Health inspection·July 9, 2025

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Let each resident or the resident's legal representative access or purchase copies of all the resident's records. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide copies of medical records to one of four sampled residents (Resident 2) Responsible Party (RP 1) upon request.This deficient practice was a violation of RP 1's right to obtain a copy of Resident 2's medical records.Findings:During a review of Resident 2's admission Record, the admission record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's admitting diagnoses included muscle wasting and atrophy (thinning of muscle mass), lack of coordination, and generalized muscle weakness.During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 5/28/2025, the MDS indicated Resident 2 did not have cognitive (ability to think and reason) impairments. The MDS indicated Resident 2 required substantial to maximal assistance from staff with all mobility while in and out of bed.During a review of Resident 2's record titled Notice of Medicare Non-Coverage (NOMNC), undated, the record indicated it was signed by Resident 2.During an interview on 7/9/2025 at 11:29 AM, with Resident 2's Responsible Party (RP 1), RP 1 stated she repeatedly requested copies of any documents signed by Resident 2, including Resident 2's record titled Notice of Medicare Non-Coverage (NOMNC). RP 1 stated she sent multiple emails to the facility and had not received a response or the requested record.During a review of RP 1's emails to the facility dated 6/18/2025 at 6:12 AM and 6/19/2025 at 9:43 AM, the emails indicated RP 1 requested copies of any documents signed by Resident 2. The emails were addressed to the facility's Business Office Manager (BOM), Social Services Director (SSD), and Administrator (ADM).During a review of an email from the SSD to RP 1 dated 6/20/2025 at 10:09 AM, the email did not indicate RP1's requests for Resident 2's signed documents were addressed. During a review of RP 1's email to the facility dated 6/20/2025 at 6:02 PM, the email indicated RP 1 requested copies of any documents signed by Resident 2. The email was sent by RP 1 to the BOM, ADM, SSD, and Medical Records Director (MRD).During a review of an email dated 6/24/2025 at 9:31 AM, the email indicated RP 1 requested copies of any documents signed by Resident 2. The email was sent to the BOM, ADM, SSD, and MRD.During an interview on 7/9/2025 at 2:09 PM, with the MRD, the MRD stated she received the emails sent by RP 1 on 6/20/2025 at 6:02 PM and 6/24/2025 at 9:31 AM. The MRD stated copies of documents signed by Resident 2, including the NOMNC, were not provided to RP 1. When asked why copies of the requested documents were not provided, the MRD stated the Administrator in Training (AIT) told her to not respond to RP 1's emails. During a concurrent interview and record review, on 7/9/2025 at 2:15 PM, with the SSD, the emails sent by RP 1 dated 6/18/2025 at 6:12 AM, 6/19/2025 at 9:43 AM, 6/20/2025 at 6:02 PM, and 6/24/2025 at 9:31 AM, were reviewed. The SSD stated she received the emails from RP 1 and stated she did not reply to RP 1's requests, including the request for a signed copy of Resident 2's NOMNC. The SSD stated she did not follow-up with any other staff to ensure the record request was fulfilled.During a concurrent interview and record review, on 7/9/2025 at 2:25 PM, with the BOM, the emails sent by RP 1 dated 6/18/2025 at 6:12 AM and 6/19/2025 at 9:43 AM were reviewed. The Page 1 of 12 056458 056458 07/09/2025 Greenfield Care Center of South Gate 8455 State Street South Gate, CA 90280

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few BOM stated she received the emails and was aware of RP 1's requests. The BOM stated she did not provide any copies of records to RP 1.During a concurrent interview and record review, on 7/9/2025 2:44 PM, with the AIT, the facility's policy and procedure (P&P) titled Access to Personal and Medical Records, undated, was reviewed. The P&P indicated it was the facility's policy to provide access to and/or copies of records within 24 hours. The AIT stated there was no reason Resident 2's signed NOMNC could not be provided to RP 1. The AIT stated RP 1's request was missed. 056458 Page 2 of 12 056458 07/09/2025 Greenfield Care Center of South Gate 8455 State Street South Gate, CA 90280

