Health inspection·November 12, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. 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 reasonably accommodate the resident's needs as indicated in the facility's policy and procedure titled, Call Lights: Accessibility and Timely Response for 1 of two residents (Resident 104) who was observed with call lights (device used by a resident to signal his or her need for assistance from professional staff) not within the resident's reach. Residents Affected - Few This deficient practice had the potential to in Resident 104 receive delayed care or not receive services and emergency care when needed. Findings: A review of Resident 104's admission Record indicated Resident 104 was initially admitted to the facility on [DATE], and readmitted on [DATE] with diagnosis that included dysphagia (difficulty swallowing foods or liquids) and type 2 diabetes mellitus (a disease in which your blood glucose, or high blood sugar levels). A review of Resident 104's History and Physical (H&P), dated 10/27/2023 indicated, Resident 104 had the capacity to understand and make decisions. A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/03/2023, indicated Resident 104 was cognitively (relating to the mental process involved in knowing, learning, and understanding things) intact. The MDS indicated Resident 104 uses a wheelchair for ambulation. During an observation in Resident 104's room on 11/10/2023 at 10:20 AM, Resident 104 was observed sitting in the wheelchair next to his bed. Resident 104 asked the surveyor Can you get my call light, they brought me back from PT (Physical Therapy-a therapy to strengthen weakened muscle) and left me here, I don't know where my call light is. Resident 104's call light was observed on the floor behind Resident 104's bedside drawer that resident could not reach. During a concurrent interview and observation in Resident 104's room with Licensed Vocational Nurse (LVN1) on 11/10/2023 at 10:28 AM, LVN stated, Resident 104's call light was on the floor behind the bedside drawer that was not withing arm reach of the resident. LVN 1 stated the call light should always be within the resident's reach to prevent an accident or injury reaching for the call light, and to be used when the resident need assistance. During an interview on 11/11/2023 at 4:58 PM with Assistant Director of Nursing (ADON), the ADON stated it was the facility's practice to always leave the call lights within reach of the residents. Page 1 of 13 555081 555081 11/12/2023 Del Mar Convalescent Hospital 3136 North Del Mar Avenue Rosemead, CA 91770

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The ADON stated everyone in the facility was responsible for making sure the residents call lights within the residents reach. The ADON stated it was important for all residents to have their call lights within reach to ensure they get assistance from the staff when in distress, or when the residents need assistance to prevent accident and to ensure we meet the residents' needs. A review of the facility's policy and procedure titled, Call Lights: Accessibility and Timely Response, revised on 12/19/2022, indicated the staff will ensure the call light is within reach of the residents and secured, as needed. 555081 Page 2 of 13 555081 11/12/2023 Del Mar Convalescent Hospital 3136 North Del Mar Avenue Rosemead, CA 91770

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed maintain a homelike environment by ensuring the facility's wall clocks in the resident's bedroom were set in the current time for 2 of two sampled residents (Resident 1 and 105). This deficient practice had the potential for Resident 1 and105 to get disoriented with time, which could affect the resident's participation with daily activities and over all wellbeing. Findings: 1. A review of Resident 1's admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis that included paraplegia (paralysis or unable to move the lower part of the body), Type 2 diabetes mellitus (a disease in which your blood glucose, or high blood sugar levels). A review of Resident 1's History and Physical, dated 7/26/2022, indicated the resident had the capacity to understand or make decisions. 2. A review of Resident 105's admission Record indicated Resident 105 was initially admitted to the facility on [DATE] with a diagnosis that included Type 2 diabetes mellitus. Unspecified Dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 105's History and Physical, dated 11/04/2023, indicated the resident did not have capacity to understand or make decisions. During an observation and initial facility tour on 11/10/23 at 10:31 AM, the facility, the wall clock in Resident 1's room showed the time of 9:35 AM. In a concurrent interview Resident 1 stated he notified the nurses that his room clock had the wrong time, but no one fixed it. Resident 1 stated he sometimes gets confused with having two clocks with two different times as he uses his personal electronic tablet to see the time as well. Resident 1 stated he likes to know what the correct time because he relies on the time on the wall clock for his daily activities. During an observation and initial facility tour on 11/10/2023 at 11AM, the facility wall clock on the wall in Resident 105's bedroom showed the time of 10AM. In a concurrent interview Resident 105 stated she sometimes gets confused with the time. Resident 105 stated she liked to know what the correct time because she relies on the time for knowing when it's time to get up and for breakfast and lunch. During an observation and concurrent interview on 11/20/2023 at 11:20 AM, the Maintenance Supervisor (MS) was observed entering Resident 105's room taking down the wall clock in front of Resident 105's bed and putting the correct time. MS stated he had forgotten to fix the clocks to display the correct time on three residents' rooms. The MS stated any staff member could have fixed the clocks to display the correct time since the time changed (daylight saving time) about a week ago. During an interview on 1/11/2022 at 5 P.M, the Assistant Director of Nursing (ADON), stated it was 555081 Page 3 of 13 555081 11/12/2023 Del Mar Convalescent Hospital 3136 North Del Mar Avenue Rosemead, CA 91770

