Health inspection·September 12, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect one of three resident's (Resident 1) right to be free from physical abuse by another resident (Resident 2). This deficient practice resulted in Resident 1 being slapped on the right side of the face by Resident 2.Findings:a. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and major depressive disorder (a mood disorder that caused a persistent feeling of sadness and loss of interest).During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 7/16/2025, the MDS indicated Resident 1 had severely impaired cognitive skills for daily decision making (ability to think and reason). The MDS indicated Resident 1 required supervision with eating and using a wheelchair. The MDS indicated Resident 1 required partial assistance (helper did less than half the effort) with oral hygiene and personal hygiene. The MDS indicated Resident 1 required maximal assistance (helper did more than half the effort) with toileting hygiene and showering/ bathing. The MDS indicated Resident 1 was dependent (helper did all the effort) on staff for bed-to-chair transferring. During a review of Resident 1's History and Physical (H&P), dated 11/1/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's care plan titled Resident at risk for recurrent fall/injury, revised on 7/23/2025, the care plan indicated staff were to observe Resident 1 frequently and to place Resident 1 in a supervised area when out of bed.During a review of Resident 1's nursing progress notes, dated 9/10/2025 at 9:33 a.m., the nursing progress notes indicated on 9/10/2025 at 9:05 a.m., Licensed Vocational Nurse (LVN) 1 reported to Registered Nurse (RN) 1 that Resident 2 slapped Resident 1. b. 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 diagnoses included dementia (a progressive state of decline in mental abilities), anxiety (a feeling of fear, dread, and uneasiness), and major depressive disorder. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 2 required setup assistance with eating, oral hygiene, toileting hygiene, and bed-to-chair transferring. The MDS indicated Resident 2 required supervision with showering/ bathing, personal hygiene, and walking. During a review of Resident 2's H&P, dated 8/18/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's care plan titled Chronic confusion related to dementia as evidenced by altered interpretation (a changed understanding or explanation of something) or response to stimuli (anything that caused a physical or behavioral change), revised on 8/29/2025, the care plan indicated staff were to maintain a pleasant and quiet environment.During a review of Resident 2's nursing progress notes, dated 9/10/2025 at 9:41 a.m., the nursing progress notes indicated on Page 1 of 7 056458 056458 09/12/2025 Greenfield Care Center of South Gate 8455 State Street South Gate, CA 90280

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 9/10/2025 at 9:05 a.m., LVN 1 reported to RN 1 that Resident 2 slapped Resident 1. During an interview on 9/11/2025 at 11:14 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated on 9/10/2025 around 8:50 a.m., he informed Resident 1 that it was time to shower, and Resident 1 replied No. CNA 1 stated Resident 2 was upset because Resident 1 yelled No when getting ready for the shower. CNA 1 stated that Resident 2 was looking at Resident 1 with furrowed eyebrows before she (CNA 1) stepped out of the room to get the Hoyer lift (a device that helped move people with limited mobility safely between surfaces). CNA 1 stated she left Resident 1 in the wheelchair by her bed. CNA 1 stated she went to get the Hoyer lift to transfer Resident 1 from wheelchair to shower chair. CNA 1 stated within four seconds of leaving the room, she heard Resident 2 cursing (using rude, offensive, or swear words) at Resident 1. CNA 1 stated Resident 1 was sitting in the wheelchair next to Resident 2's left side of the bed. CNA 1 stated Resident 1 asked Resident 2 Why are you cussing at me? I never did anything to you. CNA 1 stated Resident 2 got out of the bed, cursed at Resident 1, slapped Resident 1's right side of her face and punched Resident 1's stomach. CNA 1 stated she stopped Resident 2 and separated the residents. CNA 1 stated that she would not have left Resident 1 alone in the room with Resident 2, if she had known that Resident 1 could unlock the wheelchair and wheel to Resident 2's bedside. CNA 1 stated Resident 2 was ambulatory (able to walk) and capable of being physically aggressive (ready