Health inspection·June 12, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physician of a resident's continued episodes of orthostatic hypotension (OH- a condition in which your blood pressure quickly drops when you stand up after sitting or lying down) and failed to ensure physician involvement in the discontinuation of Physical and Occupational Therapy (PT, OT) services for one of two sampled residents (Resident 1), This failure resulted in a delay in appropriate medical intervention, placed the resident at risk for adverse outcomes including falls, syncope (dizziness), and compromised perfusion (pressure needed for blood to flow to blood vessels), and resulted in the premature termination of Medicare coverage. 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] with diagnoses that included othrostatic hypotension (OH), history of falling, pleural effusion (a condition where an excessive amount of fluid accumulates in the pleural space, which is the area between the lungs and the chest wall), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), postprocedural pneumothorax (collapsed lung), and muscle wasting. During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 5/28/2025, the MDS indicated Resident 1's cognitive skills (ability to think and reason) for daily decision making was intact. The MDS indicated Resident 1 required substantial assistance (helper does more than half the effort) for Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's History and Physical (H&P), dated 5/17/2025, Resident 1's H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Order Summary Report, dated 5/24/2025, the Order Summary Report indicated Resident 1 was ordered physical and occupational therapy (PT, OT) services five days a week for four weeks for safety awareness, balance training, wheelchair mobility, pre-gait training (a set of exercises that help a patient walk better) and patient, or care giver training on 5/16/2025. During a review of Resident 1's Notice of Medicare Non-Coverage (NOMNC- an official document issued by Medicare-certified healthcare providers and suppliers to Medicare beneficiaries. It serves as a formal notice informing beneficiaries about the termination or denial of coverage for specific Page 1 of 6 056458 056458 06/12/2025 Greenfield Care Center of South Gate 8455 State Street South Gate, CA 90280

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few healthcare services or items), dated 6/5/2025, the NOMNC indicated Resident 1 Medicare Benefits would end on 6/7/2025. During a review of Resident 1's Final Determination Letter, dated 6/7/2025, the Final Determination Letter indicated the physician reviewer agreed with the termination of services. The Final Determination Letter also indicated there was no documented evidence that continued skilled services were needed daily to maintain or prevent decline. During a review of Resident 1's PT Progress Notes, dated 6/5/2025, the PT Progress Notes indicated Resident 1 demonstrated the need for continued PT services to facilitate with all functional mobility, increase functional activity tolerance, increase independence with gait (ability to walk), promote safety awareness, improve dynamic balance, facilitate motor control, enhance rehab potential, teach compensatory, or adaptation techniques and facilitate anticipatory reactions in order to enhance patient's quality of life by improving ability to increase performance skills with functional tasks, decrease level of care required from caregivers, decrease level of assistance from caregivers and facilitate increased independence with functional mobility throughout facility . During a review of Resident 1's Physician Orders, dated 6/12/2025, the Physician Orders indicated Physician 1 ordered for Resident 1's PT and OT services to be discontinued on 6/9/2025. The Physician Orders also indicated Physician 1 ordered Restorative Nurse Aide (RNA) services for ambulation (walking) using a front wheeled walker approximately 25 to 35 feet (ft- a unit of measurement) one to two sets or as tolerated every day for five days a week with two-person assist and wheelchair follow every day shift on 6/9/2025. During an interview on 6/11/2025 at 10:33 a.m. with Family Member (FM) 1, FM 1 stated she was the Representative Party for Resident 1 and was notified Resident 1's Medicare benefits ended because Resident 1 no longer required skilled services. FM 1 stated Resident 1's Medicare benefits ended prematurely on 6/7/2025. During a concurrent interview and record review on 6/12/2025 at 1:00 p.m. with the Director of Rehabilitation (DOR), Resident 1's Physical Therapy Progress Notes, dated 6/2/2025 to 6/6/2025, were reviewed. The notes indicated Resident 1 exhibited episodes of OH during each physical therapy session during the dates of 6/2/2025 to 6/6/2025 and the charge nurses were made aware of each OH event. The DOR stated these changes of condition were reported to the nurses who were responsible for notifying the physician. During an interview on 6/12/2025 at 3:25 p.m. with Registered Nurse (RN) 2, RN 2 stated she recalled Resident 1 exhibited signs and symptoms of orthostatic hypotension days shortly after his admission to the facility in 5/15/2025. RN 2 stated, There was an incident related to his orthostatic hypotension , but could not recall the exact events that transpired. RN 2 stated she could not recall why she did not make the physician aware. RN 2 stated it was important to ensure the physician was made aware of all episodes of orthostatic hypotension so that treatments would be started right away. During a concurrent interview and record review on 6/12/2025 at 3:51 p.m. with RN 1, Resident 1's Nursing Progress Notes, dated 5/1/2025 to 6/11/2025, were reviewed. The Nursing Progress Notes, dated 5/28/2025, indicated Physician 1 was made aware Resident 1's blood pressures dropped to 80/60 millimeters of mercury ([mm hg]- unit of measurement that describes the amount of force blood uses to get through the vessels of the body [normal range of 120–129 [top number] and 80–84 [bottom number]) while he walked. The Nursing Progress note indicated Midodrine 5 milligrams (mg- a unit of 056458 Page 2 of 6 056458 06/12/2025 Greenfield Care Center of South Gate 8455 State Street South Gate, CA 90280

