Health inspection·July 2, 2025

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure that the resident received treatment and care in accordance with professional standards of practice for one of three sampled residents (Resident 1) by failing to notify the physician and responsible party regarding Resident 1's Computed Tomography (CT- a medical imaging procedure that uses X-rays to create detailed cross-sectional images of the body) scan result which indicated multiple kidney stones (hard objects made of minerals and salts in urine lodged in the kidney, very painful).This failure resulted in a delay in care and treatment to prevent urinary tract infection (UTI- an infection in the bladder/urinary tract) and abdominal pain.During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was initially admitted to the facility on [DATE] and last re-admission was on 6/25/2024 with diagnoses including Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and elevated white blood cell counts (the immune system produced more white blood cells to destroy an infection).During a review of Resident 1's Nurse Practitioner Progress Note, dated 6/28/2024, the Nurse Practitioner Progress Note indicated, Resident 1 had the capacity (ability) to understand and make decisions.During a review of Resident 1's Minimum Data Set ([MDS]-a resident assessment tool), dated 6/15/2025, the MDS indicated Resident 1 required dependent assistance (Helper does all of the effort) from two or more staff for transfer, hygiene, dressing, maximal assistance (Helper does more than half the effort) from one staff for bed mobility, and independent for eating.During an interview on 7/2/2025, at 11:29 a.m., with Resident 1 in Resident 1's room, Resident 1 stated, she had a CT scan in early June, but staff did not inform her of the results. Resident 1 stated, she had abdominal pains frequently and was hospitalized recently for abdominal pain and a UTI. Resident 1 stated, the hospital doctor told her that she had multiple kidney stones that might cause the UTI and pain, but she did not receive any treatment during hospitalization. Resident 1 stated, she would like to know how to treat the kidney stones.During a concurrent interview and record review on 7/2/2025, at 11:51 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 1's Nursing Progress Notes, dated from 6/9/2025 to 7/2/2025 were reviewed. The Nursing Progress indicated, Resident 1 left the facility for a CT scan, but there were no follow up notes and no documentation indicating the facility staff notified the physician and Resident 1's responsible party regarding the CT scan result. RNS 1 stated, any findings from a medical test are considered a change of condition and the physician should be notified, for further treatment orders. RNS 1 stated the facility staff need to update Resident 1's responsible party as well. RNS 1 stated, there was no documentation regarding notification or follow-up.During a phone interview on 7/2/2025, at 12:56 p.m., with Resident 1's Responsible Party (RP)1, RP 1 stated, staff did not inform him regarding CT scan result. RP 1 stated, he found out later that Resident 1's physician and Nurse Practitioner (NP) were not informed about the result until Resident 1 was transferred to the General Acute Care Hospital (GACH) emergency room (ER) on 6/24/2025. RP Residents Affected - Few Page 1 of 5 555070 555070 07/02/2025 Southland 11701 Studebaker Road Norwalk, CA 90650