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to timely report suspicions of abuse for one of four sampled residents (Resident 2).This deficient practice created a delay in the investigation of Resident 2's suspected abuse, and placed Resident 2 at risk for sustaining further abuse.Findings: During a review of Resident 2's admission Record, the admission record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's admitting diagnoses included muscle wasting and atrophy (thinning of muscle mass), lack of coordination, and generalized muscle weakness.During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 5/28/2025, the MDS indicated Resident 2 did not have cognitive (ability to think and reason) impairments. The MDS indicated Resident 2 required substantial to maximal assistance from staff with all mobility while in and out of bed.a. During a review of Resident 2's progress note dated 6/13/2025 at 3:13 PM, the progress note indicated on 6/13/2025, a verbal exchange, lasting approximately ten minutes, occurred between Resident 2 and RP 1. The progress note indicated RP 1 yelled at Resident 2 during the exchange.During an interview on 7/3/2025 at 12:09 PM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated verbal abuse was a type of abuse, and could appear as distress in the resident, including a change in their attitude or their demeanor. LVN 1 stated Resident 2 had a change in his demeanor since admission. LVN 1 stated Resident 2 used to smile more, but after interactions with RP 1, the resident was more upset and sadder than usual. LVN 1 stated Resident 2 told her he felt intimidated by RP 1.During a concurrent interview and record review, on 7/3/2025 at 12:18 PM, with LVN 1, Resident 2's progress note dated 6/13/2025, was reviewed. LVN 1 stated she wrote the progress note and observed the documented exchange between Resident 2 and RP 1. LVN 1 stated Resident 2's blood pressure was elevated after the incident. LVN 1 stated she reported the incident to Registered Nurse (RN) 1. LVN 1 stated she did not report the incident to any outside agencies, including the California Department of Public Health (CDPH). During an interview on 7/3/2025 at 12:47 PM, with RN 1, RN 1 stated LVN 1 informed her of the incident that occurred between Resident 2 and RP 1 on 6/13/2025. RN 1 stated she was not responsible for reporting the incident because she was not the staff who directly observed the incident. RN 1 stated that once she was made aware of the incident, she did not follow up further or assess Resident 2 for any harm or distress related to the incident. During an interview on 7/3/2025 at 1:55 PM, with the Director of Staff Development (DSD), the DSD stated all facility staff were mandated reporters and required to report suspected abuse if they had knowledge of it. The DSD stated all staff members were required to report suspected abuse, even if they did not directly witness it themselves.During a concurrent interview and record review, on 7/8/2025 at 2:01 PM, with the Director of Nursing (DON), Resident 2's progress note dated 6/13/2025 was reviewed. The progress note indicated RP 1 was yelling at the resident for approximately 10 minutes and that Resident 2 appeared visibly upset. The DON stated all staff were mandated reporters and stated the incident should have been reported in accordance with the facility's policy and procedure (P&P).During a concurrent interview and record review, on 7/8/2025 at 2:02 PM, with the DON, the facility's P&P titled Abuse and Neglect Prevention Management, revised 2/2018, was reviewed. The P&P indicated it was the facility's policy to ensure residents are safe and free from abuse. The DON stated the P&P indicated all staff were mandated reporters and that reporting of alleged abuse was to be completed according to state and federal guidance.During an interview on 7/8/2025 at 2:03 PM, with the DON, the DON stated the incident that occurred between Resident 2 and RP 1 on 6/13/2025 met the definitions of possible mental and/or verbal abuse in the facility's P&P titled Abuse and Neglect Prevention Management, revised 2/2018. The DON stated 056458 Page 3 of 12 056458 07/09/2025 Greenfield Care Center of South Gate 8455 State Street South Gate, CA 90280

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the incident should have been reported within two hours to the CDPH and other required agencies. The DON stated RN 1 and LVN 1 were both responsible for reporting.During a concurrent interview and record review, on 7/8/2025 at 2:26 PM, with the facility's Administrator in Training (AIT), Resident 2's progress note dated 6/13/2025 was reviewed. The AIT stated RP 1 yelling at Resident 2 was possible mental abuse. The AIT stated he was serving as the facility's abuse coordinator, and stated he was not made aware of the incident that occurred between Resident 2 and RP 1 on 6/13/2025. The AIT stated the incident should have been reported because RP 1 was causing distress to Resident 2. The AIT stated anyone with knowledge of the incident that occurred on 6/13/2025 should have reported it.b. During an interview on 7/3/2025 at 2:33 PM, with the Social Services Director (SSD), the SSD stated a