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few measurement) three times a day was ordered. There was no documentation (after 5/28/2025) to indicate Physician 1 was made aware of Resident 1's continued episodes of OH during physical therapy on 6/2/2025 to 6/6/2025 despite the administration of Midodrine. RN 1 stated she was the assigned Charge Nurse for Resident 1 on 6/2/2025 and was aware Resident 1 had continued episdoes of OH. RN 1 could not recall why Physcian 1 was not made aware. RN 1 stated Physician 1 should have been made aware Resident 1's order for Midodrine was not effective so that the plan of care could have been modified, and Physician 1 could have ordered other treatments to treat other possible underlying problems, like dehydration (when the body loses more fluid than it takes in) or an infection. During an interview on 6/12/2025 at 2:29 p.m. with Physician 1, Physician 1 stated he expected the licensed nurses to make him aware of any changes of condition. Physician 1 stated he was not made aware that Resident 1 continued to have episodes of orthostatic hypotension during his physical therapy sessions. Physician 1 stated that would have wanted to be notified that the treatment (Midodrine) was ineffective so he could place other orders to try to treat any other underlying problems. Physician 1 stated he would have ordered more blood work, make sure [there was] no infection, and no dehydration . Physician 1 stated, Compression stockings, different medications like Florinef (a medication used to help treat orthostatic hypotension) and other options could have been explored . 2. During an interview on 6/12/2025 at 1:00 p.m. with the DOR, the DOR stated the physician was involved in the rehabilitation plan of care through the review of evaluations and progress notes that were sent to the physician on the 14th and 30th day of treatment. The DOR stated the review of the progress notes were confirmed by the physician's signature. The DOR stated the Rehabilitation Department relied on the licensed nurses to communicate the resident's progress in rehabilitation therapy and any changes to orders, like the discontinuation of PT and OT services, to the physician. During an interview on 6/12/2025 at 2:29 p.m. with Physician 1, Physician 1 stated he was not usually involved in the plan of care for rehabilitation treatment and services and relied on the DOR to direct therapy. Physician 1 stated he was not aware Resident 1's physical therapy orders were discontinued. Physician 1 stated he would have preferred to know so that Resident 1's clinical condition could have been appropriately addressed before Resident 1's rehabilitation services ended. During an interview on 6/12/2025 at 3:25 p.m. with RN 2, RN 2 stated she received the order to discontinue the PT and OT services for Resident 1 on 6/9/2025. RN 2 stated the order was confirmed and placed by Resident 1's health plan and the DOR, not by Physician 1. During a concurrent interview and interview on 6/12/2025 at 4:05 p.m. with the Director of Nursing (DON), Resident 1's Physician Orders, dated 6/9/2025, were reviewed. The Physician Orders indicated skilled PT and OT therapy were discontinued by Physician 1. The DON stated the physician should have been involved in the plan of care for rehabilitation services so that he could properly clear the resident for the discontinuation of physical therapy. The DON stated the lack of physician involvement placed Resident 1's safety at risk. The DON stated Resident 1 would have benefitted from continued PT and OT services. During a review of the facility's Policy and Procedure (P&P) titled, Change of Condition , dated 7/2012, the P&P indicated the facility was to ensure all changes in resident condition would be communicated to the physician. During a review of the facility's P&P titled, Skilled Nursing Rehabilitation Services , dated 8/2015, the P&P indicated each patient that received rehabilitation services should have a written Plan 056458 Page 3 of 6 056458 06/12/2025 Greenfield Care Center of South Gate 8455 State Street South Gate, CA 90280

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of Care developed by the collaborative healthcare team including, but not limited to, rehabilitation services staff, nursing services, the patient's physician and other appropriate healthcare professionals. The P&P indicated patients were encouraged to make choices about their participation in rehabilitation and to develop a sense of achievement in progress. The P&P indicated the patient Plan of Care, when appropriate, should include patient rehabilitation services specific to the patient's needs and goals in the most efficient and effective manner, including specialized rehabilitation services when appropriate. The P&P indicated the patient's Plan of Care should include, at least, the following: · Diagnoses · Long-term treatment goals · Type, amount, frequency and duration of treatments In accordance with the patient's Plan of Care, progress and changes in clinical condition, functional reassessments would be performed on an ongoing basis. Reassessment includes, but are not limited to: · The patient's response to rehabilitation interventions · Changes in the patient's condition · Choices for alternative interventions · Changes to modalities and procedures · Changes in goals, including progress toward meeting rehabilitation goals and objective. The P&P indicated the rehabilitation Plan of Care should be a part of the coordinated patient Plan of Care. The P&P indicated a report of the patient's progress shall be given to the physician within two [2] weeks of the initiation of rehabilitation services. 056458 Page 4 of 6 056458 06/12/2025 Greenfield Care Center of South Gate 8455 State Street South Gate, CA 90280