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1 stated, Resident 1 was getting some pain medication, but it was not effective. RP 1 stated, he was very upset after talking to GACH doctor because Resident 1's UTI and pain were possibly caused by the kidney stones. RP 1 stated, Resident 1's kidney stones were not treated in ER and the GACH sent her back to the facility. RP1 stated, the facility staff did not know why Resident 1 was not treated. RP1 stated, he got frustrated, because the nurses could not tell him the treatment plan. RP 1 stated, he did not want Resident 1 to suffer from UTI and pain again.During a concurrent interview and record review on 7/2/2025, at 1:29 p.m., with Social Service Director (SSD), Resident 1's Grievance Resolution Form, dated 6/24/2025 was reviewed. The Grievance Resolution Form indicated, RP 1 complained Resident 1's CT scan results were not communicated to her attending physician. The SSD stated, the Director of Nursing (DON) spoke to responsible staff including Registered Nurse (RN) 2 regarding the importance of clear communication. The SSD stated, she confirmed that attending physician and NP did not notify Resident 1's physician and Responsible party regarding Resident 1's CT scan results.During an interview on 7/2/2025, at 1:46 p.m., with the Case Manager (CM), the CM stated, she received the CT scan results on 6/12/2025 and handed it to RN 2 with other documents. The CM stated, she flagged the CT scan result and believed this was the nursing responsibility to notify the attending clinician and RP.During an interview on 7/2/2025 at 2:59 p.m., with RN 2, RN 2 stated, the CM gave her a bunch of documents while she was passing the medications. RN 2 stated, the CM did not mention anything about CT scan results. RN 2 stated, the CM only asked her to re-check the appointment date. RN 2 stated, if she knew there were CT scan result, she would notify physician, NP and RP 1 as soon as she knew about it because it was considered a change of condition for further orders and treatment.During an interview on 7/2/2025, at 3:15 p.m., with the DON, the DON stated, the CM should have communicated clearly when she gave the documents including the CT result to RN 2. The DON stated, RN 2 should have reviewed all the documents the CM handed to her thoroughly before she placed them in the chart. The DON stated, nursing staff should have followed through with CT scan results, but no one did unfortunately. The DON stated, Resident 1 ended up not getting the treatment and care she needed in a timely manner and was transferred to GACH ER for abdominal pain and UTI. The DON stated, the attending physician, and the NP should be notified of any findings in laboratory result and diagnostic tests. The DON stated Resident 1's RP should have also been notified. The DON stated, Resident 1 should get a referral for Urologist (a medical specialist who diagnoses and treats conditions related to the urinary tract and reproductive system) and Nephrologist (a medical specialist who focuses on the diagnosis, treatment, and management of kidney diseases) consult to manage the kidney stones. During a review of Resident 1's CT abdomen and Pelvis without Contrast Result, faxed 6/12/2025, the CT abdomen and Pelvis without Contrast Result indicated, multiple non-obstructing renal (kidney) stones measuring up to seven millimeters (mm) on the right and five mm on left.During a review of Resident 1's Change in Condition Evaluation, dated 6/24/2025, the Change in Condition Evaluation indicated, Resident 1 had uncontrollable abdominal pain.During a review of Resident 1's Transfer Form, dated 6/24/2025, the Transfer Form indicated, Resident 1 complained pain level of 10 out of 10 and the attending physician ordered to transfer to GACH ER.During a review of the facility's Policy and Procedure (P&P) titled, Diagnostic Test Results Notification, revised 4/2025, the P&P indicated, Policy: It is the policy of this facility to obtain laboratory and radiology services when ordered by a physician to promptly notify the ordering provider of test results. Procedure:2. Results of laboratory, radiological, and diagnostic tests outside the clinical reference ranges shall be promptly reported to the resident's attending physician. 3. Notification of test results will be documented in the resident's clinical record.During a review of the facility's Policy and Procedure (P&P) titled, Change 555070 Page 2 of 5 555070 07/02/2025 Southland 11701 Studebaker Road Norwalk, CA 90650

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few in Condition, revised 4/2025, the P&P indicated, Policy: it is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical , mental, and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care. Procedure: 1. If, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware.5. There will be certain circumstances where immediate attention will be warranted, and nursing will be responsible for notifying the appropriate department for evaluation. The nurse shall contact the physician based on the urgency of the situation. The resident/resident representative will be notified of the change of condition. During to the National Institute of Health ([NIH] a U.S. government agency that is responsible for conducting and supporting biomedical and behavioral research) titled, Association of Kidney Stones and Recurrent UTIs, published 7/25/2022, indicated, UTI and Kidney Stones are mutually coexisting, and reciprocally causal and such patients should be counselled for proactive intervention by stone removal especially when UTIs are recurrent or additional risk factors are present irrespective of stone composition. To prevent further UTI episodes, if possible, a stone culture must be obtained for an effectively targeted antibiotic treatment regime. (https://pmc.ncbi.nlm.nih.gov/articles/PMC9492590/) 555070 Page 3 of 5 555070 07/02/2025 Southland 11701 Studebaker Road Norwalk, CA 90650