meeting was held with Resident 2 on 6/26/2025. The SSD stated during interactions, Resident 2 agreed with RP 1 to avoid arguing or fighting. The SSD stated that during the meeting, Resident 2 expressed distress related to his interactions with RP 1. The SSD stated Resident 2's statement indicated there was possible abuse occurring by RP 1 towards Resident 2. During a concurrent interview and record review, on 7/3/2025 at 2:50 PM, with the SSD, the SSD stated she first suspected abuse was occurring on 6/26/2025, but did not report Resident 2's suspected abuse until 6/27/2025. When asked why the reporting was delayed, the SSD stated she was waiting for guidance from the Ombudsman (a public official who advocates for residents of nursing homes and other long-term care facilities) on whether to report. The SSD stated she placed the initial call to the Ombudsman on 6/26/2025 but did not hear back from the Ombudsman until 6/27/2025. The SSD stated she was taught by the former SSD to get guidance from the Ombudsman prior to reporting suspected abuse.During a concurrent interview and record review, on 7/3/2025 at 2:56 PM, with the SSD, the facility's P&P titled Abuse and Neglect Prevention Management, revised 2/2018, was reviewed. The SSD stated the P&P did not indicate the Ombudsman was required to provide guidance on abuse reporting. The SSD stated the P&P indicated suspected abuse was to be reported right away. The SSD stated timely reporting was important to ensure the abuse was addressed and to prevent any unwanted adverse effects on the resident's wellbeing resulting from the abuse.During an interview on 7/8/2025 at 2:48 PM, with the AIT, the AIT stated he was not sure why the suspected abuse was reported late. The AIT stated the incident should have been reported on 6/26/2025, within two hours of the meeting with Resident 2. 056458 Page 4 of 12 056458 07/09/2025 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 interview and record review, the facility failed to ensure care plans were developed for two of four sampled residents (Resident 2 and Resident 3). This deficient practice placed Resident 2 and Resident 3 at risk of not receiving resident-centered care and interventions to assist them in reaching their highest practicable physical and psychosocial well-being.Findings: a. During a review of Resident 3's admission Record, the record indicated Resident 3 was originally admitted to the facility on [DATE] and was most recently re-admitted on [DATE]. Resident 3's admitting diagnoses included chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and hypotension (low blood pressure). During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 6/5/2025, the MDS indicated Resident 3 did not have cognitive impairments (a decline in one or more areas of mental function, such as memory, attention, or problem-solving). The MDS indicated Resident 3 was dependent on staff for toileting hygiene and rolling from left to right while in bed. During a concurrent interview and record review, on 7/8/2025 at 11:29 AM, with the Minimum Data Set Nurse (MDSN), Resident 3's MDS dated [DATE] was reviewed. The MDS indicated Resident 3 required two person assist for repositioning from left to right while in bed. The MDSN stated the assistance of two staff, instead of just one, was for Resident 3's safety. The MDSN stated that if two-person assistance was not provided, there was potential for Resident 3 to sustain preventable accidents and injuries. The MDSN stated it was better to prevent harm to the resident, than to have an accident and address the harm after. The MDSN stated the requirement for two-person assistance should be care planned. During an interview on 7/8/2025 at 11:33 AM, with the MDSN, the MDSN stated Resident 3 did not have a care plan indicating the level of assistance required for the provision of safe, resident-centered care. The MDSN stated care plans guided the care provided to the residents, and the absence of a care plan placed Resident 3 at risk for injury from falls. During a review of the facility's policy and procedure (P&P) titled Policies and Procedure on Nursing Assessment, undated, the P&P indicated the results of the MDS assessment were to be used to formulate a plan of care. b. During a review of Resident 2's admission Record, the record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's admitting diagnoses included muscle wasting and atrophy (thinning of muscle mass), lack of coordination, and generalized muscle weakness. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 did not have cognitive impairments. The MDS indicated Resident 2 required substantial to maximal assistance from staff with all mobility while in and out of bed. During a review of Resident 2's progress note dated 6/13/2025 at 3:13 PM, the progress note indicated a verbal exchange, lasting approximately ten minutes, occurred on 6/13/2025, between Resident 2 and his Responsible Party (RP 1). The progress note indicated RP 1 yelled at Resident 2 during the exchange. During a concurrent interview and record review, on 7/3/2025 at 12:18 PM, with Licensed Vocational Nurse (LVN) 1, Resident 2's progress note dated 6/13/2025, was reviewed. LVN 1 stated she wrote the progress note and observed the documented exchange between Resident 2 and RP 1. LVN 1 stated she felt the exchange was possible verbal abuse. During an interview on 7/3/2025 at 12:24 PM, with LVN 1, LVN 1 stated that any incidents of suspected or alleged abuse were to be care planned. LVN 1 stated the purpose of developing a care plan was to ensure the resident did not sustain any psychosocial harm from the incident and prevent repeated incidents of abuse. LVN 1 stated the care plan would include interventions to ensure that the goal was met. During an interview on 7/8/2025 at 2:05 PM, with the Director of Nursing (DON), the DON stated a care plan should have been developed after the exchange 056458 Page 5 of 12 056458 07/09/2025 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 between Resident 2 and RP 1 on 6/13/2025. The DON stated a care plan would address the suspected abuse between Resident 2 and RP 1 and would help prevent any future incidents of RP 1 yelling at Resident 2, potentially causing him distress. The DON stated the main goal of care would be to prevent any psychosocial harm to Resident 2. During a review of the facility's P&P titled Abuse and Neglect Prevention Management, revised 2/2018, the P&P indicated staff were to complete care plan updates to incorporate individualized recommendations. 056458 Page 6 of 12 056458 07/09/2025 Greenfield Care Center of South Gate 8455 State Street South Gate, CA 90280

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings: 1. During a review of Resident 3's admission Record, the admission record indicated Resident 3 was originally admitted to the facility on [DATE] and was most recently re-admitted on [DATE]. Resident 3's admitting diagnoses included chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and hypotension (low blood pressure).During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 6/5/2025, the MDS indicated Resident 3 did not have cognitive impairments (a decline in one or more areas of mental function, such as memory, attention, or problem-solving). The MDS indicated Resident 3 was dependent on staff for toileting hygiene and rolling from left to right while in bed, requiring two-person assist. During a review of Resident 3's progress note, dated 6/20/2025, the progress note indicated that on 6/20/2025 at 8:30 AM, Registered Nurse (RN) 1 overheard Certified Nursing Assistant (CNA) 1 shouting for help. The progress note indicated RN 1 went to Resident 3's room and observed Resident 3 in a face-down position on the floor next to her bed. The progress note indicated RN 1 observed blood on the floor from Resident 3's head and foot. The progress note indicated Resident 3 stated she was being cleaned from behind when she fell from her bed onto the floor.During an interview on 7/8/2025 at 8:32 AM, with Resident 3, Resident 3 stated that on 6/20/2025, CNA 1 repositioned her onto her side facing away from CNA 1. Resident 3 stated there was no other staff on the opposite side of the bed where she was facing. Resident 3 stated she began to slide off the right side of her bed and fell to the floor.During an interview on 7/8/2025 at 9:06 AM, with CNA 1, CNA 1 stated she turned Resident 3 onto her right side, towards the edge of the mattress without any other staff present. CNA 1 stated Resident 3 required two staff during care for safety. CNA 1 stated she made a mistake by not waiting for another staff person to assist. CNA 1 stated Resident 3 fell from the bed and scraped her head on the bedrail. CNA 1 stated Resident 3 was receiving blood thinners at the time and she bled from her wounds. During an interview on 7/8/2025 at 10:05 AM, with RN 1, RN 1 stated Resident 3 required assistance from two staff for safety. RN 1 stated CNA 1 did not request assistance. RN 1 stated that if a resident required two-person assist but it was not provided, there was potential for injury, and the inability to provide safe or correct care. RN 1 stated that as a result of the fall, Resident 3 sustained injuries requiring first aid (the immediate care given to someone who is injured). During a concurrent interview and record review, on 7/8/2025 at 11:06 AM, with the Director of Rehabilitation (DOR), Resident 3's assessment titled Rehab Screening Form, dated 6/20/2025, was reviewed. The DOR stated the assessment was completed for Resident 3's fall on 