Health inspection·April 10, 2025

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on interview and record review, the facility failed to ensure one of three sampled Residents (Resident 19) had an advance directive (a legal document indicating resident preference on end-of-life treatment decisions). This failure violated Resident 19 and/or representative's rights to be fully informed of the option to formulate an advanced directive and had the potential not to follow Resident 19's wishes. Findings: During a review of Resident 19's admission Information, the admission Information indicated the facility admitted Resident 19 on 9/30/2024 and readmitted Resident 19 on 3/6/2025 with diagnoses including metabolic encephalopathy (brain dysfunction caused by problems with the body's metabolism), cerebral infarction (a condition where brain tissue dies due to a lack of blood flow and oxygen) and moderate intellectual disabilities (observable developmental delays, which may be accompanied by physical impairments). During a review of Resident 19's Resident Care Conference Review dated 10/11/2024, the Resident Care Conference Review indicated Resident 19 was under the Regional Center (RC). The Resident Care Conference Review indicated Resident 19 did not have an advanced directive in place at This time and does not want to formulate one. During a review of Resident 19's History and Physical (H&P), dated 3/7/2025, the H&P indicated Resident 19's had a limited capacity to consent due to moderate intellectual disabilities. During a review of Resident 19's Minimum Data Set (MDS, a resident assessment tool), dated 4/4/2025, the MDS indicated the resident was severely cognitively (anything related to thinking, learning, and understanding) impaired for daily decision making. During an interview on 4/8/2025 at 8:16 AM with the Discharge Planner (DP), the DP stated Resident 19 needed an advance directive. The DP stated Resident 19 came from another Skilled Nursing Facility (SNF) and the DP stated she (DP) contacted the previous facility's Social Worker to check for contacts or responsible party for the resident. The DP stated she did not check to see if the resident had an advance directive. The DP stated she (DP) followed up with the RC regarding the AD but did not document. During an interview on 4/8/2025 at 9:02 AM with the DP, the DP stated Resident 19 did not have the capacity to sign an advance directive. The DP stated there was no documentation on the EMR Page 1 of 21 555019 555019 04/10/2025 Temple Park Convalescent Hospital 2411 W. Temple Street Los Angeles, CA 90026

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (Electronic Medical Record) that she (the DP) had notified the doctor of the advance directive status, and it was important to notify the doctor. During an interview on 4/10/2025 at 2:01 PM with the Director of Nursing (DON), the DON stated the advance directive was important to have when deciding Resident 19's well-being and code status (what type of intervention [if any] a healthcare team will conduct should their patient's heart stop beating. The DON stated the advance directive needed to be initiated upon admission or received from the previous facility, however due to its absence the facility would consider Resident 19 as a full code status (all life-saving measures will be taken during a medical emergency). During a concurrent interview and record review on 4/10/2025 at 2:22PM with the DON, the facility's policy and procedure (P&P) titled, Advance Directives, dated June 2023 was reviewed. The DON stated the P&P indicated, Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. The DON stated, the policy was not followed. 555019 Page 2 of 21 555019 04/10/2025 Temple Park Convalescent Hospital 2411 W. Temple Street Los Angeles, CA 90026

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on interview and record review, the facility failed to notify the State Long Term Care Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) when the facility transferred one of two sampled residents (Resident 53) to the General Acute Care Hospital (GACH). This failure had the potential for Resident 53 not to have a representative. Findings: During a review of Resident 53's admission Record, the admission Record indicated the facility admitted the resident on 11/8/2024 with diagnoses that included metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), dementia (a progressive state of decline in mental abilities), human immunodeficiency virus (HIV, a virus that attacks the body's immune system), chronic respiratory failure (a condition when the lungs cannot release enough oxygen into the blood), congestive heart failure (CHF, a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and dysphagia (difficulty swallowing). During a review of Resident 53's Minimum Data Set (MDS, a resident assessment tool) dated 1/7/2025, the MDS indicated the resident had severe cognitive impairment (impaired ability to think, understand, and reason). The MDS indicated Resident 53 required substantial/maximal assistance for eating. The MDS indicated Resident 53 was dependent on help for oral hygiene, toileting hygiene, shower/bathing self, upper body dressing, lower body dressing, putting on/taking off footwear. During a review of Resident 53's SBAR (situation, background, assessment, recommendation, a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form and progress note dated 1/10/2025 at 11:35 AM, the SBAR indicated the resident was noted with increased agitation and desaturation (a decrease in the amount of oxygen in the blood). The SBAR indicated Resident 53 had an oxygen saturation level (O2 sat, a measurement of how much oxygen the blood is carrying as a percentage) at 70% and was provided with oxygen via a rebreather mask (a medical device used to deliver high concentrations of oxygen to patients who can breathe on their own but require extra oxygen). The SBAR indicated Resident 53's physician was notified and provided orders to send the resident to the GACH via 911. During a review of Resident 53's Transfer Out Packet dated 1/10/2025 at 11:48 AM, the packet indicated the resident was discharged from the facility on 1/10/2025 via 911 to GACH 1 due to increased agitation and desaturation. During a review of Resident 53's Notice of Proposed Transfer/Discharge Form dated 1/10/2025. The notice indicated the resident was transferred to GACH 1 on 1/10/2025. The notice indicated Resident 53's transfer to GACH 1 was necessary for the resident's welfare. The notice indicated the resident's needs could not be met in the facility. There was no indication a copy of the notice was sent to the State Long Term Care Ombudsman. During a concurrent interview and record review on 4/9/2025 at 2:04 PM, Resident 53's Notice of Proposed Transfer/Discharge was reviewed with Licensed Vocational Nurse 1 (LVN 1). LVN 1 stated it was the charge nurse's (in general) responsibility to notify the Ombudsman of a resident's transfer or 555019 Page 3 of 21 555019 04/10/2025 Temple Park Convalescent Hospital 2411 W. Temple Street Los Angeles, CA 90026

