The record further indicated it was very important to Resident 45 to do her favorite activities. During an interview on 1/24/2024 at 3:26 PM, with the Activity Director (AD), the AD stated it was important for residents to participate in activities that they enjoy, increasing their quality of life and comfort in the facility. The AD stated Resident 45 enjoyed watching television, and stated Resident 45 would not be able to watch TV and participate in her preferred activity if she was unable to see. During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, dated 7/2017, the P&P indicated Resident safety and .assistance to prevent accidents are facility-wide priorities. The P&P further indicated The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. During a review of the facility's P&P titled, Social Services, dated 9/2021, the P&P indicated the DSS was responsible for ensuring medically related social services are provided to maintain or improve each resident's ability to control everyday physical needs (e.g., appropriate adaptive equipment . The P&P further indicated that social services staff were responsible for making referrals and obtaining needed services from outside entities. 056415 Page 22 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0685 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated the comprehensive, person-centered care plan reflects currently recognized standards of practice for problem areas and conditions, and further indicated that services provided for or arranged .and outlined in the comprehensive care plan are provided by qualified persons. During a review of the facility's P&P titled, Resident Self Determination and Participation, dated 8/2022, the P&P indicated Residents are provided assistance as needed to engage in their preferred activities on a routine basis. 056415 Page 23 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that precautions were maintained to prevent the development or worsening of pressure ulcers (PU, an injury that breaks down the skin and underlying tissue, caused when an area of skin is placed under prolonged pressure) for two of two sampled residents (Resident 51 and Resident 11) when the following occurred: Residents Affected - Few 1. Resident 51's weight was not accurately set on her low air loss mattress (LALM, a mattress designed to distribute body weight over a broad surface area to help prevent skin breakdown). 2. The Treatment Nurse (TN 1) was unaware of Resident 11's weight measurement to monitor accuracy of the LALM settings. The above failures had the potential to cause the avoidable development of skin breakdown for Resident 51 and the complications associated with impaired skin integrity. The above failures also increased the potential for Resident 11 to suffer an avoidable worsening in condition of her existing Stage IV PU (full-thickness skin and tissue loss extending to the muscle, tendon, ligament, cartilage, or bone). Findings: 1. During a review of Resident 51's admission Record, the record indicated the facility originally admitted Resident 51 on 12/22/2020 and re-admitted Resident 51 on 6/6/2023. Resident 51's admitting diagnoses included hemiplegia and hemiparesis (weakness and/or inability to move one side of the body) following a stroke (when the blood supply to part of the brain is blocked or reduced), muscle wasting and atrophy (a decrease in size of an organ or tissue), and unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 51's Minimum Data Set (MDS, a standardized assessment and care screening/planning tool), dated 11/24/2023, the MDS indicated Resident 51 experienced cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 51 had impairment to the upper and lower extremities on one side of her body, which interfered with daily function and placed the resident at risk of injury. The MDS indicated Resident 51 was fully dependent on staff to move from side to side in bed, and to transition from a sitting position to lying position, and a lying position to a sitting position. The MDS further indicated Resident 51 was at risk for developing PUs, and used a pressure reducing device in her bed, and was being turned and repositioned while in bed by staff. During a review of Resident 51's medical record titled, Braden Scale for Predicting Pressure Sore Risk, dated 12/7/2023, the record indicated Resident 51 was at high risk for skin breakdown. During a review of Resident 51's care plans, the care plans indicated Resident 51 was at risk for developing PUs and experiencing skin breakdown. The goals of care included Resident 51 having intact skin free of breakdown. Staff's interventions indicated LALM to prevent wounds and LALM setting according to .weight of resident. During a review of Resident 51's weight measurements, the records indicated Resident 51's most recent documented weight was 112.2 pounds (lbs., a unit of measuring weight) on 1/1/2024. 056415 Page 24 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation, on 1/22/2024 at 1:42 PM, at Resident 51's bedside, Resident 51 was observed lying on a [NAME] Medical brand Elite LALM. The weight settings on the pump that inflated the LALM indicated the LALM was set for a resident that weighed 210 lbs. During an observation, on 1/23/2024 at 4:25 PM, at Resident 51's bedside, Resident 51 was observed lying on a [NAME] Medical brand Elite LALM. The weight settings on the pump that inflated the LALM indicated the LALM was set for a resident that weighed 210 lbs. During an interview on 1/24/2024 at 8:17 AM, with Treatment Nurse (TN) 1, TN 1 stated LALMs were used to prevent a worsening condition of existing PUs, and to prevent the development of PUs in residents who were high risk. TN 1 stated the weight settings were supposed to reflect the resident's current weight. TN 1 stated that incorrect weight settings will prevent the healing of, and potentially cause a worsening in condition of, existing PUs. TN 1 stated incorrect settings could also cause the development of new PUs. TN 1 stated she checked the LALM settings daily for all residents on a LALM, and stated she checked all residents on 1/23/2024, and stated all settings were accurate. During a concurrent observation and interview, on 1/24/2024 at 8:29 a.m., at Resident 51's bedside, TN 1 observed Resident 51's LALM settings. Resident 51 was observed lying on a [NAME] Medical brand Elite LALM, and the weight settings indicated the LALM was set for a resident that weighed 210 lbs. TN 1 stated, That's too high. TN 1 then stated she had not checked Resident 51's LALM settings on 1/23/2024 and stated Resident 51 had a history of PUs and the incorrect settings on the LALM increased her risk at re-developing PUs. 2. During a review of Resident 11's admission Record, the record indicated the facility originally admitted Resident 11 on 10/24/2020 and re-admitted Resident 11 on 7/14/2023. Resident 11's admitting diagnoses included Stage IV PU to the right hip. During a review of Resident 11's MDS, dated [DATE], the MDS indicated Resident 11 had impairment to the upper extremities on one side of her body, and impairment to the lower extremities on both side of her body, which interfered with daily function and placed her at risk of injury. The MDS further indicated Resident 11 had an existing Stage IV PU, was at risk for developing PUs, and used a pressure reducing device in her bed. During a review of Resident 11's medical record titled Skin and Wound Evaluation, dated 1/18/2024, the record indicated Resident 11 had a Stage IV PU with slow wound healing. During a review of Resident 11's medical record titled [Interdisciplinary Team] Wound Management Update, dated 1/18/2024, the record indicated recommendations for continued PU care included a LALM for wound management. During a review of Resident 11's care plans, the care plans indicated Resident 11 was at risk for developing Pus. The goals of care included to minimize the risk for Resident 11 experiencing further skin breakdown. Staff's interventions indicated LALM setting according to .weight of resident. During a review of Resident 11's weight measurements, the records indicated Resident 11's most recent documented weight was 155.8 lbs. on 1/1/2024. During an interview on 1/24/2024 at 8:17 AM, with TN 1, TN 1 stated her normal practice was to document the resident's current weight by hand onto the pump for reference to ensure the settings were 056415 Page 25 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few always accurate. TN 1 stated she reviewed the residents' weights on a weekly basis and updated the settings as needed. TN 1 stated she checked the LALM settings daily for all residents on a LALM, and stated she checked all residents on 1/23/2024, and stated all settings were accurate. During a concurrent observation, interview, and record review, on 1/24/2024 at 8:26 AM, at Resident 11's bedside, Resident 11's weight measurements were reviewed. TN 1 observed Resident 11's LALM settings. Resident 11 was observed lying on a [NAME] Medical brand Elite LALM. The weight settings on the pump indicated the LALM was set for a resident that weighed 140 lbs., which matched the handwritten weight of 140 that TN 1 documented on the pump itself. TN 1 stated Resident 11's weight of 155.8 lbs. did not match the weight she was using for the LALM settings. TN 1 stated Resident 11 had not weighed 140 lbs. since 10/2023. TN 1 stated incorrect settings could cause a delay in Resident 11's wound healing. During an interview on 1/25/2024 at 9:23 AM, with the MDS Nurse (MDSN), the MDSN stated the resident's care plans identified the resident's current problems and identified the goals of the care being provided. The MDSN stated there was the potential for the goals of care to be unmet if staff were not implementing the interventions on the care plan. During a review of the facility's policy and procedure (P&P) titled, Pressure Ulcers/Skin Breakdown, dated 4/2018, the P&P did not address the use of and/or operating requirements and guidelines for LALMs in the facility. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated the comprehensive, person-centered care plan reflects currently recognized standards of practice for problem areas and conditions, and further indicated that services provided for or arranged .and outlined in the comprehensive care plan are provided by qualified persons. During a review of the facility's job description document titled, Treatment Nurse, undated, the document indicated the treatment nurse was required to provide primary skin care to residents in accordance with their care plan and ensuring that all nursing care is provided .following facility policies. 