F 0697 Provide safe, appropriate pain management for a resident who requires such services. 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 reviews, the facility failed to ensure effective pain management measures for one of three sampled resident (Resident 1), by failing to ensure Resident 1 had pain medication for moderate pain (pain scale [a tool used to assess pain intensity, with a scale of 0 to 10, where 0 represents no pain and 10 represents the worst pain imaginable] level of 4-7) and routine and breakthrough pain (a transient exacerbation of pain that occurs in individuals who are already experiencing chronic pain).This failure had the potential to result in social isolation and worsening of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and last re-admission was on 6/25/2024 with diagnoses including recurrent major depressive disorder and chronic pain syndrome (persistent pain lasting longer than three months, significantly impacting a person's physical and mental well-being).During a review of Resident 1's Nurse Practitioner Progress Note, dated 6/28/2024, the Nurse Practitioner Progress Note indicated, Resident 1 had the capacity (ability) to understand and make decisions.During a review of Resident 1's Minimum Data Set ([MDS]-a resident assessment tool), dated 6/15/2025, the MDS indicated Resident 1 required dependent assistance (Helper does all of the effort) from two or more staff for transfer, hygiene, dressing, maximal assistance (Helper does more than half the effort) from one staff for bed mobility, and independent for eating.During a concurrent observation and interview on 7/2/2025, at 11:29 a.m., with Resident 1 in Resident 1's room, Resident 1 was grimacing, and her hands were on the mid-section of her abdomen (belly). Resident 1 stated, she was having intermittent pain on her mid abdominal area with a pain level of 10 out of 10. Resident 1 stated, she did not receive pain medication routinely and the pain medication she received was not very effective. Resident 1 stated, she had to get a hold of the nurse to get her pain medication, and her pain level reached eight or nine out of 10 when the nurse brought the pain medication. Resident 1 stated, she had to go to the General Acute Care Hospital (GACH) emergency room (ER) recently for the abdominal pain.During a concurrent interview and record review on 7/2/2025, at 12:34 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 1's Order Summary Report (OSR), dated 7/2/2025 was reviewed. The OSR indicated, an order to give Tylenol (a pain medication to relieve mild pain) 325 milligram(mg) two tablets by mouth every six hours as needed for mild pain (pain scale of 1-3) was ordered on 6/27/2025. The OSR indicated, an order to give Percocet (a pain medication to relieve severe pain) 5-325mg one tablet by mouth every six hours as needed for severe pain (pain scale of 8-10) was ordered on 2/11/2025. There was no pain medication coverage for moderate pain (pain scale of 4-7). LVN 1 stated, she should have asked the physician for moderate pain coverage. LVN 1 stated, last time Percocet was given to Resident 1 was on 7/2/2025, at 1:25 a.m., and did not know that Resident 1 had pain level of eight out of 10. LVN 1 stated, Resident 1's pain level usually stayed at eight or nine and was not very effective. LVN 1 stated, she asked the Nurse Practitioner (NP) who was working with the attending physician regarding the ineffective pain management for Resident 1, but NP declined to change the medication order. LVN 1 stated she should have contacted the Medical Director (MD) to get better coverage for pain management, but she did not.During an interview on 7/2/2025, at 1:29 p.m., with the Social Service Director (SSD), the SSD stated that Resident 1 did not want to participate in group activities and to get out of the bed recently. The SSD stated, during a room visit she asked Resident 1about her pain, and Resident 1 stated that she was in pain constantly and did not feel good enough to get out of bed for activities.During an interview on 7/2/2025, at 3:15 p.m., with the Director of Nursing (DON), the DON stated, Residents Affected - Few 555070 Page 4 of 5 555070 07/02/2025 Southland 11701 Studebaker Road Norwalk, CA 90650

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few effective pain management should cover all levels of pain. The DON stated, if the administer-as-needed pain medication did not relieve the pain, the nursing staff should have asked the attending physician or covering NP for routine and breakthrough pain medications to manage the pain more effectively. The DON stated, if the attending physician or NP did not agree with suggested pain management, the staff could reach out to the Medical Director. The DON stated, Resident 1 was already suffering from depression, chronic pain from multiple previous fractures (broken bones), and kidney stones. The DON stated, if the pain was not controlled effectively, Resident 1 might suffer from insomnia, social isolation, and worsening of depression.During a review of Resident 1's Medication Administration Record (MAR), dated on 7/1/2025 and 7/2/2025, the MAR indicated, Resident 1 received one tablet of Percocet 5-325 mg by mouth for pain level of eight out of ten on 7/1/2025, at 8:32 a.m. The MAR indicated, Resident 1 received one tablet of Percocet 5-325mg by mouth for pain level of eight out of ten on 7/2/2025, at 1:25 a.m. and 12:35 p.m. The MAR indicated, Tylenol was not given on either 7/1/2025 and 7/2/2025.During a review of Resident 1's untitled Care Plan (CP), revised on 6/26/2025, the CP Focus indicated, Resident 1 had acute and chronic pain. The CP Goal indicated, Resident 1 will verbalize adequate relief of pain. The CP Interventions indicated, follow pain scale to medicate as ordered and monitor/document pain characteristics such as quality, location, onset, duration, aggravating factors and relieving factors.During a review of the facility's Policy and Procedure (P&P) titled, Pain Recognition and Management, revised 4/2025, the P&P indicated, Policy: it is the policy of this to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, comprehensive and routine assessments, person-centered care plan, and residents' goals and preferences.Procedure: 1. The resident will be interviewed and evaluated for pain upon admission, quarterly, and with any change in their status. 2. Staff will recognize when a resident is experiencing pain and identify circumstances when pain can be anticipated; evaluate existing pain and the causes; manages or prevents pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences.4. Management: c. if the pain management program is not effective, the licensed nurse will contact the resident's physician. 5. Monitoring: b. monitor for effectiveness of interventions and /or adverse consequences. C. consult physician for additional interventions if pain is not relieved by current orders. 555070 Page 5 of 5