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few important for the facility to maintain the clocks in residents' room in good working condition, so the residents were aware of the current time and day, especially for the residents who has dementia. The ADON stated ensuring that the wall clocks in the resident's room have the right time will help the residents with the orientation of time. A review of the facility's policy and procedure titled, Maintenance Inspection, revised on 12/19/ 2022, indicated It is the policy of this facility to utilize maintenance inspections to assure a safe, functional, sanitary and comfortable environment for residents, staff and the public. 555081 Page 4 of 13 555081 11/12/2023 Del Mar Convalescent Hospital 3136 North Del Mar Avenue Rosemead, CA 91770

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of resident's admission to the facility for one of 3 sampled residents (Resident 105) with a diagnosis of Type 2 Diabetes Mellitus (DM-an adult-onset disease in which the blood glucose or sugar levels are too high). This deficient practice had the potential for Resident 105 not to receive the appropriate interventions and treatments for DM and lead to complications such as hyperglycemia (high blood sugar) or hypoglycemia (low blood sugar). Findings: A review of Resident 105's admission Record indicated Resident 105 was initially admitted to the facility on [DATE] with a diagnosis that included Type 2 DM. Unspecified Dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life.). A review of Resident 105's History and Physical, dated 11/04/23, indicated the resident did not have capacity to understand or make decisions. A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/9/2023, indicated Resident 105's has an active diagnosis of DM. During an interview and concurrent record review on 11/11/2023 at 10:39 AM with the MDS nurse, the MDS nurse stated Resident 105 was admitted to facility with a diagnosis of Type 2 DM that was not addressed or included in Resident 105's baseline care plan. The MDS nurse tated the care plan should had been initiated during Resident 104's admission to the facility. During an interview on 11/13/2023 at 4:58 PM, with Assistant Director of Nursing (ADON), the ADON stated, the resident's care plans should be initiated within 48 hours upon admission for of all residents with pertinent diagnosis such as Type 2 DM. The ADON stated Resident 105's care plan for DM should had been initiated by the nurses when the Resident 105 was admitted to the facility no later than 48 hours of admission. The ADON stated since Resident 105 had no baseline care plan for DM, this could result in the resident not receiving appropriate interventions and monitoring for complications of DM such as hyperglycemia or hypoglycemia. A review of the facility's policy revised on 12/29/2022 titled Baseline Care Plan, indicated, the facility will develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care. The baseline care plan will be initiated within 48 hours of a Resident's admission. 555081 Page 5 of 13 555081 11/12/2023 Del Mar Convalescent Hospital 3136 North Del Mar Avenue Rosemead, CA 91770

