Health inspection·May 13, 2025

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 implement the care plan for one of three sampled residents (Resident 1). For Resident 1, the facility failed to assess and document weekly Resident 1 ' s moisture associated skin damage (MASD, moisture associated skin damage caused from prolonged exposure to moisture) to the buttocks area as indicated in Resident 1 ' s care plan. This deficient practice resulted in not being able to determine if Resident 1 ' s MASD had healed before Resident 1 was discharged from the facility on 4/11/25. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 4/2/25 with diagnoses including diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), difficulty in walking and dementia (a progressive state of decline in mental abilities). During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 4/6/25 indicated Resident 1 had severed cognitive impairment. Resident 1 needed moderate assistance (helper does less than half the effort) with oral hygiene, toileting hygiene, shower/bathe self, upper/lower body dressing, putting on/taking off footwear and supervision with eating). During a review of the Skin Evaluation dated 4/3/25 at 9:03 a.m., Resident 1 indicated MASD on the buttocks area. During a review of Resident 1 ' s Care Plan initiated on 4/8/25, indicated Resident 1 had actual impairment to skin integrity related to fragile skin, and with diagnoses including bilateral buttocks MASD. The care plan goal indicated Resident 1 will maintain or develop clean and intact skin by the review date. The care plan interventions included: 1. Monitor/document location, size and treatment of skin injury. 2. Weekly treatment documentation includes measurement of each area of skin breakdown ' s width, length, depth, type of tissue and exudate and any other notable changes or observations. During a review of Resident 1 ' s Treatment Administration Record (TAR, a daily documentation record used by a licensed nurse to document treatments given to a resident) indicated for the MASD in the bilateral buttocks to wash with soap and water, pat dry, and apply zinc oxide (cream used to treat Page 1 of 3 555019 555019 05/13/2025 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 and prevent skin irritation) to the site and leave open. The TAR indicated the treatment was done from 4/3/25 to 4/11/25. During a concurrent interview and record review on 5/13/25 at 12:24 p.m., Resident 1 ' s skin assessment dated [DATE] was reviewed with the registered nurse supervisor (RNS 1). RNS 1 stated Resident 1 had MASD on the buttocks when Resident 1 was admitted on [DATE]. RNS 1 stated there should be a weekly assessment of the MASD. RNS 1 stated she was unable to find documentation that the MASD was assessed weekly. During an interview on 5/13/25 at 1:26 p.m., the director of nursing (DON) stated there was no documentation of Resident 1 ' s MASD whether the MASD had improved or not. The DON stated when Resident 1 was discharged on 4/11/25, the transfer out notes indicated no skin issues. During a review of the facility policy and procedures (P&P) titled Non-Pressure Ulcers/Wound Management revised on 1/30/25, the P&P indicated a licensed nurse will document the status of all skin conditions at least weekly or as otherwise indicated in the resident ' s care plan, until the wound, non-pressure ulcer or other skin condition is resolved. The same Policy indicated treatments for skin problems, wounds and non-pressure ulcers will be assessed and documented by a licensed nurse. 555019 Page 2 of 3 555019 05/13/2025 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 the environment is free of hazard for one of three sampled residents (Resident 3). During observation on 5/13/25, the facility hall was lined with linen carts, dirty linen hampers, trash hampers and showers chairs on both sides of the hall. Residents 3 stated it was difficult for him to self-propel his wheelchair due to the clutter in the hallway. This deficient practice had the potential for accidents to occur for Resident 3 and other residents. Findings: During a review of the admission Record indicated the facility admitted Resident 3 on 3/21/24 with diagnoses including diabetes mellitus (DM, disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness and abnormalities of gait and mobility. During a review of Resident 3 ' s Minimum Data Set (MDS, a resident assessment tool) dated 3/4/25 indicated Resident 3 was cognitively intact. The MDS indicated Resident 3 was independent with activities of daily living (ADLs) and used the walker and wheelchair as mobility devices. During a concurrent observation and interview on 5/13/25 at 9:45 a.m., licensed vocational nurse (LVN 1) stated the hallway is cluttered. LVN 1 stated there are linen carts, dirty linen and trash hampers, shower chairs on both sides of the hallway. LVN 1 stated it could be better. During a concurrent observation and interview on 5/13/25 at 9:48 a.m., the infection preventionist (IP) stated the hallway is a little crowded and stated the linen carts and dirty linen hampers are placed on both sides of the hallway. IP stated this is a hazard and safety issues for residents who are using wheelchairs. During an interview on 5/13/25 at 12:24 p.m., the registered nurse supervisor (RNS 1) stated the linen carts, dirty linen hampers, thrash hampers should be placed on one side of the hallway so there is space for the residents to go through. During an interview on 5/13/25 at 1:26 p.m., the director of nursing (DON) stated the certified nursing assistants were doing morning care. DON stated the linen carts and dirty linen hampers should be placed on one side of the hall for the safety of the residents. During a review of the facility' policy and procedurs (P&P) titled Safety and Supervision of Residents reviewed on 1/30/25, the P&P indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility- wide priorities. The same Policy indicated safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring and reporting processes: Quality Assurance and Performance Improvement (QAPI) reviews of safety and incident/accident data and a facility -wide commitment to safety at all levels of the organization. 555019 Page 3 of 3