F 0623 Level of Harm - Minimal harm or potential for actual harm discharge from the facility. LVN 1 stated the charge nurses would fill out and complete the notice of transfer/discharge form and then fax it to the Ombudsman. LVN 1 stated the Ombudsman was not notified of Resident 53's transfer to GACH 1 on 1/10/2025. LVN 1 stated the notice was completed but did not indicate it was faxed to the Ombudsman. LVN 1 stated he (LVN1) could not locate the fax confirmation to the Ombudsman for the notice of Resident 53's transfer to GACH 1 on 1/10/2025. Residents Affected - Few During a concurrent interview and record review on 4/10/2025 at 1:31 PM, Resident 53's Notice of Transfer/discharge date d 1/10/2025 was reviewed with the Director of Nursing (DON). The DON stated Resident 53 was transferred to GACH 1 on 1/10/2025. The DON stated when Resident 53 was transferred to GACH 1 the Notice of Transfer/Discharge was completed but not faxed to the Ombudsman. The DON stated the Notice of Transfer/Discharge must be faxed to the ombudsman within 30 days. The DON stated if the ombudsman was not notified of the resident's transfer or discharge from the facility, the Ombudsman may not have the ability to follow up with the resident. During a review of the facility's Policy and Procedure (P&P) titled Transfer or Discharge, Facility-Initiated with a review date of 1/30/2025, the P&P indicated A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. 555019 Page 4 of 21 555019 04/10/2025 Temple Park Convalescent Hospital 2411 W. Temple Street Los Angeles, CA 90026

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 observation, interview, and record review the facility failed to ensure to implement the care plan for one of 19 sampled resident (Resident 92) for the use of a hand mitten (used to help protect residents who are prone to disrupting medical treatment). This failure had the potential to cause a lack of monitoring for Resident 93's skin integrity and circulation. Findings: During a review of Resident 92's admission Record, the admission Record indicated the facility admitted Resident 92 on 1/9/2025 with diagnoses including cerebral infarction (a serious condition where blood flow to the brain is blocked, leading to tissue damage and death), legal blindness, and need for assistance with personal care. During a review of Resident 92's Minimum Data Set (MDS, a resident assessment tool) dated 1/13/2025, the MDS indicated the resident was not oriented to the day, month, or year. The MDS indicated Resident 92 had poor recall. During an observation on 4/7/2025 at 10:29 AM in Resident 92's room, Resident 92 was lying in bed positioned facing the window, two bed siderails (are adjustable metal or rigid plastic bars that attach to the bed) were up, call light (a device used by a patient to signal his or her need for assistance) within reach. Resident 92 had a hand mitten to the right hand. Resident 92 was on an Alternating Pressure Mattress (APP, air bladders throughout the mattress that constantly inflate and deflate assisting bedridden adults in reducing, eliminating and treating bed sores). Resident 92 had an indwelling catheter (thin, flexible tube that drains urine from the bladder into a collection bag) with a dignity bag (a cover for a urine drainage bag, designed to conceal the bag from public view and maintain privacy) over the collection bag. During a concurrent observation and interview on 4/8/25 at 1:49 PM with Licensed Vocational Nurse 2 (LVN) 2, in Resident 92's room, the right-hand mitten was observed. LVN 2 stated the reason Resident 92 had the mitten on was because the resident tried to scratch her skin. During a concurrent record review Resident 92's Hand -Mitten Care plan was reviewed. LVN 2 searched for the Hand-Mitten care plan and stated she (LVN 2) was unable to find a care plan. LVN 2 stated the hand mitten was a restraint. LVN 2 stated it was important to have the care plan to monitor for contraction (a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen), skin integrity, range of motion (means the full movement potential of a joint), and circulation. LVN 2 stated she (LVN2) would release the mitten every two to four hours. During a concurrent interview and record review on 4/8/2025 at 2:26 PM with the Minimum Data Set Nurse (MDSN), the MDS dated [DATE] was reviewed. The MDSN stated that if the resident did not exhibit a requirement to have a hand mitten on admission, then the hand mitten would not be triggered on the MDS which would not trigger a care plan. The MDSN reviewed Resident 92's admission date and the resident was admitted to the facility on [DATE]. The MDSN stated Resident 92's MDS was done on 1/13/2025, and the consent for the hand-mitten was obtained on 1/16/2025 after the MDS was completed. The MDSN stated the nurse who obtained the consent would get an order from the doctor and would trigger 555019 Page 5 of 21 555019 04/10/2025 Temple Park Convalescent Hospital 2411 W. Temple Street Los Angeles, CA 90026