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 one of one sampled resident (Resident 33) was assisted by two people during transfer from wheelchair to bed, and when using a Hoyer Lift (mechanical lift device with sling used to transfer residents between the bed and the chair or other location using electrical or hydraulic power). This deficient practice placed Resident 33 at risk for falls or accidents during transfers when using the Hoyer lift that could lead to injuries including possible fractures and a decline in the resident's wellbeing. Findings: During a review of Resident 33's admission Record indicated the facility admitted Resident 33 on 11/19/2022 with diagnoses that included, osteoporosis (a condition in which bones become weak and brittle) and contracture (a condition of shortening of muscle, tendons or other tissue leading to deformity, rigidity of the joints and lead to pain with limited or no joint movement). During a review of Resident 33's History and Physical, dated 6/15/2023, indicated Resident 33 does not have the capacity to understand and make decisions. During a review of Resident 33' Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 10/10/2023, indicated Resident 33 had severely impaired cognition (ability to think and reason) for daily decision making. The MDS indicated Resident 33 was totally dependent (helper does all of the effort to complete the activity with the assistance of 2 or more helpers) on lying to sitting on side of bed, chair/bed-to-chair transfer, and tub/shower transfer. During an observation on 11/10/2023 at 12:31 PM in Resident 33's room, Resident 33 was at the foot of her bed sitting in the wheelchair with a Hoyer sling (a sling creates a hammock to cradle a person when transferring with a mechanical lift). In a concurrent interview Certified Nursing Assistant (CNA) 1 stated, she was going to transfer Resident 33 from her wheelchair to the bed. CNA 1 positioned the Hoyer Lift in front of Resident 33 and did not request assistance from other staffs. CNA 1 attached four sling hooks onto the sling attachment points of the Hoyer Lift. Then CNA 1 moved behind Resident 33 and stood behind the Hoyer Lift facing Resident 33. CNA 1 informed Resident 33 that she will lift her up now, then, CNA grabbed the Hoyer Lift remote control and pressed button to lift up resident from the wheelchair to the bed. The Surveyor immediately stopped CNA 1. CNA 1 stated she was going to transfer Resident 33 with the Hoyer Lift by herself. CNA 1 stated the Hoyer Lift should be operated by two people, and she was in hurry to transfer the resident and forgot to get assistance from other staffs. CNA 1 stated it was important to use have two people to transfer Resident 33 from the wheelchair to the bed with the Hoyer Lift for the resident's safety. During an interview on 11/11/2023 at 5:16 PM with the Acting Director of Nursing (ADON), the ADON stated a Hoyer Lift required two people to operate. The ADON stated one person could not operate the Hoyer Lift remote control and watch over the resident to prevent fall or injury at the same time during transfer. The ADON stated when using the Hoyer Lift, one person should operate the remote control and another person stays next to the resident to prevent the resident from fall and injury during the transferring process. 555081 Page 6 of 13 555081 11/12/2023 Del Mar Convalescent Hospital 3136 North Del Mar Avenue Rosemead, CA 91770

F 0689 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure titled, Safe Resident Handling/Transfers, dated 12/19/2022, indicated it is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. When using Mechanical Lift two staff members must be utilized when transferring residents. Residents Affected - Few 555081 Page 7 of 13 555081 11/12/2023 Del Mar Convalescent Hospital 3136 North Del Mar Avenue Rosemead, CA 91770

F 0760 Ensure that residents are free from significant medication errors. 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 ensure one of four residents (Resident 3) was free from significant medication errors. Resident's 3's heart rate was not assessed before administering Metoprolol Tartrate (a medication to treat high blood pressure and heart failure) based on physician's order to hold if Systolic Blood Pressure (SBP, measures the pressure of your blood in your arteries [tube like structure responsible for transporting blood]) less than (<) 110 milliliters per mercury (mmHg, unit of measurement) or heart rate (HR) < 60 beats per minute (bpm, unit of measurement). Residents Affected - Few This deficient practice place Resident 3 at risk to experience adverse reaction (undesired effect) of Metoprolol that included dangerously low blood pressure and heart rate that could lead to death. Findings: A review of Resident 3's admission Record indicated Resident 3 was initially admitted to the facility on [DATE] with a diagnosis that included, hemiplegia (muscle weakness or partial paralysis [loss ability to move] on one side of the body that can affect the arms, legs, and facial muscles) and Type 2 diabetes mellitus (a disease in which results in high blood glucose or sugar levels). A review of Resident 3's History and Physical, dated 10/29/2023, indicated the resident does not have the capacity to understand or make decisions. A review of Resident 3's record, titled Order Summary Report (a physician's order), ordered on 11/8/2023, indicated to administer Metoprolol 25 mg (a unit of measure) via G-tube (a gastrostomy tube surgically inserted into the stomach used to deliver nutritional fluids, medications) every 12 hours for hypertension and hold for SBP <110 and HR<60. During a medication pass observation, on 11/12/2023, from 8:11 AM to 8:50 AM, Licensed Vocational Nurse (LVN) 2 crushed one tablet of Metoprolol 25 mg and did not assess Resident 3's heart rate before administering Metoprolol 25 mg via G-tube. During an interview with LVN 2 on 11/12/2023 at 8:51 AM, LVN 2 stated, she forgot to check Resident 3's heart rate prior to administering the Metoprolol. LVN 2 stated I forgot to check the heart rate of the resident (Resident 3), I only checked the resident's blood pressure, and I did not read the whole physician's order before giving the medication. LVN 2 stated the consequences of not checking the resident's heart rate before administration of Metoprolol is lowering the heart rate too low. LVN 2 stated it was important to check the resident's blood pressure and heart rate were within the parameters as ordered by the physician before administration of Metoprolol. During an interview with the Assistant Director of Nursing (ADON) on 11/12/23 at 2PM, the ADON stated all nurses should always check and follow the doctor's orders before administering medications to prevent any complications when giving medications to residents. A review of the facility's policy revised on 12/29/2022 titled Medication administration, indicated, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. 555081 Page 8 of 13 555081 11/12/2023 Del Mar Convalescent Hospital 3136 North Del Mar Avenue Rosemead, CA 91770