to fight or forceful) toward other residents. CNA 1 stated she should have taken Resident 1 with her when she left the room to get the Hoyer lift to prevent Resident 2 from physically attacking Resident 1. During an interview on 9/11/2025 at 12:23 p.m. with LVN 1, LVN 1 stated on 9/10/2025 at 9 a.m., she was passing medication outside room [ROOM NUMBER]. LVN 1 stated CNA 1 power-walked to her from room [ROOM NUMBER] and informed her that Resident 2 slapped Resident 1 on the right side of her face. LVN 1 stated CNA 1 did not bring Resident 1 with her. LVN 1 stated Resident 1 was sitting in the wheelchair at her bedside and Resident 2 was sleeping in bed. LVN 1 stated she separated the residents and placed Resident 1 in another room. LVN 1 stated neither Residents 1 nor 2 were able to provide any details about what happened. LVN 1 stated it was not acceptable to leave Resident 1 with an upset roommate because it might escalate to verbal, physical, or emotional abuse. LVN 1 stated staff should take precautions to separate the residents for safety, remove the upset resident, and de-escalate the situation. LVN 1 stated the incident would have been prevented if CNA 1 had removed Resident 1 from the room when Resident 2 became upset. During an interview on 9/12/2025 at 10:41 a.m. with RN 1, RN 1 stated on 9/10/2025 around 9 a.m., LVN 1 informed her that Resident 2 slapped Resident 1 on the right side of the face. RN 1 stated CNA 1 was wheeling Resident 1 out of her (Resident 1's) room when she (RN 1) arrived. RN 1 stated Resident 2 was resting in bed. RN 1 stated leaving Resident 1 with Resident 2, who was upset with Resident 1, might further escalate the situation. RN 1 stated Resident 1 could self-propel in the wheelchair and go to Resident 2's side of the room. RN 1 stated it was not acceptable to leave Resident 1 in the room with Resident 2 after Resident 2 slapped Resident 1. RN 1 stated CNA 1 should have removed Resident 1 away from Resident 2 immediately when Resident 2 became verbally aggressive toward Resident 1. RN 1 stated Resident 1 was not protected. RN 1 stated CNA 1 should have taken Resident 1 with her to report the incident to LVN 1. RN 1 stated the incident was preventable. RN 1 stated all staff should protect the residents. During an interview on 9/12/2025 at 12:25 p.m. with the Administrator in Training (AIT), the AIT stated staff should have immediately separated the residents after Resident 2 slapped Resident 1. The AIT stated the facility should provide as safe of an environment as possible. The AIT stated it was not acceptable to leave Resident 1 in the same room as Resident 2 after the incident. The AIT stated Resident 1 was not protected. The AIT stated Resident 2 slapping Resident 1 was preventable. The AIT stated 056458 Page 2 of 7 056458 09/12/2025 Greenfield Care Center of South Gate 8455 State Street South Gate, CA 90280

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few CNA 1 should have left Resident 1 in bed or asked someone to bring the Hoyer lift to the room. During a review of the facility's Policy and Procedure (P&P) titled Abuse Policy, dated 10/2024, the P&P indicated residents would be protected from abuse and harm while residing at the facility. The P&P indicated no abuse or harm of any type would be tolerated, and residents would be monitored for protection. The P&P indicated all staff should monitor residents and identify potential signs and symptoms of abuse. The P&P indicated residents would be protected from the alleged offenders. The P&P further indicated that staff witnessing abuse would immediately intervene to protect the resident. 056458 Page 3 of 7 056458 09/12/2025 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 - Some 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 licensed nurse failed to follow physician's orders for two of three sampled residents (Resident 2 and Resident 3) when:1. Resident 2's blood pressure readings and heart rate were not recorded and documented on the Medication Administration Record (MAR), for six days in the month of August 2025 and one day in the month of September 2025.2. Resident 3's arteriovenous fistula (AV fistula, direct connection between an artery and a vein) dressing was not removed four hours after dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) treatment on 9/10/2025 and 9/11/2025.3. Resident 3 was not administered oxygen as ordered at two liters (measurement for gas volume) per minute.4. Resident 3's oxygen saturation level (O2 sat- a measurement of how much oxygen the blood was carrying as a percentage) was not assessed on room air.These deficient practices demonstrated a lack of nursing competency in assessment, documentation, and implementation of care, which had the potential to compromise the residents' health and safety. Findings:1. 