F 0656 the care plan. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/8/25 at 3:02 PM with the Director of Nursing (DON), the DON stated there was no interdisciplinary team (IDT, group of diverse health care professionals from different fields) meeting, no care plan for Resident 92's hand mitten. The DON stated if there were a change of condition the nurse should get informed consent for the hand mitten, a doctor's order, and trigger the care plan. The DON stated any license nurse can trigger the care plan. The DON stated the risk to Resident 92 without a hand mitten care plan would be safety and lack of monitoring of her skin integrity and circulation. Residents Affected - Few During a review of the facility's policy and procedure titled, Care Plan - Comprehensive Person - Centered dated 10/2023, indicated that the comprehensive care plan has been designed to incorporate identified problem areas and incorporate risk factors. During a review of the facility's policy and procedures titled, Use of Restraints dated 5/1/2024, indicated that care plans for residents in restraints will reflect interventions that address not only the immediate medical symptoms, but the underlying problems that may be causing the symptoms. 555019 Page 6 of 21 555019 04/10/2025 Temple Park Convalescent Hospital 2411 W. Temple Street Los Angeles, CA 90026

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide care and services to maintain good hygiene for one of one sampled residents (Resident 68). Residents Affected - Few This failure had the potential to expose Resident 68 to skin irritation, skin breakdown, and possible infection. Findings: During a review of Resident 68's admission Record), the admission Record indicated the facility admitted Resident 68 on 1/24/2025 with diagnoses that included muscle weakness, need for assistance with personal care (bathing, dressing, eating, toileting, and transferring - moving from one place to another), hemiplegia (the loss of the ability to move, feel, or otherwise control muscles on one side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting left non-dominant (the side that is not your preferred side of the body for performing tasks) side. During a review of Resident 68's Minimum Data Set (MDS, a resident assessment tool) dated 1/28/2025, the MDS indicated Resident 68 had the ability to make himself understood and had the ability to understand others. The MDS indicated Resident 68 was dependent (relying on others) for personal hygiene (bathing, showering, brushing teeth, toileting, cleaning oneself). The MDS indicated an active diagnosis of hemiplegia or hemiparesis and need for assistance with personal care. During a review of Resident 68's Order Summary Report (a doctor's written or spoken instruction for what needs to be done for a patient, whether it's medications, treatments, or tests) dated 4/10/2025, indicated the facility would perform a Braden Scale Assessment (a tool used to assess a patient's risk of developing a pressure ulcer/bed sore [refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device]) weekly for three weeks starting on 3/28/2025. The Order Summary Report indicated an order for a low air loss mattress (LAL, mattress that operates using a blower-based pump that was designed to circulate a constant flow of air) for skin management. The Order Summary Report indicated an order for right buttock pressure injury - stage 3 (mattress that operates using a blower-based pump that was designed to circulate a constant flow of air) cleanse with Dakin's solution (a liquid to clean and disinfect wounds, preventing infection), pat dry. During a review of Resident 68's care plan (a detailed document outlining an individual's care needs and how a facility would meet these needs, ensuring a person-centered approach to care) dated 2/5/2025 titled at risk for ADL (activities of daily living, activities such as bathing, dressing and toileting a person performs daily) decline related to: aging process, generalized weakness, mental illness had a goal for the resident to be kept clean, dry, and appropriately dress. The care plan interventions indicated for the facility to check the resident every two hours for soiling/wetness, to clean him after each episode of incontinence (trouble controlling when you pee or poop), to assist the resident with ADLs, to cleanse his skin and to apply lotion. During a review of Resident 68's care plan dated 2/5/2025 titled at risk for skin impairment (a situation where the skin's normal protective barrier is compromised, making it more vulnerable to damage and infection), UTI (urinary tract infection - an infection in the bladder/urinary tract), 555019 Page 7 of 21 555019 04/10/2025 Temple Park Convalescent Hospital 2411 W. Temple Street Los Angeles, CA 90026

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few pressure sores decline in bowel and bladder function (parts of the digestive and urinary systems that work together to maintain bodily functions) related to: always incontinent had a goal for the resident to not have any skin breakdown. The care plan had a goal to provide good incontinence care. During a review of Resident 68's care plan dated 2/5/2025 titled the resident has bowel incontinence related to limited mobility had an intervention to provide pericare (cleaning a patient's genital and anal areas) after each incontinent episode. During an interview on 4/7/2025 at 11:30 AM with Treatment Nurse 1 (TN 1), TN 1 stated Resident 68 was soiled, and he (TN1) was waiting for someone to help him clean Resident 68. During an observation on 4/7/2025 at 11:38 AM, Certified Nursing Assistant 2 (CNA 2) entered Resident 68's room. CNA 2 exited Resident 68's room a minute later without cleaning or changing the resident. During a concurrent observation and interview on 4/7/2025 at 11:41 AM with CNA 2 in front of Resident 68's room CNA 2 stated he had just been told Resident 68 had soiled himself and stated he was looking for someone to help him clean Resident 68. During a concurrent observation and interview on 4/7/2025 at 11:46 AM with Licensed Vocational Nurse 3 (LVN 3) at the entrance of Resident 68's room, CNA 2 was observed helping Resident 68's neighbor, Resident 85. LVN 3 stated CNA 2 was helping Resident 85 because Resident 85 had taken off his adult brief (disposable underwear). During an observation on 4/7/2025 at 11:50 AM in Resident 68's room, CNA 2 and CNA 3 were observed cleaning Resident 68. During an interview on 4/72025 at 12 PM with Resident 68 in Resident 68's room, Resident 68 was asked how he felt having to wait 20 minutes for the facility to clean him after he soiled himself. Resident 68 did not respond and stared at the surveyor. During an interview on 4/8/2025 at 2:56 PM with the Director of Nursing (DON), the DON stated staff would need to clean a resident (in general) as soon as they (the staff) knew the resident needed to be cleaned. The DON stated 20 minutes was a long time for the facility to change a resident. The DON stated CNA2 should have asked another staff member to help clean Resident 68 instead of having the resident wait. The DON stated Resident 68 could have been exposed to skin infection or worsening of his pressure ulcer. During a record review of the facility's policy and procedure (P&P) titled, Perineal Care (cleaning the private areas of a patient) dated1/2024, the P&P indicated the purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. During a record review of the facility's P&P titled, Activities of Daily Living (ADLs), Supporting, dated 4/2023, the P&P indicated residents who are unable to carry our activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene (regularly cleaning your teeth, gums, and tongue to prevent tooth decay and gum disease). The P&P indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of 555019 Page 8 of 21 555019 04/10/2025 Temple Park Convalescent Hospital 2411 W. Temple Street Los Angeles, CA 90026

