Health inspection·September 25, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 low air loss mattress ([LAL] special mattress for wound management) for one of three sampled residents (Resident 1), as ordered by the physician. Residents Affected - Few This failure placed the resident ' s wound at risk for poor healing and worsening condition. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included Stage four (4) pressure ulcer (full thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bones)on the sacral (tail bone) region and muscle weakness. During a review of Resident 1 ' s Order Summary Report dated 9/19/2024, the Order Summary Report indicated a LAL mattress every shift. During a review of Resident 1 ' s care plan titled, Alteration in skin condition, dated 9/19/2024, the interventions indicated to provide pressure relieving surface as ordered. During a review of Resident 1 ' s Pressure Sore Risk Assessment dated 9/19/2024, Pressure Sore Risk Assessment indicated Resident 1 was at high risk of developing pressure ulcers. During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardize care screening and assessment tool) dated 9/23/2024, the MDS indicated Resident could understand and be understood by others. The MDS indicated Resident 1 was dependent and required a two or more person ' s assist with activities of daily living (ADLs) such as toileting hygiene, dressing, and bed mobility. The MDS indicated Resident 1 had a Stage 4 pressure ulcer. During a concurrent observation and interview on 9/25/2024 at 12:04 p.m., with Resident 1, Resident 1 was observed laying on a regular mattress. Resident 1 stated he was supposed to get an air loss mattress 7 days ago because he had a pressure ulcer stage 4 on his back, and he did not get the mattress. During a concurrent observation, interview and record review on 9/25/2024 at 2:00 p.m. with Licensed Vocational Nurse (LVN 1), Resident 1 ' s physician order dated 9/19/2024 was reviewed. LVN 1 stated the physician ' s order indicated LAL mattress every shift for Resident 1. LVN 1 stated Resident 1 was not on LAL as per physician order. LVN 1 stated the LAL mattress was important for Resident 1 Page 1 of 3 555040 555040 09/25/2024 Lotus Care Center 6011 West Blvd Los Angeles, CA 90043

F 0686 to prevent worsening of current pressure ulcer and to prevent future skin breakdown. Level of Harm - Minimal harm or potential for actual harm During a review of the facility ' s undated policy and procedure (P&P) titled, Physicians Orders, the P&P indicated the facility should provide care and services to the resident in accordance with the physician ' s order. Residents Affected - Few 555040 Page 2 of 3 555040 09/25/2024 Lotus Care Center 6011 West Blvd Los Angeles, CA 90043

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the facility ' s telephone system was able to receive outside calls from one of three resident ' s (Resident 1) representative or an outside caller. Residents Affected - Some This deficient practice had the potential for all the residents in the facility not receiving phone calls from family members. Findings: 1). During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included Stage four (4) pressure ulcer (full thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bones) on the sacral (tail bone) region and muscle weakness. During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardize care screening and assessment tool) dated 9/23/2024, the MDS indicated Resident could understand and be understood by others. The MDS indicated Resident 1 was dependent and required a two or more person ' s assist with activities of daily living (ADLs) such as toileting hygiene, dressing, and bed mobility. The MDS indicated Resident 1 had a Stage 4 pressure ulcer. During a phone interview on 9/25/2024 at 10:34 a.m., with Family Member 1 (FM 1), FM 1 stated she had been calling the facility ' s phone number at [PHONE NUMBER] every day since Resident 1 was admitted to the facility on [DATE], and her calls were sent to a voicemail. FM 1 stated she had left several voicemails; however, no one had returned the call. This Surveyor placed a phone call to facility ' s phone number at [PHONE NUMBER] on 9/25/2024 at 10:50 a.m., however, the call was sent directly to a voicemail. Surveyor left a message to call back. No facility staff returned the call. This Surveyor placed a phone call to facility ' s phone number at [PHONE NUMBER] on 9/26/2024 at 9:54 a.m., no one answered the call. A voice message was left and no facility staff returned the call. This Surveyor placed a phone call to facility ' s phone number at [PHONE NUMBER] on 9/26/2024 at 11:29 a.m., no one answered the call. A voice message was left and no facility staff returned the call. This Surveyor placed a phone call to facility ' s phone number at [PHONE NUMBER] on 9/26/2024 at 3:53 p.m., no one answered the call. A voice message was left and no facility staff returned the call. During a phone interview on 9/26/2024 at 8:55 a.m., with Director of Nursing (DON), the DON stated she was not aware the facility had a voicemail set up for incoming phone calls. The DON stated she did not have access to the facility ' s voicemail. The DON stated when resident ' s family members call and the facility was unable to answer, and did not call back, it could cause the residents and residents ' families frustrations and worries. 555040 Page 3 of 3