056415 Page 26 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents with a urinary catheter device (a flexible tube placed in the bladder used to collect urine by attaching to a drainage bag) received proper assessment and the urinary catheter and tubing were off the floor for two sampled residents (Resident 64 and Resident 84). These deficient practices had the potential for Resident 84 to have an undiagnosed urinary tract infection (UTI, bladder infection) and placed Resident 64's and Resident 84's urinary catheter drainage system at risk for possible exposure to infectious agents. Findings: 1. During a review of Resident 64's admission Record, the admission record indicated Resident 64 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities) and psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality). During a review of Resident 64's History and Physical (H&P) dated 12/27/2023, the H&P indicated Resident 64 did not have the capacity to understand and make decisions. The H&P indicated Resident 64 had a supra pubic catheter (a medical device that enters the body through a small incision in the abdomen to drain urine). During a review of Resident 64's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/19/2023, the MDS indicated Resident 64's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision was impaired. The MDS indicated Resident 64 required substantial assistance with activities of daily living (ADLs, self-care activities performed daily such as dressing, personal hygiene, and grooming). The MDS indicated Resident 64 had a history of obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow and can be either structural or functional). During an observation on 1/23/2024 at 11:45 a.m. in Resident 64's room, observed Resident 47's urinary catheter tubing and draining bag touching the floor. During an observation on 1/23/2024 at 1:55 p.m. in Resident 64's room, observed Resident 47's urinary catheter tubing and draining bag touching the floor. 2. During a review of Resident 84's admission Record, the admission record indicated Resident 84 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including psychosis and obstructive uropathy. During a review of Resident 84's H&P dated 12/23/2023, the H&P indicated Resident 84 had fluctuating capacity to understand and make decisions. The H&P indicated Resident 84 had a diagnosis of hypertension (high blood pressure). During a review of Resident 84's MDS, dated [DATE], the MDS indicated Resident 84's cognitive 056415 Page 27 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few skills for daily decision was moderately impaired. The MDS indicated Resident 84 required moderate assistance with personal hygiene and oral hygiene. During a review of Resident 84's care plan addressing the resident's use of an indwelling catheter, dated 1/22/2024, the care plan indicated the staff's interventions were to check the tubing, monitor/record/report to the physician for signs and symptoms of a UTI such as pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, and increased temperature. During an observation on 1/24/2024 at 1:24 p.m. in Resident 84's room, observed Resident 84's urinary catheter drainage bag and tubing on the floor. During an observation on 1/26/2024 at 9:11 am. in Resident 84's room, observed Resident 84's urinary catheter drainage bag not covered. During an observation on 1/26/2024 at 12:30 p.m. in Resident 84's room, observed Resident 84's urinary catheter drainage bag not covered. The urinary catheter tubing was observed with sediments and red tinged urine. During an interview on 1/26/2024 at 12:57 p.m. with Certified Nursing Assistant (CAN) 5, in Resident 84's room, CNA 5 stated Resident 84's urinary catheter drainage bag was not covered because Resident 84 moved a lot and pulled on his catheter tubing. CNA 5 stated the urinary catheter drainage bag was supposed to be covered to provide privacy to residents. CNA 5 stated he did not notice the sediments and red tinged urine in the catheter tubbing. CNA 5 stated he emptied out the bag earlier and had not noticed it. CNA 5 stated sediments in the urine and red tinged urine meant that it had contamination. CNA 5 stated he drained the urinary bag without notifying a licensed nurse because he did not know he had to notify them. CNA 5 stated he did not know this was a change in condition for Resident 84. During an interview on 1/26/2024 at 1:14 p.m. with Registered Nurse (RN) 1, in Resident 84's room, RN 1 stated sediments in the urine and red tinged urine was a change in condition for a resident and must be reported to a licensed nurse right away. RN 1 stated a urinary catheter drainage bag must be covered to provide privacy to the resident. RN 1 stated Resident 84 had a history of UTI and CNAs must closely monitor the appearance of the resident's urine. RN 1 stated the urinary catheter tubing and drainage bag must not touch the floor for infection prevention. During an interview on 1/25/2024 at 4:04 p.m. with the Director of Staff Development (DSD), the DSD stated the urinary catheter drainage bag and tubing should not touch the floor. The DSD stated the catheter drainage bag must be covered to provide privacy. The DSD stated the practice was to place the catheter drainage bag in a basin to prevent it from touching the floor. The DSD stated the catheter bag and tubing must not touch the floor for infection control, to prevent the spread of germs. During an interview on 1/26/2024 at 3:25 p.m. with the Director of Nursing (DON), the DON stated when a CNA observed a resident with a change of condition, they must fill out a stop and watch form (a form to report resident change of condition) and inform the charge nurse. The DON stated it was important to inform the charge nurse and physician to address the issue quickly. The DON stated his expectation was CNAs were to report any changes in urine, place privacy bags over the urinary catheter drainage bags, and drainage bags and tubing should not touch the floor. The DON stated the catheter drainage bag and tubing must not touch the floor because there were germs on the floor and which could contaminate the urinary drainage bag. 056415 Page 28 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0690 During a review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, dated 8/2022, the P&P indicated the catheter tubing and drainage bag are kept off the floor for infection control. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 056415 Page 29 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to connect the nasal cannula (device used to deliver supplemental oxygen or increased airflow through the nose) to the oxygen concentrator (a device that provides supplemental oxygen) when oxygen therapy was provided to one of three sample residents (Resident 60). Residents Affected - Few This failure had the potential for Resident 60's oxygen saturation (amount of oxygen circulating in the blood, normal value 95 percent [%] to 100%) to decrease which could lead to shortness of breath and respiratory distress. Findings: During a review of Resident 60's admission Record (Face Sheet), the admission Record indicated Resident 60 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses included but not limited to chronic obstructive pulmonary disease (COPD, a lung disease characterized by long-term poor airflow), type 2 diabetes mellitus condition that results in too much sugar circulating in the blood), and schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). During a review of Resident 60's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 12/22/2023, the MDS indicated Resident 60 was able to make herself understood and understood others. The MDS indicated Resident 60's cognition (process of thinking) was intact. The MDS indicated Resident 60 received oxygen therapy in the facility. During a review of Resident 60's Order Summary Report, dated 1/22/2024, the Order Summary Report indicated to administer continuous oxygen at 2 liters (unit of measurement) per minute (L/min) via nasal cannula, may titrate (change rate) up to 5L/min, every shift, for shortness of breath and COPD. During an observation on 1/23/2024 at 9:22 a.m., in Resident 60's room, Resident 60 was in the restroom and her nasal cannula was observed disconnected from the oxygen concentrator and the attachment piece was on the floor. During an observation on 1/23/2024 at 9:34 a.m., in Resident 60's room, Resident 60 returned to her bed and placed the nasal cannula to her nose. The nasal cannula remained disconnected from the oxygen concentrator. Licensed Vocational Nurse (LVN) 1 informed Resident 60 that she would prepare Resident 60's medications for administration. During an observation on 1/23/2024 at 9:38 a.m., in Resident 60's room, LVN 1 assisted Resident 60 with her nasal cannula, inserted the prongs into Resident 60's nostrils and looped the tubing over Resident 60's ears. LVN 1 administered medication to Resident 60 and began to walk away from Resident 60's bedside. During a concurrent observation and interview on 1/23/2024 at 9:40 a.m. with LVN 1, in Resident 60's room, LVN 1 was informed that Resident 60's nasal cannula was not connected to the oxygen concentrator. LVN 1 removed the nasal cannula from Resident 60 and requested for a new nasal cannula to be brought to Resident 60. LVN 1 stated she had assisted Resident 60 with her nasal cannula and did not realize that the nasal cannula was not connected to the oxygen concentrator. LVN 1 stated she was 056415 Page 30 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few responsible for assessing Resident 60's oxygen administration by ensuring the nasal cannula was connected to its oxygen source. LVN 1 stated if Resident 60 had continued without oxygen therapy, Resident 60 was at risk of desaturation (decrease in oxygen saturation). During an interview on 1/24/2024 at 11:39 a.m., with Registered Nurse (RN) 1, RN 1 stated when placing the oxygen tubing onto the resident, the nurse was responsible for checking the physician's order, placing the nasal cannula properly on the resident, and ensuring the tubing was connected to the oxygen concentrator. RN 1 stated it was an issue that Resident 60 had the nasal cannula in her nose without any oxygen because the nasal cannula had the potential to block Resident 60's airway, which could cause respiratory issues. RN 1 stated Resident 60 was dependent on supplemental oxygen and without it, Resident 60 was at risk for respiratory distress. During an interview on 1/25/2024 at 4:30 p.m., with the Director of Nursing (DON), the DON stated all nurses were responsible for assessing residents who were receiving oxygen therapy. The DON stated nurses were responsible for assessing the placement of the nasal cannula on the resident, the integrity of the tubing whether it needed to be changed, and the connection between the nasal cannula tubing and the oxygen concentrator. The DON stated residents, who received oxygen therapy, required oxygen to maintain their oxygenation at the appropriate level. The DON stated without proper oxygen therapy, the resident was at risk of not reaching their optimal oxygenation status, which could result in desaturation. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, revised 10/2010, the P&P indicated steps in oxygen administration that include to check the tubing connected to the oxygen cylinder. 056415 Page 31 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the licensed staff failed to ensure the accurate and complete documentation of the administration of Lomotil (a controlled medication used to treat loose and watery stools, contains small quantities of narcotics) in the Medication Administration Record (MAR) and the Controlled Drug Record (CDR) to account for all eight doses (16 tablets) for one of three sampled residents (Resident 10). This failure had the potential for Resident 10 to overdose, the doses of Lomotil to become missing or unaccounted for, drug diversion (the act of health care providers stealing prescription medicines or controlled substances such as opioids for their own use), and/or the potential for a medication error to occur. Findings: During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included but not limited to diabetes (poor blood sugar control) and lack of coordination. During a review of Resident 10's Minimum Data Set ([MDS]- a standardized resident assessment and care planning tool), dated 11/1/2023, the MDS indicated Resident 10's cognition (mental action or process of acquiring knowledge and understanding) was intact. During a review of Resident 10's Order Summary Report, dated 1/23/2024, the Order Summary Report indicated that Resident 10 was prescribed Lomotil Oral Tablet 2.5 to 0.025 milligrams ([MG]- a unit of measurement) to be given two tablets by mouth, every eight hours, as needed for diarrhea (loose and watery stools). During a concurrent interview and observation, on 1/23/2024, at 11:40 a.m., with Licensed Vocational Nurse (LVN) 2, Resident 10's bubble pack (a card used to store medications for the residents) for Lomotil was observed. LVN 2 confirmed that Resident 10's bubble pack housed 34 remaining doses of Lomotil and that eight (8) doses of Lomotil had been administered. During a concurrent interview and record review, on 1/23/2024, at 11:50 a.m., with Registered Nurse (RN) 1, Resident 10's Controlled Drug Record (CDR), dated 12/2023 to 1/2024, was reviewed. The CDR indicated there were 84 tablets of Lomotil dispensed to the facility (equivalent to 42 doses). The CDR indicated the licensed nurses signed for the administration of six doses of Lomotil, instead of eight doses on the following dates and times: Dose 42 administered on 1/15/24 at 9 p.m. Dose 41 was left blank. Dose 40 administered on 12/27/23 at 9:04 a.m. Dose 39 administered on 12/27/2023 at 7:00 p.m. 056415 Page 32 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0755 Dose 38 administered on 1/1/2024 at 12:51 a.m. Level of Harm - Minimal harm or potential for actual harm Dose 37 was administered 1/5/2024 at 5:57 p.m. Dose 36 was administered 1/11/2024 at 1:33 a.m. Residents Affected - Few Dose 35 indicated the originally documented administration was crossed off and the administration was documented in error. RN 1 confirmed the CDR indicated doses 41 and 35 were left unaccounted for, and that there should have been signatures that indicated that the licensed nurse administered the medication to account for all eight administered doses. During a concurrent interview and record review, on 1/23/2024, at 11:50 a.m., with RN 1, Resident 10's Medication Administration Record (MAR), dated 12/2023 to 1/2024, was reviewed. The MAR indicated Resident 10 received six (instead of eight) doses of Lomotil on the following dates and times: 1 dose on 12/27/2023 at 9:04 a.m. 1 dose on 1/1/2024 at 12:51 a.m. 1 dose on 1/5/2024 at 5:57 p.m. 1 dose on 1/11/2024 at 1:33 a.m. 1 dose on 1/11/2024 at 4:40 p.m. 1 dose on 1/20/2024 at 5:35 p.m. RN 1 confirmed there were two signatures missing on the MAR to account for all eight doses administered. RN 1 stated, It is important to document in the MAR. If we do not document, that means the medication was not given. It is a form of communication amongst the nurses, it is our way of ensuring that we are keeping all [narcotic] the doses accounted for, and so the nurses do not overdose [the resident]. RN 1 also stated that it was best practice for the licensed nurses to accurately account of every narcotic medication by assigning each tablet, (not each dose) a number on the CDR, so that each tablet can be accounted for when administering the narcotic medication. During an interview, on 1/23/2024, at 11:58 a.m., with LVN 2, LVN 2 stated he did not recall noticing the discrepancy when he performed the narcotic count earlier that morning because there was a lot of stuff going on. LVN 1 stated that it was important to ensure that count was accurate, and that documentation of the narcotics are accurate and complete to limit the possibility of drug diversion, keep every dose accounted for, to ensure the resident actually gets the medication and to limit medication errors. During an interview, on 1/23/2024, at 2:29 p.m., with LVN 3, LVN 3 confirmed that she worked on 1/20/2023, during the night shift (3 p.m. to 11 p.m.). LVN 3 stated she administered the ordered Lomotil dose to Resident 10, signed the MAR, but failed to document the administration on the CDR. LVN 3 stated, I was in between patients, that is why I forgot. LVN 3 stated, If there is no documentation for the administration of the medication in the CDR, then we (the licensed nurses) can double dose 056415 Page 33 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0755 Level of Harm - Minimal harm or potential for actual harm (administer two doses), [there is a] potential for narcotic diversion, and it is not [considered] accurate and complete documentation. During a concurrent interview and record review on 1/24/2024, at 1:48 p.m., with the Director of Nursing (DON), Resident 10's Lomotil bubble pack, the CDR and MAR was reviewed. Residents Affected - Few 1) Resident 10's Lomotil bubble pack had 34 out of 42 doses of Lomotil remaining. 2) The CDR indicated the licensed nurses signed off on six doses of Lomotil, instead of the eight administered doses. 3) The MAR indicated the licensed nurses signed off on six doses of Lomotil, instead of the eight administered doses. The DON stated that it was not acceptable to have missing documentation in both the MAR and CDR. The DON stated that LVN 4 and LVN 5 failed to document in the MAR for their administrations (of Lomotil), and LVN 3 failed to document in the CDR for her administration (of Lomotil). The DON stated that the expectation of the licensed nurses was to document the administration of the medications accurately and completely. The DON stated that it was also best practice for the licensed nurses to accurately account of every narcotic medication by assigning each tablet, (not each dose) a number on the CDR. The DON stated that if all narcotic medications and tablets are not accurately documented and accounted for in the CDR or the MAR, then there would be potential for an accidental overdose for a resident, a medication error and drug diversion to occur. During a review of the facility's Policy and Procedure (P&P), titled, Controlled Substances, dated 11/2022, the P&P indicated the facility was to comply with all federal laws, regulations and other requirements related to the documentation of controlled medications. The P&P also indicated the controlled substance inventory is monitored and reconciled to identify loss or potential diversion. During a review of facility's P&P, titled, Administering Medications, dated 11/2022, the P&P indicated the facility was to ensure that the individual administering the medications records the dosage, date, and time in the resident's medical record. During a review of the facility's P&P, titled, Documentation of Medication Administration, dated 11/2022, the P&P indicated the facility was to ensure that the medication administration record was used to document all medications administered. 056415 Page 34 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure their medication error rate was less than five (5) percent (5%) when three medication errors out of 38 total opportunities contributed to an overall medication error rate of 7.89%, affecting one of ten residents (Resident 85), based on the following: Residents Affected - Few 1. Resident 85's heart rate was not assessed prior to the administration of hydrochlorothiazide (a medication used to treat high blood pressure and fluid retention) 12.g milligrams (mg, a unit of measurement) and losartan potassium (a medication used to treat high blood pressure) 25 mg. 2. Resident 85 was not instructed to rinse their mouth after the administration of one puff of Fluticasone-Salmeterol (a medication used to treat breathing problems). These failures had the potential for Resident 85 to experience medical complications such as bradycardia (a slow heart rate) which could lead to dizziness, chest pain, and confusion. These failures also had the potential for development of oral thrush (a fungal infection of the mouth). Findings: During a review of Resident 85's admission Record (Face Sheet), Resident 85 was admitted to the facility on [DATE] with diagnoses included but not limited to asthma (a condition where the airways become inflamed, narrow, and swell, and produce extra mucus that makes it difficult to breathe), hypertension (high blood pressure), and hyperlipidemia (high levels of fat particles in the blood). During a review of Resident 85's History and Physical Examination (H&P), dated 10/28/2023, the H&P indicated Resident 85 had the capacity to understand and make decisions. During a review of Resident 85's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 11/3/2023, the MDS indicated Resident 85 was able to make himself understood and understood others. The MDS indicated Resident 85's cognition (process of thinking) was moderately impaired. During a review of Resident 85's Order Summary Report, dated 1/24/2024, the Order Summary Report indicated to administer for the following medications: 1. Hydrochlorothiazide 12.5 mg tablet, by mouth, once a day for hypertension. Hold medication if the systolic blood pressure (SBP, the maximum blood pressure during contraction of the ventricles [the two lower chambers of the heart responsible for pumping blood out of the heart]) was less than 110 millimeters of mercury (mmHg, unit of measurement of pressure in blood vessels) or if the heart rate was less than 60 beats per minute (BPM). 