F 0677 care, including appropriate support and assistance with: Level of Harm - Minimal harm or potential for actual harm a. Hygiene (bathing, dressing, grooming, and oral care); b. Mobility (transfer and ambulation, including walking); Residents Affected - Few c. Elimination (toileting); d. Dining (meals and snacks); and e. Communication (speech, language, and any functional communication systems). 555019 Page 9 of 21 555019 04/10/2025 Temple Park Convalescent Hospital 2411 W. Temple Street Los Angeles, CA 90026

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 Based on interview and record review, the facility failed to administer insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) according to the facility's policy by failing to rotate the administration site when administering insulin to one of one sampled residents (Resident 4). Residents Affected - Few This failure had the potential for Resident 4 to experience skin complications. Findings: During a review of Resident 4's admission Record, the admission Record indicated the facility re-admitted the resident on 1/26/2025 with diagnosis that included type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 4's Physician Orders dated 1/27/2025, the Physician Order indicated the resident was to receive Humulin R Insulin (a medication used to manage type 2 diabetes by lowering blood sugar levels) per sliding scale (varies the dose of insulin based on blood glucose level) subcutaneously (a method of administering medication by injecting it into the fatty layer of tissue just beneath the skin) before meals and at bedtime for DM. During a review of Resident 4's Medication Administration Record (MAR) dated from 2/1/2025 to 2/28/2025, the MAR indicated the resident received consecutive doses of insulin in the left lower quadrant of her abdomen on 2/14/2025 at 3:59 PM, 2/15/2025 at 11:46 AM, and on 2/15/2025 at 5:05 PM. The MAR indicated Resident 4 received consecutive doses of insulin in the right lower quadrant of her abdomen on 2/20/2025 at 11:30 AM and on 2/21/2025 at 11:45 AM. During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool) dated 3/17/2025, the MDS indicated the resident had moderate cognitive impairment (some impairment in the ability to think, understand, and reason). The MDS indicated Resident 4 was receiving a hypoglycemic medication (medication used to lower blood sugar levels). During a review of Resident 4's MAR dated from 3/1/2025 to 3/31/2025, the MAR indicated the resident received consecutive doses of insulin in the left lower quadrant (the area left of the midline and below the umbilicus) of her abdomen on 3/2/2025 at 8:11 PM, 3/3/2025 at 4:46 PM, and on 3/6/2025 at 8:21 PM. The MAR indicated Resident 4 received consecutive doses of insulin in the right upper quadrant of her abdomen on 3/21/2025 at 4:01 PM, and on 3/21/2025 at 8:30 PM. During a concurrent interview and record review on 4/10/2025 at 11:10 AM Resident 4's MAR dated from 2/1/2025 to 2/28/2025 and 3/1/2025 to 3/31/2025 were reviewed with Licensed Vocational Nurse 2 (LVN 2). LVN 2 stated Resident 4 did not have her administration sites rotated when insulin was administered on 2/14/2025, 2/15/2025, 2/20/2025, 2/21/2025, 3/2/2025, 3/3/2025, 3/6/2025, and 3/21/2025. LVN 2 stated staff had the ability to see where the previous injection sites were given prior to the administration of insulin to ensure injection sites were rotated. LVN 2 stated if insulin was previously administered in the left lower quadrant of the abdomen, the next dose of insulin should be in a different location. LVN 2 stated insulin administered in the same location could lead to hard lumps under the skin. During a concurrent interview and record review on 4/10/2025 at 1:40 PM, Resident 4's MARs dated 555019 Page 10 of 21 555019 04/10/2025 Temple Park Convalescent Hospital 2411 W. Temple Street Los Angeles, CA 90026

F 0684 Level of Harm - Minimal harm or potential for actual harm from 2/1/2025 to 2/28/2025 and 3/1/2025 to 3/31/2025 were reviewed with the Director of Nursing (DON). The DON stated administration sites of insulin should be rotated. The DON stated administering insulin in the same location could lead to lipohypertrophy (a condition where lumps of fat and scar tissue form under the skin, often at insulin injection sites, due to repeated injections in the same area that can impair insulin absorption and lead to inconsistent blood sugar levels and difficulty managing diabetes). Residents Affected - Few During a review of the facility's Policy and Procedure (P&P) titled, INSULIN ADMINISTRATION with a review date of 1/30/2025, the P&P indicated to provide guidelines for the safe administration of insulin to residents .Injection sites should be rotated, preferably within the same general area. 555019 Page 11 of 21 555019 04/10/2025 Temple Park Convalescent Hospital 2411 W. Temple Street Los Angeles, CA 90026