6/20/2025, and the assessment indicated she re-educated staff on having at least two staff present when assisting Resident 3 while repositioning in bed due to obesity (a medical condition characterized by excessive accumulation of body fat). The DOR stated Resident 3 had required two-person assistance since her admission to the facility and staff were aware. The DOR stated all obese residents required at least two-person assist for safety. The DOR stated staff were educated to not overestimate what they can safely perform alone and to always have a second person to assist them.During a concurrent interview and record review, on 7/8/2025 at 11:29 AM, with the Minimum Data Set Nurse (MDSN), Resident 3's MDS dated [DATE] was reviewed. The MDS indicated Resident 3 required two staff to perform repositioning from left to right while in bed. The MDSN stated the assistance of two staff, instead of just one, was for Resident 3's safety. The MDSN stated that if two-person assistance was not provided, there was potential for Resident 3 to sustain preventable accidents and injuries. The MDSN stated it was better to prevent harm to the resident than to have an accident and address 056458 Page 7 of 12 056458 07/09/2025 Greenfield Care Center of South Gate 8455 State Street South Gate, CA 90280

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the harm after. During a concurrent interview and record review, on 7/8/2025 at 1:42 PM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled Safey and Supervision of Residents, undated, was reviewed. The DON stated the P&P indicated indicate staff were to use various sources to identify risk factors for falls, including the resident's MDS.During an interview on 7/8/2025 at 1:43 PM, with the DON, the DON stated Resident 3 required assistance from two staff for repositioning in bed and toileting hygiene. The DON stated Resident 3's fall on 6/20/2025 could have been avoided if CNA 1 had waited for another staff to assist her.During a review of the facility's P&P titled Safety and Supervision of Residents, undated, the P&P indicated resident safety and assistance to prevent accidents were facility-wide priorities. The P&P indicated staff were to analyze information obtained from assessments to identify specific accident hazards or risks for the resident, and target interventions to reduce the potential for accidents.2. During a review of Resident 1's admission Record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and most recently re-admitted on [DATE]. Resident 1's admitting diagnoses included reduced mobility and broken bones in her right leg.During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1 did not have cognitive impairments. The MDS indicated Resident 1 had impairments to her upper extremities (shoulder, elbow, wrist, hand) on both sides of her body. The MDS indicated Resident 1 required substantial to maximum assistance from staff for rolling left to right in bed. The MDS indicated Resident 1 was dependent on staff for toileting hygiene, and transitioning from a sitting to lying position (and vice versa) and sitting to standing position (and vice versa).During a review of Resident 1's physician order, dated 6/23/2025, the order indicated staff were to ensure Resident 1 had floor mats on both sides of her bed.During a review of Resident 1's care plan titled Resident at risk for recurrent fall/injury related tohistory of falls., dated 6/22/2025, the care plan indicated goals of care included fall prevention and no injury from falls. Care plan interventions indicated staff were to place floor mats on both sides of Resident 1's bed.During a review of Resident 1's Fall Risk Assessment, dated 6/24/2025, the assessment indicated Resident 1 was at high risk for falls.During an observation on 7/3/2025 at 9:35 AM, at Resident 1's bedside, no floor mats were observed on the floor next to Resident 1's bed. During an observation on 7/7/2025 at 9:03 AM, at Resident 1's bedside, a blue floor mat was placed on the floor to Resident 1's right side. There was no floor mat observed to Resident 1's left side. Observed a gray floor mat folded and placed under Resident 1's roommate's bed.During a concurrent observation and interview, on 7/7/2025 at 9:10 AM, at Resident 1's bedside, with RN 1, RN 1 stated Resident 1 had floor mats on one side of her bed. RN 1 stated she was not sure if Resident 1 required floor mats to one side or both sides of her bed.During a concurrent observation and interview, on 7/7/2025 at 9:16 AM, at Resident 1's bedside, with RN 1, observed RN 1 unfold the gray floor mat from under Resident 1's roommate's bed, and place it to Resident 1's left side of the bed. RN 1 stated Resident 1 had orders for floor mats to both sides of her bed. RN 1 stated the purpose of the floor mats