2. Losartan potassium 25 mg tablet, my mouth, once a day for hypertension. Hold medication if the SBP was less than 110 mmHg or if the heart rate was less than 60 BMP. 3. Fluticasone-Salmeterol Inhalation Aerosol 45-21 microgram (mcg, unit of measurement) per actuation (act, the process of spraying medication) (mcg/act), one puff inhaled by mouth once a day for chronic obstructive pulmonary disease (a lung disease characterized by long-term poor airflow). Rinse mouth with water after use. 056415 Page 35 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 1/23/2024 at 9:41 a.m., in Resident 85's room, LVN 1 checked Resident 85's blood pressure, which was 122/80 mmHg. LVN 1 did not check Resident 85's heart rate. LVN 1 informed Resident 85 that she would prepare his medications. During a current observation and interview on 1/23/2024 at 9:43 a.m., outside of Resident 85's room, LVN 1 prepared a total of three medications for Resident 85. LVN 1 stated she prepared three medications that consisted of two tablets and one inhaler. LVN 1 entered Resident 85's room and two tablets were administered with water and LVN 1 provided one puff of the inhaler to Resident 85. The three medications administered were hydrochlorothiazide, losartan potassium, and Fluticasone-Salmeterol. LVN 1 expressed appreciation to Resident 85 and provided no other instruction. During an interview on 1/23/2024 at 9:49 a.m., with LVN 1, LVN 1 stated she did not check Resident 85's heart rate prior to administering the hydrochlorothiazide and losartan potassium. LVN 1 stated she was responsible to check the medication orders for any parameters (when a medication is not administered based on a specific condition) prior to administering any medication. LVN 1 stated it was important to assess the heart rate prior to administering those medication because they had the potential to decrease the resident's heart rate. LVN 1 stated if Resident 85's heart rate was to decrease, it could cause bradycardia which could lead to a decrease in blood pressure, dizziness, or headache. During an interview on 1/23/2024 at 11:45 a.m., with LVN 1, LVN 1 stated after administering a dose from an inhaler, she was supposed to instruct Resident 85 to rinse his mouth after. LVN 1 stated she did not instruct Resident 85 to rinse his mouth. LVN 1 stated Resident 85 was at risk of developing oral thrush. During an interview on 1/24/2024 at 11:21 a.m., with the interim Infection Preventionist Nurse (IPN), the interim IPN stated after administering medication from an inhaler, the resident must rinse their mouth after to remove any medication residue from their mouth. The interim IPN stated this was essential in preventing the development of oral thrush. During an interview on 1/25/2024 at 4:36 a.m., with the Director of Nursing (DON), the DON stated the nurses were responsible to check the medication order for any parameters they had to be aware of. The DON stated administering blood pressure medications without checking the ordered parameters could potentially lower the resident's heart rate and blood pressure. The DON stated if the resident were to experience a decrease in heart rate, they could experience lethargy and weakness. The DON stated the nurses were also responsible to check any additional instructions prior to administering medication. The DON stated after administering medication from an inhaler, the resident was supposed to rinse their mouth to prevent oral thrush. The DON stated if the resident did not rinse their mouth after receiving medication from an inhaler, they were at risk of developing an oral infection. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, revised 4/2019, the P&P indicated, Medications are administered in accordance with prescriber orders . The following information is checked/verified for each resident prior to administering medications: allergies to medications and vital signs, if necessary. 056415 Page 36 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

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 maintain medications in a proper storage room for two sampled Residents (Resident 1 and Resident 57) when: 1. Medicated ointment and another unidentified substance was stored in a resident restroom. 2. Medicated ointment and Vaseline was kept at Resident 1's and Resident 57's bedside. This deficient practice had a potential risk for a resident or residents ingesting the medications. Findings: 1. During a review of Resident 1's admission Record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including chronic kidney disease (gradual loss of kidney function) and cardiomegaly (enlargement of the heart). During a review of Resident 1's History and Physical (H&P) dated 10/10/2023, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care planning tool), dated 12/22/2023, the MDS indicated Resident 1's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision was intact The MDS indicated Resident 1 required moderate assistance with activities of daily living (ADLs, daily self-care activities such as grooming, personal hygiene, and dressing). During a concurrent observation and interview on 1/23/2024 at 10:44 a.m. with Resident 1, in Resident 1's room, observed 1 closed container with ointment and 1 cup with ointment at Resident 1's bedside. Resident 1 stated the container and cup contained medicated Vaseline to put on his buttocks. Resident 1 stated a nurse gave him the ointment so he could apply it every time he used the restroom. Resident 1 stated he kept the ointments at his bedside all the time. 2. During a review of Resident 57's admission Record, the admission record indicated Resident 57 was admitted to the facility on [DATE] with diagnoses including kidney failure (occurs when kidneys suddenly become unable to filter waste products from the blood, kidneys lose their filtering ability, dangerous levels of wastes may accumulate, and blood's chemical makeup may get out of balance), and dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). During a review of Resident 57's H&P dated 10/10/2023, the H&P indicated Resident 57 had a history of alertness with episodes of confusion. During a review of Resident 57's MDS, dated [DATE], the MDS indicated Resident 57's cognitive skills for daily decision was severely impaired. The MDS indicated Resident 57 was dependent on staff for ADLs. The MDS indicated Resident 57 had a history of functional quadriplegia (complete immobility due to severe disability or frailty from another medical condition without injury to the brain or 056415 Page 37 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0761 spinal cord). Level of Harm - Minimal harm or potential for actual harm During an observation on 1/22/2024 at 9:18 a.m., observed 3 opened containers of A& D ointment with zinc (medication used to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations, such as diaper rash, skin burns from radiation therapy) in the medicine cabinet in a resident restroom. Observed 2 unlabeled disposable cups with white substance in them and a tongue depressor. Residents Affected - Few During an observation on 1/23/2024 at 9:45 a.m., in Resident 57's room, observed a medicine cup with yellowish-colored ointment at Resident 57's bedside. During an interview on 1/23/2024 at 9:50 a.m. with Certified Nursing Assistant (CNA) 3, in Resident 57's room, CNA 3 stated she had not noticed the ointment at Resident 57's bedside and did not know what the ointment was for. CNA 3 stated it looked like an ointment that a treatment nurse (TN) used to treat the resident's skin. CNA 3 stated only licensed nurses deal with that ointment because it was a prescribed medication. CNA 3 stated that ointment should not be kept at the bedside because any resident could take it and possibly eat it. During an interview on 1/23/2024 at 9:58 a.m. with Resident 57, in Resident 57's room, Resident 57 stated he did not know the ointment was at the bedside. Resident 57 stated that was not a good place to have the ointment because another resident could take it and use it. During an interview on 1/25/2024 at 8:48 a.m. with TN 1, TN 1 stated A&D and A&D with Zinc medication needed a physician's order. TN 1 stated that medication should not be left at a resident's bedside and should be discarded. TN 1 stated that licensed nurses were the only ones that have access to that medication and it was kept under lock and key. TN 1 stated the medication should not be kept at a resident's bedside or restroom because a resident might think it was food and they might want to eat it. TN 1 stated she did not know who put the medication in the restroom or who left the medicine cup with medicated ointment at Resident 1's and Resident 57's bedside. TN 1 stated that was not a safe practice and leaving it behind increased the risk of a resident ingesting the ointment. TN 1 stated she was the only one that dealt with medications on that side of the facility and was not aware that the ointments were missing from her medication cart. During a review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, dated 2/2023, the P&P indicated the facility would store all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. 