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to ensure Treatment Nurse 1 (TN1) monitored the progression of the pressure ulcers (pressure injury, localized damage to the skin and/or underlying tissue usually over a bony prominence) for one of one sampled residents (Resident 53). Residents Affected - Few This failure had the potential for Resident 53's pressure ulcers to worsen. Findings: During a review of Resident 53's admission Record, the admission Record indicated the facility re-admitted the resident on 2/1/2025 with diagnoses that included metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), dementia (a progressive state of decline in mental abilities), human immunodeficiency virus (HIV, a virus that attacks the body's immune system), chronic respiratory failure (a condition when the lungs cannot release enough oxygen into the blood), congestive heart failure (CHF, a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and dysphagia (difficulty swallowing). During a review of Resident 53's Care Plan dated 2/2/2025, the Care Plan indicated the resident had an unstageable (a type of pressure injury where the extent of damage cannot be determined because the wound bed is covered by necrotic tissue [dead or damaged tissue]) pressure ulcer of his medial back related to immobility (state of not being able to move around). The Care Plan indicated a goal for Resident 53's pressure ulcer was to show signs of healing and to remain free from infection. The Care Pan indicated interventions that included weekly treatment documentation to include the measurement of each area of the skin breakdown's such as the width, length, depth, type of tissue, and exudate (fluid that seeps out of a wound); and to monitor/document/report as needed any changes in skin status, appearance, color, wound healing, signs and symptoms of infection, wound size, and stage. During a review of Resident 53's Care Plan dated 2/2/2025, the Care Plan indicated the resident had an unstageable pressure ulcer of his coccyx (tailbone area) related to immobility. The Care Plan indicated a goal for Resident 53's pressure ulcer was to show signs of healing and remain free from infection. The Care Plan indicated interventions to monitor/document/report as needed any change in skin status, appearance, color, wound healing, signs and symptoms of infection, wound size, and stage. During a review of Resident 53's Minimum Data Set (MDS, a resident assessment tool) dated 2/28/2025, the MDS indicated the resident had severe cognitive impairment (impaired ability to think, understand, and reason). The MDS indicated Resident 53 was dependent on help for eating, oral hygiene, upper body dressing, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 53 was at risk of developing pressure ulcers/injuries. The MDS indicated Resident 53 had two unstageable pressure ulcers that were present upon reentry to the facility. During a review of Resident 53's Pressure Sore Skin Problem Report, dated 2/28/2025 at 12:56 PM, the Pressure Sore Skin Problem Report indicated the resident had an unstageable pressure ulcer to his medial back that was 1.5 centimeters (cm, a unit of measurement) in length and 1.0 cm in width. The Pressure Sore Skin Problem Report indicated Resident 53 had an unstageable pressure ulcer to his coccyx that was 3.0 cm in length and 2.0 cm in width. There were no other Pressure Sore Skin Problem Reports documented by nursing staff after 2/28/2025. During a concurrent interview and record review on 4/9/2025 at 10:45 AM, Resident 53's Pressure 555019 Page 12 of 21 555019 04/10/2025 Temple Park Convalescent Hospital 2411 W. Temple Street Los Angeles, CA 90026

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Sore Skin Problem Report dated 2/28/2025 was reviewed with TN1. TN 1 stated he was in charge of monitoring and providing treatment to Resident 53's pressure ulcers. TN 1 stated he was supposed to document his monitoring of Resident 53's pressure ulcers on the Pressure Sore Skin Problem Report weekly. TN 1 stated he was supposed to document the measurements, location, and description of Resident 53's pressure ulcers on the Pressure Sore Skin Problem Report. TN 1 stated the last Pressure Sore Skin Problem Report was documented on 2/28/2025. TN 1 stated he was having trouble keeping up with his documentation because he felt overwhelmed with the amount of documentation he had to do. TN 1 stated it was important to keep up with Resident 53's documentation to keep track of the progress of the resident's pressure ulcers. TN 1 stated there was a potential to for Resident 53's pressure ulcers to worsen if weekly documentation and monitoring was not completed. During an interview on 4/10/2025 at 1:50 PM with the Director of Nursing (DON), the DON stated licensed nurses (in general) needed to monitor and document on the Pressure Sore Skin Problem Reports weekly the progression of the resident's pressure injuries. The DON stated the last Pressure Sore Skin Problem Report for Resident 53 was last documented on 2/28/2025. The DON stated it was important for TN1 to document on the Pressure Sore Skin Problem Report to ensure Resident 53 received the appropriate pressure injury treatment. The DON stated there was a potential for the resident's pressure injuries to worsen if the Pressure Sore Skin Problem Reports were not documented weekly. During a review of the facility's Policy and Procedure (P&P) with a review date of 6/18/2024, the P&P indicated The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores for example, immobility, recent weight loss, and a history of pressure ulcer(s). In addition, the nurse shall describe and document/report the following: a. assessment of pressure sore including location, stage, length, width, and depth; b. pain assessment; c. Resident's mobility status; d. Current treatments, including support surfaces; and e. active diagnoses. The staff will examine the skin of a new admission for ulcerations or alterations in the skin. 555019 Page 13 of 21 555019 04/10/2025 Temple Park Convalescent Hospital 2411 W. Temple Street Los Angeles, CA 90026