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 diagnoses included dementia (a progressive state of decline in mental abilities), anxiety (a feeling of fear, dread, and uneasiness), and major depressive disorder (a mood disorder that caused a persistent feeling of sadness and loss of interest). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 8/29/2025, the MDS indicated Resident 2 had severely impaired cognitive skills for daily decision making (ability to think and reason). The MDS indicated Resident 2 required setup assistance with eating, oral hygiene, toileting hygiene, and bed-to-chair transferring. The MDS indicated Resident 2 required supervision with showering/ bathing, personal hygiene, and walking. During a review of Resident 2's History and Physical (H&P), dated 8/18/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Order Summary Report, dated 9/11/2025, the report indicated to hold lisinopril (medication to treat high blood pressure [HTN]) and metoprolol tartrate (medication to treat HTN) for systolic blood pressure (top number in a blood pressure reading) less than 110 beats per minute (BPM) or heart rate less than 60 BPM. During a review of Resident 2's Medication Administration Records (MAR), dated from 8/1/2025 to 9/11/2025, the MAR indicated Resident 2's blood pressure was below the parameter (a set value that helped control something) and did not receive lisinopril and metoprolol on 8/2, 8/14, 8/16, 8/21, 8/23, 8/27, and 9/6/2025. During a concurrent interview and record review on 9/11/2025 at 12:23 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 2's Vital Summary, dated from 8/1/20259/11/2025 was reviewed. There were no blood pressure or heart rate readings documented on 8/2, 8/14, 8/16, 8/21, 8/23, 8/27, and 9/6/2025. LVN 1 stated that Resident 2's blood pressure or heart rate readings should be documented. LVN 1 stated the licensed nurse was responsible for taking vital signs (basic measure of how your body was working) and documenting in the residents' progress notes or MAR. LVN 1 stated the licensed nurse should have completed the documentation by the end of the shift to make sure the residents were in safe and stable condition. LVN 1 stated it was important to document the blood pressure readings and heart rate on the Vital Summary or the MAR for residents' safety. LVN 1 stated it was important to know the residents' blood pressure to prevent medication error (mistake in giving medicine). LVN 1 stated that incomplete documentation posed risks such as not knowing if Resident 2's blood pressure was too low, the next shift being unaware of prior events, difficulty tracing the resident's history, and potential delays in necessary care.During an interview on 9/12/2025 at 11:36 a.m. with the Director of Nursing (DON), the DON 056458 Page 4 of 7 056458 09/12/2025 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 - Some stated the licensed nurse should measure and document the residents' blood pressure on the MAR. The DON stated that documentation was necessary so the next shift would know the previous blood pressure reading. The DON stated it was important to document the blood pressure readings in the MAR to ensure the continuity of care. The DON stated documentation must be completed by the end of the shift to serve as a baseline for the next shift. The DON stated that documentation should be timely and accurate, and failing to document blood pressure was unacceptable. The DON stated that without documented blood pressure, administering blood pressure medication could cause hypotension (low blood pressure) leading to dizziness, weakness, or fainting. The DON stated the facility's policy required blood pressure readings to be documented in the MAR.During a review of the facility's policy and procedure (P&P) titled Vital Sign, dated 7/2012, the P&P indicated the vital signs and O2 saturations would be documented in all appropriate areas in the resident's medical record. 2a. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included end stage renal disease (ESRD, irreversible kidney failure), congestive heart failure (CHF, a heart disorder which caused the heart to not pump the blood efficiently), and chronic respiratory failure (a long-term condition where the lungs could not get enough oxygen).During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had intact cognitive skills for daily decision making. The MDS indicated Resident 3 required setup assistance with eating and oral hygiene. The MDS indicated Resident 3 required supervision with personal hygiene. The MDS indicated Resident 3 was dependent (helper did all the effort) on staff for toileting hygiene, showering/ bathing, and bed-to-chair transferring. During a review of Resident 3's H&P, dated 6/17/2025, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's care plan for ESRD, revised on 6/17/2025, the care plan goals indicated Resident 3 would remain free from complications daily. The care plan interventions indicated staff were to monitor Resident 3's left upper arm arteriovenous fistula (AV fistula, a direct connection between an artery and a vein) site for redness, swelling, local warmth, tenderness, bruit (a swishing sound over a blood vessel), thrill (a vibration over a blood vessel), and bleeding.During a review of Resident 3's nursing progress notes, dated 9/10/2025 at 7:27 p.m., the nursing progress notes indicated on 9/10/2025 at 4:10 p.m., Resident 3 returned from dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed).During a concurrent observation and interview on 9/11/2025 at 10:50 a.m. with Resident 3, in Resident 3' room, observed Resident 3's left upper arm. The arm was covered with a pressurized dressing (dressing that applied firm and consistent pressure to a site) over the AV fistula site. Resident 3 stated the licensed nursing staff did not check her AV fistula site or dressing after she returned from dialysis on 9/10/2025. During a concurrent observation and interview on 9/11/2025 at 1:24 p.m. with LVN 1, in Resident 3's room, observed Resident 3's left upper arm. The arm was covered with a pressurized dressing over the AV fistula site. LVN 1 stated the pressurized dressing was from Resident 3's dialysis center and should have been removed four hours after returning. LVN 1 stated the licensed nurse should remove the dressing on the AV fistula site to prevent clogging. LVN 1 stated Resident 3 could not be dialyzed if the AV fistula was clogged. During an interview on 9/12/2025 at 10:40 a.m. with Registered Nurse (RN) 1, RN 1 stated it was not acceptable that Resident 3 still had the dressing over her AV fistula site on the morning of 9/11/2025. RN 1 stated the licensed nurse should remove the AV fistula dressing within four hours of returning from the dialysis center to ensure enough blood flow. RN 1 stated the licensed nurse would not be able to assess for signs and symptoms of infection or bleeding if the AV fistula site was covered with a dressing. RN 1 056458 Page 5 of 7 056458 09/12/2025 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 - Some stated it was important to assess the AV fistula site. RN 1 stated it was a nursing intervention to remove the dressing after four hours and did not require a physician's order. RN 1 stated that leaving the pressure dressing on the AV fistula posed risks of fistula occlusion (something that obstructed the blood flow) and malfunction. RN 1 stated the residents could not start dialysis and might have hypovolemia (the body had too little blood or fluid), electrolytes imbalance, and even a heart attack. During an interview on 9/12/2025 at 11:36 a.m. with the DON, the DON stated it was standard of care to remove the pressurized dressing on the AV fistula in four hours of returning from dialysis. The DON stated that all the licensed nurses should know this. During a review of the facility's P&P titled Dialysis Services, dated 8/2012, the P&P indicated staff should assess the dialysis accesses site for bruit and thrill, any signs of bleeding or swelling, any sign and symptoms of infection.2b. During a review of Resident 3's Order Summary Report, dated 9/11/2025, the report indicated to administer oxygen at a rate of two liters (measurement for gas volume) per minute via nasal cannula (NC, a small plastic tube, which fit into the person's nostrils for providing supplemental oxygen) as needed for shortness of breaths (SOB), wheezing (a high-pitched sound made when breathing was restricted/obstructed in the lungs), chest pain, and oxygen saturation level (O2 sat, a measurement of how much oxygen the blood was carrying as a percentage) less than 90 percent (%) on room air. During a review of Resident 3's care plan for chronic respiratory failure, revised on 7/23/2025, the care plan interventions indicated