056415 Page 38 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 ensure kitchen staff adhered to menus approved by the Registered Dietician (RD), and their respective standardized recipes, while preparing meals for 86 out of 89 facility residents when the following occurred: 1. Resident 11 and Resident 40 received cheese and vegetable quesadillas that did not have vegetables. 2. The Dietary Supervisor (DS) did not make the Registered Dietitian (RD) and the residents of the facility aware of the menu substitution changes made on 1/23/2024 and 1/24/2024. The above failures had the potential for 86 out of 89 residents to not receive the expected calories, proteins, and other micronutrients (vitamins and minerals needed by the body in very small amounts) from the meals served by the facility. Findings: 1. During a review of Resident 11's admission Record, the record indicated the facility originally admitted Resident 11 on 10/24/2020 and re-admitted Resident 11 on 7/14/2023. Resident 11's admitting diagnoses included acute kidney failure (when your kidneys suddenly become unable to filter waste products from your blood), hyperkalemia (high potassium levels in the blood), and anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues). During a review of Resident 11's History and Physical (H&P), dated 7/5/2023, the H&P indicated Resident 11 had the capacity to understand and make decisions. During a review of Resident 11's Minimum Data Set (MDS, standardized resident assessment and care screening tool) dated 1/16/2024, the MDS indicated Resident 11's cognition was intact (ability to think and reason). During a review of Resident 11's physician orders dated 9/2/2023, the orders indicated Resident 11 was receiving a regular diet (a diet that does not include any dietary restrictions) with no added salt. During a review of Resident 11's care plans, the care plans indicated Resident 11 had a nutritional risk and increased nutrient needs. Staff's interventions indicated to provide diet/supplements [as ordered]. During a concurrent observation and interview on 1/23/2024 at 12:41 PM, at Resident 11's bedside, observed resident sitting up at the right edge of her bed with a lunch tray in front of her. Resident 11 stated she ordered the cheese and vegetable quesadilla. The plate had a quesadilla, shredded lettuce topped with diced tomato, and black beans. Resident 11 separated the tortilla to show the contents of the quesadilla and stated there were no vegetables in the quesadilla. No vegetables observed in the quesadilla. Resident 11 stated she did not plan to eat the quesadilla and stated she ate food brought in by another facility resident instead. 056415 Page 39 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview on 1/23/2024 at 12:52 PM, with Resident 11, Resident 11 stated that in the last two to three months, the trays delivered have not matched the menu. Resident 11 stated facility residents brought this up to facility staff, and facility staff told them that the ingredients required for the recipe had not been delivered. 2. During a review of Resident 40's admission Record, the record indicated the facility admitted Resident 40 on 1/30/2019 and readmitted Resident 40 on 11/12/2019, and again on 1/30/2021. Resident 40's admitting diagnoses included hypokalemia (low levels of potassium in the blood), high blood pressure, and heart failure (a condition where your heart doesn't pump enough blood for your body's needs). During a review of Resident 40's H&P, dated 5/11/2023, indicated Resident 40 was oriented to person, place, and time. During a review of Resident 40's MDS, dated [DATE], the MDS indicated Resident 40's cognition was intact. During a review of Resident 40's physician orders dated 3/13/2021, the orders indicated Resident 40 was receiving a regular diet with no added salt. During a review of Resident 40's care plans, the care plans indicated Resident 40 was at risk for potential malnutrition due to her medical conditions, and goals of care included Resident 40 being adequately nourished and hydrated. Staff's interventions indicated to provide, serve diet as ordered. During a concurrent observation and interview, on 1/23/2024 at 12:39 PM, at Resident 40's bedside with Resident 40, Resident 40 was observed sitting in a wheelchair eating lunch. Resident 40 stated she ordered the cheese and vegetable quesadilla and stated there were no vegetables in the quesadilla. Resident 40 had a small piece of quesadilla remaining on her plate, and observation of the quesadilla showed there were no vegetables. Resident 40 stated she had ordered the cheese and vegetable quesadilla in the past, and it did not have vegetables. During an interview on 1/24/2024 at 1:08 PM, with the Registered Dietician (RD), the RD stated she had not been notified that the facility was serving cheese and vegetable quesadillas without vegetables. The RD stated she was supposed to be notified by the Dietary Supervisor (DS) that the cheese and vegetable and quesadilla recipe was not being followed. The RD stated she would have instructed the kitchen staff to substitute alternative vegetables if the original vegetables required in the recipe were not available. The RD stated that the vegetables in the quesadilla recipe added nutritional value, and omitting the vegetables would decrease its nutritional value. During a review of the undated facility document titled, DT Cheese and Veggie Quesadilla, the document indicated the recipe and instructions for preparation of the cheese and vegetable quesadilla. The document indicated prepare the filling: .combine the zucchini, corn, onions, jalapenos, beans . and add the cheese. The document then indicated place filling on one half of each tortilla .place quesadillas on the griddle and cook. 3. During a review of the facility's Menu, dated 1/21/2024 to 1/27/2024, the Menu indicated the facility was to serve seasoned broccoli florets for lunch on 1/23/2023, and French toast for breakfast on 1/24/2024. 056415 Page 40 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0803 Level of Harm - Minimal harm or potential for actual harm During a review of Resident 29's admission Record, the admission Record indicated Resident 29 was admitted to the facility on [DATE] with a fracture of the humerus (broken arm bone). During a review of Resident 29's MDS, dated [DATE], the MDS indicated Resident 29's cognition was moderately impaired. Residents Affected - Many During a review of Resident 29's Diet order, dated 12/14/2023, the diet order indicated Resident 29 was to have a regular consistency, no added salt, and reduced sweets diet. During an observation, on 1/23/2024, at 12:44 p.m., of Resident 29's meal tray, the meal tray had a scoop of zucchini, a scoop of white rice, and a serving of chicken. During an observation, on 1/24/2024, at 8:03 a.m., of Resident 29's meal tray, the meal tray had one waffle, one scoop of ground meat, a bowl of oatmeal, and a cup of coffee. During a review of the Menu Substitution Log, dated 11/13/2023 to 1/24/2024, the log indicated the broccoli for lunch (1/23/2024) was replaced by zucchini, and the French toast for breakfast (1/24/2023) was replaced by waffles. The log indicated that the broccoli was missing in [the] order and the French toast was unavailable. During a concurrent review and interview, on 1/24/2023, at 9:13 a.m., with the DS, the Diet Type Report, dated 1/24/2023, was reviewed. The report indicated 86 out of 89 residents were recipients of meals (any diet types) prepared by the kitchen. The report had indicated the remaining three residents had a nothing-by-mouth diet order (not able to eat food by mouth). The DS stated that all 86 recipients were supposed to receive broccoli (instead of zucchini) for lunch 1/23/2024 and waffles (instead of French toast) for breakfast on 1/24/2024. During an interview, on 1/24/2023, at 9:13 a.m., with the DS, the DS stated that the food delivery was missing broccoli, which was why the kitchen staff had to use zucchini to replace the broccoli. The DS stated that the Kitchen [NAME] (KC) had notified her that there would not be enough French toast for the residents the day before it was supposed to be served and did not know why there was inadequate supply for the residents. The DS stated that she did not inform the Registered Dietitian and the residents about the substitution of the food items (the broccoli and the French toast) on both dates (1/23/2024 and 1/24/2024) because she did not have enough time. The DS stated that it was important to tell the RD of the change so that the RD can approve the changes and ensure the substituted food items meet the nutritional value of the originally planned food items. The DS stated that it was important to let the residents know about the substitutions because it was their right to know about the meals that were served. During an interview, on 1/24/2024, at 12:11p.m., with the RD, the RD stated that the normal process for substituting food items was that the DS would inform her (the RD) of the specific food item change and the RD would approve of the substitution. The RD stated that she was not aware of any menu food item substitutions made on 1/23/2024 and 1/24/2024. The RD stated that it was important that the RD knew of the substitution to ensure that the food item was an appropriate substitution and had the same nutritional value. The RD stated that failing to make her aware of the food substitutions could result in the residents not receiving the intended amount of nutrients that he or she needs. During an interview, on 1/24/2024, at 2:16 p.m., with the Director of Nursing (DON), the DON stated that it was important that the DS made the RD aware of any food changes to ensure that it each 056415 Page 41 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0803 substitution was adequate to ensure that the residents' caloric needs are met. Level of Harm - Minimal harm or potential for actual harm During a review of the facility policy and procedure (P&P) titled, Menus, dated 10/2017, the P&P indicated the dietician reviews and approves all menus, menus provide a variety of foods from the basic daily food groups and indicate standard portions at each meal, and input from the residents is considered when menu planning. Residents Affected - Many During a review of the facility job description document titled Dietary Supervisor, undated, the job description indicated essential duties and responsibilities of the Dietary Supervisor included partnering with the Dietician to ensure diet is in accordance with the resident's nutritional needs. 