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop an individualized care plan for orthostatic hypotension (OH- a condition in which your blood pressure quickly drops when you stand up after sitting or lying down) for one of three sampled residents (Resident 1) when the facility failed to include clinically indicated instruction to administer Midodrine (an anti-hypotensive [low blood pressure] drug) prior to therapy sessions, despite the resident's history of symptomatic OH that affected participation in physical therapy. This failure placed Resident 1 at risk for falls, bodily injury, and early discontinuation of skilled therapy services. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses that included orthostatic hypotension (OH), history of falling, pleural effusion (a condition where an excessive amount of fluid accumulates in the pleural space, which is the area between the lungs and the chest wall), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), postprocedural pneumothorax (collapsed lung), and muscle wasting. During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 5/28/2025, the MDS indicated Resident 1's cognitive skills (ability to think and reason) for daily decision making were intact. The MDS indicated Resident 1 required substantial assistance (helper does more than half the effort) for Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's History and Physical (H&P), dated 5/17/2025, Resident 1's H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Order Summary Report, dated 5/24/2025, the Order Summary Report indicated Resident 1 was ordered physical and occupational therapy (PT, OT) services five days a week for four weeks for safety awareness, balance training, wheelchair mobility, pre-gait training (a set of exercises that help a patient walk better) and patient, or care giver training on 5/16/2025. During a review of Resident 1's Nursing Progress Notes, dated 5/28/2025, the Nursing Progress Notes indicated the rehabilitation staff notified the charge nurses Resident 1's blood pressure dropped to 80/60 millimeters of mercury ([mm hg]- unit of measurement that describes the amount of force blood uses to get through the vessels of the body [normal range of 120–129 [top number] and 80–84 [bottom number]) when Resident 1 walked. The Nursing Progress Notes indicated Physician 1 ordered Midodrine 5 milligrams (mg- a unit of measurement) three times a day. During a concurrent interview and record review on 6/12/2025 at 1:00 p.m. with the Director of Rehabilitation (DOR), Resident 1's Physical Therapy Progress Notes, dated 6/2/2025 to 6/6/2025, were reviewed. The notes indicated Resident 1 exhibited continued episodes of OH during each physical therapy session during the dates of 6/2/2025 to 6/6/2025. 056458 Page 5 of 6 056458 06/12/2025 Greenfield Care Center of South Gate 8455 State Street South Gate, CA 90280

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review on 6/12/2025 at 2:14 p.m. with Minimum Data Set Nurse (MDSN) 1, all of Resident 1's active care plans, dated 5/2025 to 6/2025, were reviewed. There were no care plans specific to Resident 1's diagnosis of OH. MDSN 1 stated an OH care plan was necessary for Resident 1's safety and for the prevention of falls. MDSN 1 stated she developed care plans according to the residents' conditions and assessments. MDSN 1 stated an At Risk for Falls Related to Orthostatic Hypotension care plan should have been developed for Resident 1. MDSN 1 stated proper interventions would have included to assess the resident prior to therapy sessions, and to specifically indicate therapy sessions (RNA, or PT) were to start approximately thirty minutes after the administration of Midodrine was given, if needed, and to recheck orthostatic vital signs (a series of measurements of a patient's blood pressure and heart rate taken while they are lying down [supine], sitting, and standing). During an interview on 6/12/2025 at 4:05 p.m. with the Director of Nursing (DON), the DON stated care plans for a specific diagnosis should be developed and implemented especially if the facility was treating the diagnosis. The DON stated care plans were important to determine if the current plan of care allowed the resident to progress to his or her defined goals. The DON stated Resident 1 should have had individual care plans specific to his diagnosis of OH and for the medication, Midodrine. The DON stated the lack of care plans placed Resident 1 at risk for another fall. During a review of the facility's Policy and Procedure (P&P) titled, Formulation of Care Plan , dated 7/2012, the P&P indicated the facility was to ensure a care plan would incorporate concerns, goals, and objectives to lead the resident's highest obtainable level of independence or highest practicable well-being. The P&P indicated the care plan was formulated based on the result of resident assessment done upon admission, quarterly, annually, and ongoing as needed. The P&P indicated concerns or problems secondary to change of conditions were also included in the care plan. During a review of the facility's P&P titled, Care Planning-Interdisciplinary Team , dated 7/2017, the P&P indicated the facility's care planning interdisciplinary team was responsible for the development of an individualized comprehensive care plan for each resident. 056458 Page 6 of 6