was to prevent injury from falls. RN 1 stated there was potential for Resident 1 to sustain injury from a fall if the floor mats were not placed as ordered.During an observation on 7/8/2025 at 8:35 AM, at Resident 1's bedside, observed a blue floor mat on Resident 1's right side of the bed. There was no floor mat to Resident 1's left side. Observed a gray floor mat was observed folded under Resident 1's roommate's bed.During a concurrent interview and record review, on 7/8/2025 at 1:45 PM, with the DON, Resident 1's care plan titled Resident at risk for recurrent fall/injury related to history of falls., dated 6/22/2025, was reviewed. The DON stated the care plan indicated Resident 1 was to have floor mats on both sides of her bed.During a concurrent interview and record review on 7/8/2025 at 1:47 PM, with the DON, the facility's 056458 Page 8 of 12 056458 07/09/2025 Greenfield Care Center of South Gate 8455 State Street South Gate, CA 90280

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few P&P titled Fall Risk Intervention and Monitoring, undated, was reviewed. The P&P indicated it was the facility's policy to try and minimize complications from falling and staff were to implement relevant interventions to try and minimize serious consequences of falling. The DON stated floor mats were one of those interventions. The DON stated that residents should have floor mats as ordered and/or care planned. The DON stated floor mats helped to prevent injury from falls, and the absence of floor mats could result in the resident sustaining injuries from a fall.During a concurrent interview and record review, on 7/8/2025 at 1:48 PM, with the DON, Resident 1's records titled Fall Investigation Form, dated 3/24/2025, and Fall Risk Assessment, dated 5/1/2025, were reviewed. The DON stated the Fall Investigation Form indicated Resident 1 sustained a fall on 3/24/2025 when she slid out of her wheelchair. The DON stated the Fall Risk Assessment indicated Resident 1 did not have a fall in the last six months. The DON stated the assessment was not accurate and stated the inaccuracy affected the resident's fall risk score. The DON stated the assessment should be accurate because it guided the plan of care to prevent Resident 1 from sustaining future falls.3. During a review of Resident 4's admission Record, the record indicated Resident 4 was originally admitted to the facility on [DATE] and was most recently re-admitted on [DATE], Resident 4's admitting diagnoses included difficulty walking, history of falling, and convulsions (a sudden, violent, irregular movement of a limb or of the body, caused by involuntary contraction of muscles). During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 5 had severe cognitive impairments and required supervision or touch assistance from staff for all mobility while in and out of bed.During a review of Resident 4's Fall Risk Assessment, dated 4/9/2025, the assessment indicated Resident 4 was at high risk for falls.During a review of Resident 4's care plan titled Resident at risk for further falls/injury related to impaired balance ., [history of] falls, trying to get out of bed unassisted.,, dated 5/5/2025, the care plan indicated goals of care included prevention of falls and injury from falls. Care plan interventions indicated staff were to place floor mats on both sides of Resident 4's bed.During an observation on 7/7/2025 at 9:17 AM, at Resident 4's bedside, observed Resident 4 lying in bed with a floor mat to his left side. There was no floor mat to Resident 4's right side.During an observation on 7/7/2025 at 10:01 AM, at Resident 4's bedside, observed no floor mats to either side of Resident 4's bed. Observed two floor mats folded and placed against the wall on Resident 4's left side of the bed. During a concurrent observation and interview, on 7/7/2025 at 10:05 AM, at Resident 4's bedside, with RN 2, observed Resident 4's floor mats folded up against the wall. RN 2 stated Resident 4 was at risk for falls. RN 2 stated Resident 4's floor mats were not in place. RN 2 stated the floor mats were moved by a CNA in preparation for Resident 4's shower. RN 2 stated the CNA was in another room with another resident. RN 2 stated the floor mats should not have been moved until the CNA was at the bedside and ready to take Resident 4 to the shower. RN 2 stated the absence of the floor mats could lead to injuries if Resident 4 fell. During an observation on 7/8/2025 at 8:36 AM, at Resident 4's bedside, observed a blue fall mat to Resident 4's left side. Observed no floor mat to Resident 4's right side. During a concurrent interview and record review, on 7/8/2025 at 1:46 PM, with the DON, Resident 4's care plan titled Resident at risk for further falls/injury related to impaired balance ., [history of] falls, trying to get out of bed unassisted.,, dated 5/5/2025, was reviewed. The DON stated the care plan indicated Resident 4 was to have floor mats to both sides of his bed.During a concurrent interview and record review on 7/8/2025 at 1:47 PM, with the DON, the facility's P&P titled Fall Risk Intervention and Monitoring, undated, was reviewed. The P&P indicated it was the facility's policy to try and minimize complications from falling. The DON stated the P&P indicated staff were to implement relevant interventions to try and minimize serious consequences of falling. The 056458 Page 9 of 12 056458 07/09/2025 Greenfield Care Center of South Gate 8455 State Street South Gate, CA 90280