056415 Page 42 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents' food was appealing, appetizing, and palatable (pleasant to taste) when the facility served pale-yellow, square-shaped egg bites for breakfast, when residents verbalized feelings of dissatisfaction of the facility's food due to the lack of palatability and appeal, and food served in disposable Styrofoam dinnerware which did not maintain temperature for nine out of nine sampled residents (Residents 29, 30, 68, 77, 82, 85, 90, 57 and 63). Residents Affected - Some This deficient practice had the potential for the residents to experience poor meal intake and weight loss, and lack of dignity. Findings: During a review of Resident 29's admission Record, the admission Record indicated Resident 29 was originally admitted to the facility on [DATE]. Resident 29's diagnoses included but not limited to fracture of the humerus (broken arm bone), muscle wasting, and protein calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function). During a review of Resident 29's Minimum Data Set ([MDS]- a standardized resident assessment and care planning tool), dated 12/18/2023, the MDS indicated Resident 29's cognition (mental action or process of acquiring knowledge and understanding) was moderately impaired. During a review of Resident 30's admission Record, the admission Record indicated Resident 30 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 30's diagnoses included but not limited to diabetes (high blood sugar levels in the blood) and hypertension (high blood pressure). During a review of Resident 30's MDS, dated [DATE], the MDS indicated Resident 30's cognition was intact. During a review of Resident 68's admission Record, the admission Record indicated Resident 68 was originally admitted to the facility on [DATE]. Resident 68's diagnoses included but not limited to diabetes and high blood pressure. During a review of Resident 68's MDS, dated [DATE], the MDS indicated Resident 68's cognition intact. During a review of Resident 77's admission Record, the admission Record indicated Resident 77 was originally admitted to the facility on [DATE] and readmitted [DATE]. Resident 77's diagnoses included but not limited to diabetes and obesity (abnormal or excessive fat accumulation that presents a risk to health). During a review of Resident 77's MDS, dated [DATE], the MDS indicated Resident 77's cognition was moderately impaired. During a review of Resident 82's admission Record, the admission Record indicated Resident 82 was 056415 Page 43 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0804 Level of Harm - Minimal harm or potential for actual harm originally admitted to the facility on [DATE]. Resident 82's diagnoses included but not limited to muscle weakness, pressure ulcer (a wound caused by prolonged pressure over a bony prominence), and diabetes. During a review of Resident 82's MDS, dated [DATE], the MDS indicated Resident 82's cognition was moderately impaired. Residents Affected - Some During a review of Resident 85's admission Record, the admission Record indicated Resident 85 was originally admitted to the facility on [DATE]. Resident 85's diagnoses included but not limited to muscle wasting and high blood pressure. During a review of Resident 85's MDS, dated [DATE], the MDS indicated Resident 85's cognition was moderately impaired. During a review of Resident 90's admission Record, the admission Record indicated Resident 90 was originally admitted to the facility on [DATE]. Resident 90's diagnoses included but not limited to diabetes and muscle weakness. During a review of Resident 90's MDS, dated [DATE], the MDS indicated Resident 90's cognition was moderately impaired. During a review of Resident 57's admission Record, the admission record indicated Resident 57 was admitted to the facility on [DATE] with diagnoses including kidney failure (occurs when the kidneys suddenly become unable to filter waste products from the blood), and dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). During a review of Resident 57's History and Physical (H&P) dated 10/10/2023, the H&P indicated Resident 57 had a history of alertness with episodes of confusion. During a review of Resident 63's admission Record, the admission record indicated Resident 63 was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses of kidney disease (advanced kidney damage) and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). During a review of Resident 63's H&P dated 1/20/2024, the H&P indicated Resident 63 had the capacity to understand and make decisions. The H&P indicated Resident 63 had a history of end stage of renal disease (ESRD, a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). During a review of Resident 63's MDS, dated [DATE], the MDS indicated Resident 63's cognitive skills for daily decision making was intact. The MDS indicated Resident 63 required maximal assistance with ADLs. During an interview, on 1/22/2024, at 9:00 a.m., with Resident 29, Resident 29 stated that the food was usually tasteless and did not look good. During an interview, on 1/22/2024, at 10:25 a.m., with Resident 85, Resident 85 stated that the 056415 Page 44 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0804 Level of Harm - Minimal harm or potential for actual harm food was cold sometimes and there was no meat served with his breakfast, and that the food did not taste good. During an interview, on 1/22/2024, at 10:54 a.m., with Resident 82, Resident 82 stated that the food was usually tasteless and did not look good. Residents Affected - Some During an observation and test tray tasting of a pureed diet (food that has a soft, easy to chew texture) test tray, on 1/22/2024 at 12:07 p.m., the test tray contained one scoop of orange pureed carrots, one scoop of ground white fish, and one scoop of pinto beans. All three items tasted bland (no flavor) and did not look appetizing. During an interview, on 1/22/2024, at 12:44 p.m. a.m., with Resident 30, Resident 30 stated she usually did not like the food that was served by the facility and usually ate a fruit plate instead. During a concurrent observation and interview, on 1/23/2024, at 7:35 a.m., with Resident 82, Resident 82's breakfast tray was observed. The breakfast tray had to two pieces of toast, one bowl of cereal and a pale-yellow egg shaped as a square with four pieces of a green vegetables cooked within the egg. Resident 82 stated that her breakfast was yucky and unappealing. During a concurrent observation and interview, on 1/23/2024, at 7:38 a.m., with Resident 85, Resident 85's breakfast tray was observed. The breakfast tray had to two pieces of toast, one bowl of white oatmeal, and a pale-yellow egg shaped square with four pieces of a green vegetables cooked within the egg. Resident 85 stated that the food was nasty and unappealing and that he did not like his breakfast. During a concurrent observation and interview, on 1/23/2024, at 7:44 a.m., with Resident 77, Resident 77's breakfast tray was observed. The breakfast tray had to two pieces of toast, one bowl of white oatmeal, and a yellow egg shaped as a square with four pieces of a green vegetables cooked within the egg. Resident 77 stated, I am scared to eat. I [have] never [eaten an] egg like that. It does not taste like anything. It tastes like powder eggs. During an interview, on 1/23/2024, at 7:49 a.m., with Resident 68, Resident 68 stated that his breakfast tray was not good, did not taste like anything, and that his tray needed a protein. During an interview, on 1/23/2024, at 7:53 a.m., with Resident 90, Resident 90 stated that he did not like the egg on his breakfast tray because it had no taste. During a concurrent observation and interview, on 1/23/2024, at 3:19 p.m., with Resident 90's family member (FM) 1 and Resident 90, inside of Resident 90's room, Resident 90's lunch meal tray was observed. The lunch meal tray remained untouched and intact. FM 1 stated that she bought Resident 90 food from outside because Resident 90 did not eat his lunch meal tray. Resident 90 stated he did not like the food at the facility because it tasted bad. During an interview and concurrent observation of a photo taken of Resident 85's breakfast tray (on 1/23/2024 at 7:38 a.m.), on 1/24/2024, at 9:13 a.m., with the Dietary Supervisor (DS), the photo revealed a breakfast tray that had two pieces of toasted bread, one bowl of oatmeal, one carton of milk, and a pale-yellow egg shaped as a square with four pieces of a green vegetables cooked within the egg. The DS stated the breakfast did not look appealing or palatable to her. The DS stated that if residents received meals that looked unappealing, residents would get mad, stop eating and it would 056415 Page 45 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0804 place the residents at risk for weight loss. Level of Harm - Minimal harm or potential for actual harm During an interview and concurrent observation of a photo taken of Resident 85's breakfast tray (on 1/23/2024 at 7:38 a.m.), on 1/24/2024, at 11:30 a.m., with Registered Nurse (RN) 1, the photo revealed a breakfast tray that had two pieces of toasted bread, one bowl of oatmeal, one carton of milk, and a pale-yellow egg shaped as a square with four pieces of green vegetables cooked within the egg. RN 1 stated that the breakfast did not look appealing to her, and that it was the residents' right to have palatable foods. RN 1 stated that there was a potential for weight loss for the residents if the residents did not like their food because of the taste or do not find the food appealing. Residents Affected - Some During an interview, no 1/24/2024, at 2:16 p.m., with the Director of Nursing (DON), the DON stated that if the residents did not like the food, then there would a potential for the residents to exhibit weight loss. During an observation on 1/25/2024 at 8:13 a.m. in the hallway, observed staff passing out resident food trays. Observed food served in white Styrofoam to-go boxes. During an observation on 1/26/2024 at 8:00 a.m., in the hallway, observed all residents breakfast trays served in