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. Based on observation, interview, and record review the facility failed to ensure not to leave a lighter unattended (left alone without supervision) and unsecured (unprotected) at a resident's bedside table for one of two sampled residents (Resident 55). This failure had the potential Resident 24 to sustain burns and/or cause a fire. Findings: During a review of Resident 55's admission Record dated 4/10/2025, the admission Record indicated the facility originally admitted Resident 55 on 4/30/2026 and readmitted Resident 55 on 10/28/2024 with the diagnoses of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and nicotine dependence (a person's body and brain become used to having nicotine, the addictive substance in tobacco products such as cigarettes), cigarettes, uncomplicated. During a review of Resident 55's Minimum Data Set (MDS - a resident assessment tool) dated 2/11/2025, indicated Resident 55 had the ability to make himself understood and had the ability to understand others. The MDS indicated Resident 55 was independent or needed set up/clean up assistance for self-care. The MDS indicated a diagnosis of COPD and nicotine dependence, cigarettes, uncomplicated. During a review of Resident 55's History and Physical (H&P - the physician obtains a thorough medical history from the patient, performs a physical examination, and then documents their findings) dated 10/30/2024, the H&P indicted the resident's physician educated Resident 55 about smoking cessation (quitting smoking). During a review of Resident 55's care plan titled resident is capable of smoking in a designated (specific) area with supervision only, initiated 10/5/2023, the care plan indicated a goal that Resident 55 will comply with facility policy regarding smoking daily. During a review of Resident 55's care plan titled, potential risk for injury related to smoking, initiated 10/5/2023, the care plan indicated an intervention for the facility to observe resident for unsafe smoking materials from outside source, immediately inform facility management. During a review of Resident 55's Nurse Risk Evaluations/Assessments Section V. Smoking Safety Evaluation, dated 2/13/2025, the Nurse Risk Evaluations/Assessments indicated Resident 55's smoking evaluation score was 22. The Nurse Risk Evaluations/Assessments indicated total score above 2 = Supervised smoking and/or offer assistance to hold the cigarette. During a concurrent observation and interview on 4/8/2025 at 10:09 AM in the facility's designated smoking area, Resident 55 was observed wearing a smoking apron and smoking a cigarette. The surveyor asked Resident 55 if the facility allowed him to keep a lighter at the bedside and Resident 55 initially stated yes but then quickly stated no. The surveyor asked Resident 55 when the facility last allowed him to keep a lighter at the bedside and Resident 55 stated a long time ago. During an observation on 4/8/2025 at 10:18 AM a green, fluorescent lighter was observed on the corner of Resident 55's bedside table approximately 12 inches to the right and 12 inches above his bed. The lighter was observed to be unattended since the resident was outside in the patio smoking. A 555019 Page 14 of 21 555019 04/10/2025 Temple Park Convalescent Hospital 2411 W. Temple Street Los Angeles, CA 90026

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few photo of the lighter on top to the bedside table was taken that included a portion of the resident's bed for reference. During a concurrent observation and interview on 4/8/2025 at 10:10 AM with Licensed Vocational Nurse 3 (LVN 3), in Resident 55's room, a green a green, fluorescent lighter was observed on the corner of Resident 55's bedside table approximately 12 inches to the right and 12 inches above his bed. LVN 3 stated she would speak with Resident 55 to educate him that residents (in general) could not store lighters at the bedside. LVN 3 stated having a lighter at the bedside could be a fire hazard risk. LVN 3 stated she (LVN3) would bring Resident 55's lighter to the Activities Director (AD). During an interview on 4/8/2025 at 10:24 AM with Certified Nursing Assistant 4 (CNA 4), CNA 4 stated she he (Resident 55) sometimes brings it with him, referring to Resident 55's lighter when he went to the designated smoking area. During an interview on 4/8/2025 at 10:33 AM with the AD, the AD stated the facility did not allow residents (in general) to store lighters or cigarettes in their rooms. The AD stated the facility had a place to store the residents' cigarettes and lighters. The AD stated if the facility discovered any lighters or cigarettes, the facility would confiscate (take away) them. The AD stated the facility staff should be making rounds to check for contraband (something that is not allowed or against the rules). The AD stated the facility would take the residents (in general) to the liquor store and then would store the smoking materials for the residents. The AD stated a resident who had cigarettes or a lighter in their room would be a fire risk to the facility or a resident could be at risk for burning themself. The AD stated LVN 3 confiscated Resident 55's lighter and put it in the activities lock box. The AD stated the facility had 2 locked boxes where they stored residents' smoking material. The AD stated when smoke time for the residents was over, the smoking material would be returned to the locked boxes. During an interview on 4/8/2025 at 10:46 AM with the Assistant Director of Nursing (ADON), the ADON stated she was not sure about the facility's policy regarding whether or not a resident could keep cigarettes or lighters in their rooms. The ADON stated she (ADON) thought the residents were not allowed to keep cigarettes or lighters in their room and would need to check the facility's policy. The ADON stated if a resident had cigarettes and lighter in their room, the resident would be at risk for burning themselves or could cause a fire in the facility. During an interview on 4/8/2025 at 12:04 PM with the Director of Nursing (DON), the DON stated the facility allowed residents to keep lighters and cigarettes at the bedside. The DON stated an unattended lighter could pose a fire risk because the facility left it unguarded. When asked if there was a potential for another resident to pick up the lighter, the DON stated yes. The DON stated an unattended lighter could pose a fire risk to the facility. During a record review of the facility's policy and procedure (P&P) titled, Smoking Policy and Guidelines, dated 1/30/2025, indicated smoking is only allowed on designated outdoor patio. The P&P indicated No one, including residents, staff, or guests may smoke inside the facility. Residents who need staff supervision must smoke only at the supervised /smoking times. Supervised smoking times will be posted at TPC (Temple Park Convalescent). The P&P indicated if TPC staff determines that you have safety risks related to your smoking -You will not be allowed to keep cigarettes, matches, or lighters in your possession. 555019 Page 15 of 21 555019 04/10/2025 Temple Park Convalescent Hospital 2411 W. Temple Street Los Angeles, CA 90026