F 0689 Level of Harm - Minimal harm or potential for actual harm DON stated floor mats were one of those interventions. The DON stated that residents should have floor mats in placed as ordered and/or care planned. The DON stated floor mats helped to prevent injury from falls, and absence of floor mats could result in the resident sustaining injuries from a fall. Residents Affected - Few 056458 Page 10 of 12 056458 07/09/2025 Greenfield Care Center of South Gate 8455 State Street South Gate, CA 90280

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1, Registered Nurse (RN) 1, and the Social Services Director (SSD) implemented the facility's policy and procedure titled Abuse and Neglect Prevention Management, revised 2/2018, related to abuse reporting, for one of four sampled residents (Resident 2).This deficient practice resulted in LVN 1 and RN 1 not reporting suspicions of Resident 2's abuse on 6/13/2025, and the SSD not reporting suspicions of Resident 2's abuse on 6/26/2025. Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's admitting diagnoses included muscle wasting and atrophy (thinning of muscle mass), lack of coordination, and generalized muscle weakness.During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 5/28/2025, the MDS indicated Resident 2 did not have cognitive impairments (a decline in mental abilities, such as memory, thinking, and problem-solving). The MDS indicated Resident 2 required substantial to maximal assistance from staff with all mobility while in and out of bed.a. During a review of Resident 2's progress note dated 6/13/2025 at 3:13 PM, the progress note indicated a verbal exchange, lasting approximately ten minutes, occurred on 6/13/2025, between Resident 2 and his Responsible Party (RP 1). The progress note indicated RP 1 yelled at Resident 2 during the exchange.During an interview on 7/3/2025 at 12:09 PM, with LVN 1, LVN 1 stated she received training related to abuse and abuse reporting about a month ago. During a concurrent interview and record review, on 7/3/2025 at 12:18 PM, with LVN 1, Resident 2's progress note dated 6/13/2025, written by LVN 1, was reviewed. LVN 1 stated on 6/13/2025, she observed the documented exchange between Resident 2 and RP 1. LVN 1 stated Resident 2's blood pressure was elevated after the incident. LVN 1 stated she felt the exchange was possible verbal abuse and stated she reported the incident to Registered Nurse (RN) 1. LVN 1 stated she did not report the incident to any outside agencies, including the California Department of Public Health (CDPH). During an interview on 7/3/2025 at 12:47 PM, with RN 1, RN 1 stated she received training related to abuse and abuse reporting in the last month. RN 1 stated LVN 1 informed her of the incident that occurred between Resident 2 and RP 1 on 6/13/2025. RN 1 stated she did not report the suspected verbal abuse. RN 1 stated she was not responsible for reporting the incident because she was not the staff who directly observed the incident.During an interview on 7/3/2025 at 1:55 PM, with the Director of Staff Development (DSD), the DSD stated all facility staff were mandated reporters and required to report if they had knowledge of suspected abuse. The DSD stated all staff members were required to report suspected abuse, even if they did not directly witness it themselves.During a concurrent interview and record review, on 7/8/2025 at 2:01 PM, with the Director of Nursing (DON), Resident 2's progress note dated 6/13/2025 was reviewed. The progress note indicated RP 1 was yelling at the resident for approximately 10 minutes and that Resident 2 appeared visibly upset. The DON stated all staff were mandated reporters and stated the incident should have been reported in accordance with the facility's policy and procedure (P&P).During a concurrent interview and record review, on 7/8/2025 at 2:02 PM, with the DON, the facility's P&P titled Abuse and Neglect Prevention Management, revised 2/2018, was reviewed. The P&P indicated it was the facility's policy to ensure residents are safe and free from abuse. The DON stated the P&P indicated all staff were mandated reporters and that reporting of alleged abuse was to be completed according to state and federal guidance. The DON stated the incident that occurred between Resident 2 and RP 1 on 6/13/2025 met the definitions of possible mental and/or verbal abuse according to the facility's P&P. The DON stated the incident should have been reported within two hours to 056458 Page 11 of 12 056458 07/09/2025 Greenfield Care Center of South Gate 8455 State Street South Gate, CA 90280