to administer oxygen at a rate of two liters per minute via NC as needed for SOB, wheezing, chest pain, and O2 sat less than 90% on room air. During a concurrent observation and interview on 9/11/2025 at 1:24 p.m. with LVN 1 in Resident 3's room, observed Resident 3 receiving oxygen at a rate of five liters per minute via NC. LVN 1 stated Resident 3 should have received two liters of oxygen instead of five liters per minute. LVN 1 stated it was not acceptable to administer five liters oxygen per minute to Resident 3 because it was not ordered. LVN 1 stated Resident 3 could not adjust the oxygen level. LVN 1 stated the licensed nurses should ensure the oxygen was administered as ordered during rounds (regular checks by nurses to ensure resident safety and care) throughout the shift. LVN 1 stated Resident 3 was receiving too much oxygen, and it put Resident 3's health at risk. LVN 1 stated it was important to follow the physician's order. LVN 1 stated that administering oxygen at a rate of five liters per minute did not align with the care plan's intervention. LVN 1 stated staff should implement the care plan's interventions. During an interview on 9/12/2025 at 10:40 a.m. with RN 1, RN 1 stated Resident 3 should not receive more oxygen than ordered because of the diagnosis of CHF and chronic respiratory failure. RN 1 said Resident 3 could drown (lungs were overwhelmed, making it hard to breathe) from excessive oxygen, causing an imbalance in oxygenation and blood gas exchange (how oxygen entered the blood and carbon dioxide left it). RN 1 stated the licensed nurse should follow and comply with the physician's orders. During an interview on 9/12/2025 at 11:36 a.m. with the DON, the DON stated the certified nursing assistant should not adjust the oxygen level and should notify the licensed nurses. The DON stated the licensed nurse needed to ensure the oxygen was administered as ordered during the shift because it was important to follow the physician's order. The DON stated Resident 3 had a diagnosis of CHF and chronic respiratory failure and should not receive too much oxygen because it would increase cognitive confusion. 2c. During a concurrent interview and record review on 9/11/2025 at 1:46 p.m. with LVN 1, Resident 3's Weights and Vitals Summary, dated from 9/1/2025 - 9/11/2025, was reviewed. The Weights and Vitals Summary indicated Resident 3's O2 sat was obtained when the resident was receiving oxygen via NC and not on room air from 9/1/2025 - 9/11/2025. LVN 1 stated the licensed nurse should check Resident 3's O2 sat on room air to ensure an accurate assessment. During an interview on 9/12/2025 at 10:40 a.m. with RN 1, 056458 Page 6 of 7 056458 09/12/2025 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 - Some RN 1 stated the licensed nurse should check Resident 3's O2 sat on room air as ordered. RN 1 stated it was not acceptable to obtain an O2 sat when on oxygen because it was not a correct assessment. RN 1 stated the licensed nurses should assess the resident before administering the oxygen. RN 1 stated giving oxygen could unnecessarily cause more harm than good for the residents because of overcompensation (when the body tried to fix an imbalance, but the correction seemed too strong) in blood gas exchange. RN 1 stated that competent staff were essential to provide services that met residents' needs. RN 1 stated this highlighted a need for additional training to improve staff competency levels because any mistakes could compromise the health of the residents.During an interview on 9/12/2025 at 11:36 a.m. The DON stated for an accurate reading, the licensed nurse should have residents breathe room air for 30 minutes before checking the O2 sat. During a review of the facility's Charge Nurse Job Description, undated, the Job Description indicated, the charge nurse's responsibilities included following standards of nursing practices and implementing the facility's policies and procedures. The Job Description indicated the charge nurse should administer and document direct resident care, medications, and treatments per physicians' orders, and accurately record all care provided. The Job Description further indicated the charge nurse should implement an accurate comprehensive care plan based on resident's needs and assessment, and competently perform basic nursing skills. During a review of the facility's P&P titled Oxygen Therapy, dated 1/2024, the P&P indicated it was the policy of the facility that oxygen was administered as ordered by the physician. 056458 Page 7 of 7