F 0689 -You will only be allowed to smoke at the supervised smoking times under staff supervision Level of Harm - Minimal harm or potential for actual harm -Your plan of care will document the concern or interventions about your smoking. Residents Affected - Few 555019 Page 16 of 21 555019 04/10/2025 Temple Park Convalescent Hospital 2411 W. Temple Street Los Angeles, CA 90026

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 provide the necessary respiratory care services for one of two sampled residents (Resident 78), by failing to ensure Resident 78 who was receiving oxygen through a nasal cannula tubing (device used to deliver supplemental oxygen or increased airflow to a person in need of respiratory help) was not wrapped around a trash can while Resident 78 used the nasal cannula. Residents Affected - Few This failure had the potential for Resident 78 to experience respiratory infections (infections of parts of the body involved in breathing) associated with using an unsanitary (dirty, unhealthy, or unclean in a way that could endanger health) nasal cannula tubing. Findings: During a review of Resident 78's admission Record, the admission Record indicated the facility originally admitted Resident 78 on 4/23/2024 and readmitted [DATE] with diagnoses that included pneumonia (an infection/inflammation in the lungs), acute and chronic respirator failure (a sudden and gradual condition in which your lungs have a hard time loading your blood with oxygen) with hypoxia (ow levels of oxygen in your body tissues), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), Alzheimer's (a disease characterized by a progressive decline in mental abilities), and dementia (a progressive state of decline in mental abilities. During a review of Resident 78's Minimum Data Set (MDS, a resident assessment tool) dated 3/30/2025, the MDS indicated Resident 78 sometimes had the ability to make himself understood and sometimes had the ability to understand others. The MDS indicated Resident 78 had diagnoses of respiratory failure and COPD. During a review of Resident 78's Order Summary Report ( a doctor's written or spoken instruction for what needs to be done for a patient, whether it's medications, treatments, or tests) dated 4/10/2025, the Order Summary Report indicated the facility was to administer (give) oxygen to Resident 78 at two to four liters per minute (LPM - how much oxygen is given to the resident every minute) via nasal cannula up to five to 10 LPM via oxygen mask to reach O2 saturation (the percentage of hemoglobin [a protein in red blood cells that binds to oxygen and carries it from the lungs to the body's tissue] in your blood that is carrying oxygen) equal to or more than 92% as needed for shortness of breath (the frightening sensation of being unable to breathe normally or feeling suffocated). During a review of Resident 78's care plan (a detailed document outlining an individual's care needs and how a facility would meet these needs, ensuring a person-centered approach to care) dated 4/1/2025 titled the resident has COPD, indicated the resident will be free of signs and symptoms of respiratory infections as a goal. The care plan indicated the facility they would monitor/document/report as needed any signs and symptoms of respiratory infection. During a concurrent observation and interview on 4/7/2025 at 10 AM with Certified Nursing Assistant 1 (CNA 1), Resident 78's oxygen nasal cannula tubing was observed wrapped around the trashcan at the resident's bedside. CNA 1 stated the facility left Resident 78's oxygen nasal cannula tubing wrapped around the trashcan. CNA1 stated he (CNA1) needed to replace the tubing with a new one because Resident 78's current tubing was dirty and could be a source of infection. 555019 Page 17 of 21 555019 04/10/2025 Temple Park Convalescent Hospital 2411 W. Temple Street Los Angeles, CA 90026

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent observation and interview on 4/7/2025 at 10:15 AM with Licensed Vocational Nurse 3 (LVN 3), Resident 78's oxygen nasal cannula tubing was observed wrapped around the trashcan at the resident's bedside. LVN 3 stated the tubing wrapped around the trash can was an infection control (prevents or stops the spread of infections) issue and the facility would need to change the tubing right away. During an interview on 4/8/2025 at 2:56 PM with the Director of Nursing (DON), the DON stated a dirty or soiled nasal cannula tubing would need to be exchanged for a new one to prevent a resident (in general) from getting an infection. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated 4/8/2025, the P&P indicated the purpose of this procedure is to provide guidelines for safe oxygen administration. The P&P indicated the facility would replace a resident's nasal cannula tubing every 7 days or as necessary when soiled. During a record review of the facility's P&P, Infection Control, dated 1/30/2025, indicated an infection prevention and control program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases (diseases spread from one person to another) and infections. The P&P indicated prevention of infection included identifying possible infections and educating staff and ensuring that they adhere to proper techniques and procedures. The P&P indicated prevention of infection control also included instituting measures (taking steps) to avoid complications or dissemination (to spread) and the facility would follow established general and disease-specific guidelines such as those of the Centers for Disease control. 555019 Page 18 of 21 555019 04/10/2025 Temple Park Convalescent Hospital 2411 W. Temple Street Los Angeles, CA 90026