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the CDPH and other required agencies. The DON stated RN 1 and LVN 1 were both responsible for reporting.During a review of RN 1's job description and performance standards, titled RN Supervisor, dated 6/2/2025, the document indicated the purpose of this position was to supervise and coordinate nursing care in compliance with facility policies and procedures. The document indicated RN 1 was responsible for the safety of residents under their supervision, and RN 1 was to observe all facility policies and procedures. During a review of LVN 1's job description and performance standards, titled Medication Nurse, dated 1/27/2022, the document indicated the LVN 1 was responsible for the safety of residents under their supervision, and LVN 1 was to observe all facility policies and procedures,b. During an interview on 7/3/2025 at 2:33 PM, with the SSD, the SSD stated on 6/26/2025, a meeting was held with Resident 2 following a visit from the local police department related to an Adult Protective Services report filed by RP 1. The SSD stated that during the meeting, Resident 2 expressed distress related to his interactions with RP 1. The SSD stated Resident 2's statement indicated there was possible abuse occurring by RP 1 towards Resident 2. During a interview on 7/3/2025 at 2:50 PM, with the SSD, of Resident 2's the SSD stated she first suspected abuse was occurring on 6/26/2025, but did not report Resident 2's suspected abuse until 6/27/2025. When asked why the reporting was delayed, the SSD stated she was waiting for guidance from the Ombudsman (a public official who advocates for residents of nursing homes and other long-term care facilities) on whether to report. The SSD stated she placed the initial call to the Ombudsman on 6/26/2025 but did not hear from the Ombudsman until 6/27/2025. The SSD stated she was taught by the former SSD to get guidance from the Ombudsman prior to reporting suspected abuse.During a concurrent interview and record review, on 7/3/2025 at 2:56 PM, with the SSD, the facility's P&P titled Abuse and Neglect Prevention Management, revised 2/2018, was reviewed. The P&P did not indicate the Ombudsman was required to provide guidance on abuse reporting. The SSD stated the P&P indicated suspected abuse was to be reported right away. The SSD stated timely reporting was important to ensure the abuse was addressed and to prevent any unwanted adverse effects on the resident's wellbeing resulting from the abuse.During an interview on 7/3/2025 at 3:20 PM, with the DSD, the DSD stated staff were not trained to get approval from the Ombudsman prior to reporting alleged or suspected abuse.During a concurrent interview and record review on 7/3/2025 at 3:42 PM, with the DSD, the SSD's abuse training post-test results, dated 9/16/2024, were reviewed. The post-test indicated the SSD scored five out of 10 questions correct on her abuse training post-test upon hire. The DSD stated a score of five out of 10 was not a passing score. When asked what was done to address the score of five out of 10, the DSD stated nothing was done and the SSD proceeded to begin her role as the SSD.During a concurrent interview and record review, on 7/8/2025 at 2:44 PM, with the Administrator in Training (AIT), the SSD's abuse training post-test results, dated 9/16/2024, were reviewed. The AIT stated the post-test score indicated the SSD failed the test. The AIT stated it was not sufficient for the DSD to accept the score and provide no further training, in-service, or re-evaluation to ensure the SSD had the required competencies related to abuse prevention. The AIT stated it was not acceptable, and stated it was important for the SSD to be competent in the facility's abuse policies because she was an advocate for the facility residents and she should be able to identify possible abuse and take the required actions. During a review of the SSD's job description and performance standards, titled Social Service Director (Designee), dated 6/6/2025, the document indicated the SSD was responsible for observing all facility policies and procedures, and was to provide services that meet the social and/or emotional needs affecting the resident's ability to achieve their highest level of function. 056458 Page 12 of 12