a white to-go box. During an interview on 1/26/2024 at 9:12 a.m. with Resident 57, in Resident 57's room, Resident 57 stated his breakfast was cold and he ate his food because he was hungry but the food was cold. Resident 57 stated the kitchen food was never good and it was worse when it was cold. During an interview on 1/26/2024 at 9:33 a.m. with Resident 63, in Resident 63's room, Resident 63 stated his breakfast was cold that morning (1/26/2024). Resident 63 stated he always ate the food but could not that day. Resident 63 stated the taste was bad because the food was cold. Resident 63 asked who liked to eat cold food. During an interview on 1/26/2024 at 1:47 p.m. with the Dietary Supervisor (DS), the DS stated residents received their meals in Styrofoam because the plate bases got destroyed. The DS stated the plate bases got destroyed because they were stacked on top of the toaster and they melted. The DS stated it was important not to serve residents food in disposable plates because it was a dignity issue. The DS stated this was residents' home and they should be treated with dignity and respect. The DS stated she had already ordered new plate bases and they should be arriving soon. The DS stated the to go boxes would not maintain the food temperature like the other plates but she could reheat the food if residents asked. During a review of the kitchen Order Form, dated 1/26/2024 at 2:19 p.m., the order form indicated the new plates bases had not been ordered. During a review of the facility's policy and procedure (P&P), titled Food and Nutrition Services, dated 10/2017, the P&P indicated the facility was to provide each resident with a palatable diet that meets his or her daily nutritional needs, taking into account his or her preferences. 056415 Page 46 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. 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 two of three sampled residents (Resident 6 and Resident 62) were provided the opportunity to make an informed decision prior to entering into a binding arbitration agreement (the submission of a dispute to a neutral party who hears the case and makes a decision) when the following occurred: Residents Affected - Few 1. Facility staff did not inform Resident 6's responsible party about what a binding arbitration entailed, or that entrance into a binding arbitration agreement was optional. 2. Facility staff did not contact Resident 62's responsible party and power of attorney (POA, a legal document that allows someone else to act on your behalf), prior to Resident 62 signing a binding arbitration agreement. This failure caused Resident 6 and Resident 62, and/or their responsible parties, to unknowingly forfeit their right to resolve any disputes with the facility in court, with a judge and/or jury. Findings: 1. During a review of Resident 6's admission Record, the record indicated the facility originally admitted Resident 6 on 1/5/2024. Resident 66's admitting diagnoses included metabolic encephalopathy (when another health condition makes it hard for the brain to work) and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 6's Minimum Data Set (a standardized assessment and screening tool), dated 1/9/2024, the MDS indicated Resident 6 had severely impaired cognition (loss of the ability to understand the meaning or importance of something and the ability to talk or write, resulting in the inability to live independently). During a review of Resident 6's progress notes, dated 1/8/2024, the progress note indicated Resident 6 responds to her name, but otherwise she mumbles incoherently in Spanish and doesn't make any sense. The progress notes also indicated Resident 6 did not have the ability to make medical decisions. During an interview, on 1/23/2024 at 12:29 PM, with Resident 6's Responsible Party (RP) 2, RP 2 stated he vaguely recalled signing documents upon Resident 6's admission to the facility. RP 2 stated he was told that the documents were related to billing, and stated he did not recall receiving any information related to binding arbitration agreements, and stated he did not know what a binding arbitration agreement meant. RP 2 further stated he was not explicitly informed that he was not required to sign the binding arbitration agreement. 2. During a review of Resident 62's admission Record, the record indicated the facility originally admitted Resident 62 on 8/21/2023. Resident 62's admitting diagnoses included metabolic encephalopathy, cognitive communication deficit (difficulty with thinking and language), and dementia. During a review of Resident 62's Minimum Data Set, dated [DATE], the MDS indicated Resident 62 had severely impaired cognition. 056415 Page 47 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0847 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 62's progress note, dated 8/21/2023, the progress note indicated Resident 62 was admitted to the facility by ambulance on 8/21/2023, was only oriented to his name, and was very forgetful. The progress notes further indicated Resident 62's responsible party (RP 1) had been called by telephone but did not answer. During a review of Resident 62's Minimum Data Set, dated [DATE], the MDS indicated Resident 62 had severely impaired cognition. During an interview, on 1/25/2024 at 12:02 PM, with RP 1, RP 1 stated facility staff had not spoken to him about binding arbitration agreements. RP 1 stated he had been Resident 62's responsible party and POA since prior to Resident 62's admission to the facility. RP 1 stated Resident 62 was confused when admitted to the facility, and stated Resident 62 would not have had the capacity to make the decision to enter into a binding arbitration agreement. During a review of the undated facility document titled, Resident-Facility Binding Arbitration Agreement, the document indicated by signing this contract, you are agreeing to have any issue of medical malpractice decided by neutral arbitration and you are giving up your right to a jury or court trial. The document indicated Resident 62 digitally signed the document on 8/22/2023. The signature line labelled Signature on behalf of the resident was left blank. The document was also signed by the Social Services Assistant (SSA). During a concurrent interview and record review, on 1/25/2024 at 2:26 PM, with the SSA, the undated facility document titled, Resident-Facility Binding Arbitration Agreement was reviewed. The SSA stated she witnessed Resident 62 sign the document himself. The SSA stated she did not know Resident 62 had a responsible party. The SSA stated that if a resident was not self-responsible, it was not appropriate for them to consent to entering into a binding arbitration agreement. The SSA further stated residents and/or their responsible parties were supposed to be educated about binding arbitration agreements in a manner they understand. The SSA stated residents and/or their responsible parties had the right to make an informed decision prior to entering into a binding arbitration agreement and stated that they should not be required to sign. 056415 Page 48 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement effective infection prevention measures for three of 11 sampled residents (Resident 23, 49, and 74) when the facility failed to: Residents Affected - Few 1. Ensure Treatment Nurse (TN) 1 performed hand hygiene (a way of cleaning one's hands that substantially reduces the potential germs on the hands) throughout Resident 23's wound treatment. 2. Ensure Licensed Vocational Nurse (LVN) 2 donned (to put on) personal protective equipment (PPE, protective garments or equipment such as gowns, gloves, masks, eye wear that is designed to protect the wearer's body from infection) when providing care to Resident 49 and Resident 74 who were on Enhanced Standard Precautions (ESP, infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug resistant organisms). These failures had the potential to result in the transmission of infectious microorganisms and increase the risk of infection. Findings: 1. During a review of Resident 23's admission Record (Face Sheet), the admission Record indicated Resident 23 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses included but not limited to chronic obstructive pulmonary disease (COPD, a lung disease characterized by long-term poor airflow), atrial fibrillation (an irregular, often rapid heart rate that can cause poor blood flow), and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). During a review of Resident 23's History and Physical Examination (H&P), dated 11/23/23, the H&P indicated Resident 23 had the capacity to understand and make decisions. During a review of Resident 23's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 11/14/2023, the MDS indicated Resident 23 was able to make herself understood and understood others. The MDS indicated Resident 23's cognition (process of thinking) was intact. The MDS indicated Resident 23 had cellulitis (skin infection that spreads rapidly) and moisture associated skin damage (MASD, inflammation and erosion of the skin that resulted from prolonged exposure to different sources of moisture such as feces or urine). During a review of Resident 23's Progress Notes, dated 1/25/2024, the Progress Notes indicated fungal dermatitis was found on Resident 23's lower back on 1/3/2024 and the physician was notified. During a review of Resident 23's Order Summary Report, dated 1/24/2024, the Order Summary Report indicated the following daily wound care orders: 1. Cleanse with normal saline (NS, solution made of salt and water), pat dry, apply Nystatin-Triamcinolone External Cream (medicated cream to treat fungal skin infections) 100000-0.1 unit per gram (GM, unit of measurement) to the lower back, and keep open to air, once a day for 21 days. 2. Cleanse with NS, pat dry, apply Zinc Oxide Ointment 20 percent (%) (medicated cream that treats 056415 Page 49 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0880 or prevents skin irritation such as cuts, burns, or diaper rash) to the left buttock, once a day for 21 days. Level of Harm - Minimal harm or potential for actual harm 3. Cleanse with NS, pat dry, apply Zinc Oxide Ointment 20 percent to the right buttock, once a day for 21 days. Residents Affected - Few During an observation on 1/24/2024 at 9:02 a.m., with TN 1 in Resident 23's room, TN 1 explained that she would