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview and record review the facility failed to document and monitor for manifestations of behavior (how a person's personality or inner state is expressed through their outward actions and reactions) for one of five sampled residents (Resident 3) who was taking Aripiprazole (Abilify, a medication known as an antipsychotic medication used to treat and manage schizophrenia [a disorder that affects a person's ability to think, feel, and behave clearly]). This failure had the potential for Resident 3 to take unnecessary medication. Findings: During a review of Resident 3's admission Record, the admission Record indicated the facility admitted the resident on 11/22/2023 with diagnoses that included dementia (a progressive state of decline in mental abilities), schizophrenia, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool) dated 2/25/2025, the MDS indicated the resident was cognitively intact (had the ability to think, understand, and reason). The MDS further indicated Resident 3 was taking antidepressant medication (medication used to treat major depressive disorder). The MDS did not indicate Resident 53 was taking antipsychotic medication. During a review of Resident 3's Order Summary Report, the Order Summary Report indicated the resident had a Physician Order (PO) dated 4/6/2025 to receive Abilify 5 milligrams (mg, a unit of measurement) by mouth one time a day for schizophrenia. The PO did not indicate any manifestations of Resident 3's schizophrenia. The Order Summary Report did not indicate there was a PO to monitor Resident 3 for any manifestations of behavior related to schizophrenia. During a concurrent interview and record review on 4/10/2025 at 11:08 AM, Resident 3's Order Summary Report was reviewed with Licensed Vocational Nurse 2 (LVN 2). LVN 2 stated Resident 3 started taking Abilify on 4/7/2025 for schizophrenia. LVN 2 stated Resident 3 had behaviors and episodes of agitation and yelling at staff. LVN 2 stated Resident 3's physician orders for Abilify did not indicate any of Resident 3's behavior manifestations related to schizophrenia. LVN 2 stated Resident 3 did not have any physician orders to monitor the resident's behavior related to schizophrenia. LVN 2 stated if Resident 3's behaviors were being monitored there would be a physician order and documentation on the resident Medication Administration Record (MAR). LVN 2 stated she could not locate documentation on the MAR for the monitoring of Resident 3's behavior related to schizophrenia. LVN 2 stated it would be difficult to evaluate if Abilify was effective on Resident 3's behavior without the nursing staff monitoring the resident's behavior. During a concurrent interview and record review on 4/10/2025 at 11:25 AM, Resident 3's Order Summary Report was reviewed with the Assistant Director of Nursing (ADON). The ADON stated Resident 3's physician orders for Abilify did not include the resident's behavior manifestations related to schizophrenia. The ADON stated Resident 3 did not have any physician orders to monitor the resident's behavior related to schizophrenia. The ADON stated when a medication like Abilify was ordered, the order should include the resident's behavior manifestations and an additional order to monitor for 555019 Page 19 of 21 555019 04/10/2025 Temple Park Convalescent Hospital 2411 W. Temple Street Los Angeles, CA 90026

F 0758 behaviors. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 4/10/2025 at 1:55 PM, Resident 3's Order Summary Report was reviewed with the Director of Nursing (DON). The DON stated Resident 3's physician order for Abilify should have indicated the resident's manifestations for schizophrenia. The DON stated Resident 3 needed to have Resident 3's behaviors monitored. The DON stated staff (in general) would monitor the resident's behaviors to assess if the medication the resident took was effective. The DON stated it may be difficult to evaluate if the resident's medication was effective if the behaviors were not monitored. Residents Affected - Few During a review of the facility's Policy & Procedure titled Antipsychotic Medication Use, with a review date of 1/30/2025, indicated Resident will receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective .The Attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medication condition, specific symptoms, and risks to the resident and others .Diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident. Diagnoses alone do not warrant the use of antipsychotic medication. In addition to the above criteria, antipsychotic medication will generally only be considered if the following conditions are also met. The behavior symptoms present a danger to the resident or others; and the symptoms are identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations; delusions, paranoia or grandiosity); or behavioral interventions have been attempted and included in the plan of care, except in an emergency .The staff will observe, document, and report to the Attending Physician information regarding the effectiveness of any interventions, including antipsychotic medications .Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the Attending physician. 555019 Page 20 of 21 555019 04/10/2025 Temple Park Convalescent Hospital 2411 W. Temple Street Los Angeles, CA 90026

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. Based on observation, interview, and record review the facility failed to ensure two opened insulin pens (a device used to administer insulin, a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) were discarded per facility's policy. This failure had the potential for the medication dispensing errors. Findings: During a concurrent observation and interview on 4/9/2025 at 2:23 PM, the facility's medication refrigerator was observed with Licensed Vocational Nurse (LVN) 1 in the facility's medication storage room. In the medication refrigerator the following were observed: 1. Novolog Flexpen (a type of insulin pen) labeled with an open date of 3/8/2025 and a discard date of 4/5/2025. 2. Lantus Solostart pen (a type of insulin pen) with an open date of 2/5/2025 and labeled discard. During a concurrent observation and interview on 4/9/2025 at 2:23 PM, LVN 1 stated that opened insulin pens should not be kept in the refrigerator and if the insulin pens were labeled discard they should be discarded and not left in the refrigerator. LVN 1 stated there was a potential for staff to give medication to a resident that should have been discarded if it was left in the refrigerator. LVN 1 stated if the medication was past the use date and administered to a resident the medication might not be as effective. During an interview on 4/10/2025 at 2 PM with the Director of Nursing (DON), the DON stated open insulin pens should not be kept in the refrigerator. The DON stated if the insulin pen was labeled discard, then the medication should be discarded and not left in the refrigerator. The DON stated there was a potential for a resident to receive medication that should have been discarded if it was left in the refrigerator. During a review of the facility's Policy and Procedure (P&P) titled Storage of Medication with a review date of 1/30/2025, the P&P indicated The facility stores all drugs and biologicals in a safe, secure, and orderly manner .Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 555019 Page 21 of 21