be doing Resident 23's wound treatment. Resident 23 stated she did not have any pain and consented for TN 1 to continue with the wound treatment. TN 1 prepared her supplies, performed hand hygiene, and applied gloves. Resident 23 was lying on her left side, previous dressing removed prior to wound treatment. TN 1 cleansed the right and left buttock with NS, patted dry, removed her gloves, and applied new gloves. TN 1 applied Zinc Oxide Ointment with a wooden spatula applicator (small, broad, flat, blunt instrument, can also be called a tongue depressor) to the right buttock. TN 1 applied Zinc Oxide Ointment with a new wooden spatula applicator to the left buttock. TN 1 applied a padded dressing on the buttock, removed her gloves, and applied new gloves. TN 1 cleansed the lower back with NS, patted dry, and applied Nystatin-Triamcinolone Cream to the lower back. TN 1 cleaned her area, removed her gloves, and performed hand hygiene. During an interview on 1/24/2024 at 9:19 a.m., with TN 1, TN 1 stated she was supposed to perform hand hygiene throughout Resident 23's wound treatment. TN 1 stated she was supposed to perform hand hygiene when she removed her gloves and before applying new gloves. TN 1 stated she was supposed to perform hand hygiene when she moved to a new wound area. TN 1 stated hand hygiene was done to prevent the spread of infection and prevent contamination of other wounds. During an interview on 1/24/2024 at 11:22 a.m., with the interim Infection Preventionist Nurse (IPN), the interim IPN stated staff had to perform hand hygiene after touching any surfaces, before, during, and after providing care to a resident because there was the potential of germs carried on their hands. The interim IPN stated staff were to perform hand hygiene before and after glove use and especially throughout a wound treatment. The interim IPN stated when a resident has multiple wound treatments to multiple areas, hand hygiene should be performed before after the completion of one site and before moving to the next site. The interim IPN stated not performing hand hygiene put the resident at risk of contamination of wounds and infection. During an interview on 1/25/2024 at 4:47 p.m., with the Director of Nursing (DON), the DON stated hand hygiene was performed to prevent infection by killing germs and bacteria on the hands. The DON stated during a wound treatment, after removing gloves and before moving to another area, hand hygiene was supposed to be performed. The DON stated the absence of hand hygiene throughout the wound treatment increased Resident 23's likelihood of infection. During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, revised 10/2023, the P&P indicated, This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections . Hand hygiene is indicated immediately before touching a resident; before performing an aseptic task; after contact with body, body fluids, or contaminated surfaces; after touching a resident; after touching the resident's environment; before moving from work on a soiled body site to a clean body site on the same resident; and immediately after glove removal. 2a. During a review of Resident 49's admission Record (Face Sheet), the admission Record indicated Resident 49 was initially admitted to the facility on [DATE] and readmitted to the facility on 056415 Page 50 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few [DATE] with diagnoses included but not limited to hemiplegia (one-sided weakness) and hemiparesis (inability to move one side of the body) following a cerebral infarction (damage to the tissues in the brain due to a loss of oxygen to the area) affecting left non-dominant side, dysphagia (difficulty swallowing), and type 2 diabetes mellitus (condition that results in too much sugar circulating in the blood). During a review of Resident 49's MDS, dated [DATE], the MDS indicated Resident 23 was rarely able to make herself understood and rarely understood others. The MDS indicated Resident 23's cognition was severely impaired. The MDS indicated Resident 23 had a feeding tube (a tube that is surgically inserted into the resident's stomach to allow access for food, fluids, and medications). During a review of Resident 49's Order Summary Report, dated 1/25/2024, the Order Summary Report indicated Resident 49 was on Enhanced Standard Precautions due to use of a feeding tube, which was an indwelling device. During an observation on 1/23/2024 at 8:12 a.m., with Licensed Vocational Nurse (LVN) 2, in Resident 49's room, LVN 2 entered Resident 49's room without donning a gown and gloves. LVN 2 explained to Resident 49 that he would administer her medications after he checked her blood pressure. LVN 2 took Resident 49's blood pressure, which was 110/60 millimeters of mercury (mmHg, unit of measurement of pressure in blood vessels). LVN 2 performed hand hygiene and sanitized the blood pressure cuff and stethoscope (a medical instrument for listening to internal sounds of the human body). LVN 2 prepared Resident 49's medication by crushing the tablets and diluting with water. LVN 2 donned only gloves and assessed the placement of Resident 49's feeding tube by inserting air into the tube and listening to her stomach with the stethoscope. LVN 2 continued to administer Resident 49's medication through her feeding tube. LVN 2 reconnected Resident 49's enteral feeding (a special liquid food mixture containing protein, carbohydrates, fats, vitamins, and minerals) to her feeding tube and continued the infusion. LVN 2 removed his gloves and performed hand hygiene. During an interview on 1/23/2024 at 8:45 a.m., with LVN 2, LVN 2 stated he was supposed to wear gown and gloves when he provided care to Resident 49 by means of checking her blood pressure and administering her medications through her feeding tube. LVN 2 stated ESP was used for residents who were prone to infection and was implemented to protect them from infection. 2b. During a review of Resident 74's admission Record (Face Sheet), the admission Record indicated Resident 74 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses included but not limited to end stage renal disease (a stage where the kidneys can no longer support the body's needs for waste removal and fluid balance), type 2 diabetes mellitus, and peripheral vascular disease. During a review of Resident 74's H&P, dated 12/15/2023, the H&P indicated Resident 74 had the capacity to understand and make decisions. During a review of Resident 74's MDS, dated [DATE], the MDS indicated Resident 74 was able to make himself understood and understood others. The MDS indicated Resident 74's cognition was intact. The MDS indicated Resident 74 received dialysis (the process of removing waste products and excess fluid from the body using a machine when the kidneys are not able to do so). During a review of Resident 74's Order Summary Report, dated 1/24/2024, the Order Summary Report indicated Resident 74 was on Enhanced Standard Precautions due to having a hemodialysis (type of 056415 Page 51 of 52 056415 01/25/2024 Lynwood Post Acute Care Center 3611 East Imperial Highway Lynwood, CA 90262

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dialysis where the blood is treated to filter wastes and water) catheter (access point for dialysis), which was an indwelling device. During an observation on 1/23/2024 at 8:54 a.m., with LVN 2, in Resident 74's room, LVN 2 donned a gown and gloves and entered Resident 74's room. LVN 2 explained to Resident 74 that he would administer his medications after he checked his blood pressure, heart rate, and blood glucose level (amount of sugar in the blood stream). LVN 2 checked Resident 74's blood pressure which was 110/80 mmHg, 6and his heart rate was 85 beats per minute (bpm). LVN 2 doffed (removed) his gown and gloves and performed hand hygiene. LVN 2 retrieved the glucometer (a device for measuring the concentration of glucose in the blood, typically using a small drop of blood placed on a disposable test strip), did not don a gown and only applied gloves and checked Resident 74's blood glucose level, which was 120 milligrams (mg, unit of measurement) per (/) deciliter (dL, unit of measurement). LVN 2 removed his gloves, performed hand hygiene, and sanitized the blood pressure cuff, stethoscope, and glucometer. LVN 2 prepared Resident 74's medications and administered Resident 74's medications with water. During an interview on 1/23/2024 at 9:10 a.m., with LVN 2, LVN 2 stated he was supposed to don a gown and gloves when he checked Resident 74's blood glucose level. LVN 2 stated Resident 74 was on ESP and donning PPE was required during any kind of invasive procedure, such as piercing Resident 74's skin to obtain his blood glucose level. LVN 2 stated this placed Resident 74 at risk for infection. During an interview on 1/24/2024 at 11:18 a.m., with the interim IPN, the interim IPN stated ESP was implemented as a special precaution for residents with dialysis access or other indwelling devices that put them at a higher risk for infections. The interim IPN stated donning PPE while providing care to residents on ESP reduced the risk of transfer of infection. The interim IPN stated any touch-based care with a resident on ESP required the staff member to don a gown and gloves. During an interview on 1/25/2024 at 4:43 p.m. with the DON, the DON stated ESP was implemented to prevent the spread of multi-drug resistant organisms to residents who were more susceptible due to the presence of indwelling devices or open wounds. The DON stated when a staff member provided direct care to the resident, they had to don a gown and gloves. The DON stated donning a gown and gloves was especially important when accessing the resident's indwelling device because those devices were a direct entry way to the resident. The DON stated not donning a gown and gloves when providing care to residents on ESP exposed them to germs and bacteria that could cause an infection. During a review of the facility's P&P titled, Enhanced Barrier Precautions, dated 8/2022, the P&P indicated, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents . EBPs employe targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Gown and gloves are applied prior to performing the high contact resident care activity . Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include device care or use. 056415 Page 52 of 52