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to properly store foods in the refrigerator. Residents Affected - Few 1. 15 Cups of poured milk were not labeled or dated. 2. 6 Prepared sliced peaches were not labeled or dated. 3. A cracked egg was observed saturating the egg crate. These deficient practices had the potential to result in residents being exposed to food borne illnesses. Findings: During an observation of the kitchen during the initial kitchen tour on 11/10/2023 at 9:36 AM with the Dietary Supervisor (DS), refrigerator 1 was observed to have prepared milk in cups, and prepared sliced peaches without labels or dates. DS stated the cups with milk and cups with sliced peaches should have been labeled with what the contents of what the food was, and the date the food was prepared. The DS stated dating and labeling food was important to ensure food were not expired, and to prevent residents from becoming sick. During an observation in the kitchen, during the initial kitchen tour on 11/10/2023 at 9:45 AM with the DS, refrigerator 2 was observed with one (1) cracked egg in a carton with the egg components spilled into the egg crate. and found one cracked egg in a large cartons that holds 36 eggs the substance inside the egg had saturated the surrounding wells. DS stated the cracked egg and carton should have been thrown away since the egg components spilled inside and outside the egg carton and could contaminate other food in the refrigerator, and could harm residents due to bacterial growth. A review of the facility's policy titled, Food Safety Requirements dated 12/19/2022, indicated food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. The policy indicated practices to maintain safe refrigerated storage include: labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date. 555081 Page 9 of 13 555081 11/12/2023 Del Mar Convalescent Hospital 3136 North Del Mar Avenue Rosemead, CA 91770

F 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure one of four sampled Residents (Resident 51) and the resident's responsible party (RP) were informed and understood the concept of the proposed arbitration (solving disputes with a neutral third party instead of the court) and the Binding Arbitration Agreement (BAA, a binding agreement by the parties to submit to arbitration all or certain disputes between them in respect of a defined legal relationship, whether contractual or not) before having the resident/RP enter into a binding arbitration agreement. Residents Affected - Few The deficient practice had the potential resulted in Resident 51 unknowingly giving up their right to resolve any disputes with the facility through a court of law before a jury. Findings: During a review of Resident 51's admission Record indicated the facility admitted Resident 51 on 10/14/2023 with diagnoses that included hemiplegia (paralysis of one side of the body) and diabetes mellitus (a diseases that affect how the body uses blood sugar and results in high blood sugar). During a review of Resident 51 Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 10/20/2023, indicated Resident 51 had severely impaired memory and cognitive impairment (able to make decision and think reasonably). During an interview on 11/11/2023 at 12:09 PM with the admission Director (AD), the AD stated She was responsible for explaining and obtaining the BAA to the residents and their RPs in the facility. The AD stated when the BAA was signed by the resident or the Responsible Party (RP), it was effective immediately and the resident or RP could not rescind (take back or cancel) the BAA unless the resident was discharged from the facility. During a concurrent interview and record review on 11/11/2023 at 5:05 PM with Resident 51's RP (RP1), the BAA, dated 10/16/2023 was reviewed. RP 1 stated she did not recognize the BAA, which she had signed electronically on 10/16/2023. RP 1 stated the staff did not explain what BAA was. The RP 1 stated she did not agree on the terms on the BAA and if there was any dispute with the facility related to Resident 51, she should have the right to resolve the dispute in court. During an interview on 11/12/2023 at 12:05 PM with the AD, the AD stated she it was important to explain the BAA to resident and the RP to make sure both parties understand what a BAA is and be informed that they have 30 days after the BAA was signed to rescind the BAA. The AD stated it was the residents and their RPs' right to be informed and understand the binding BAA, so that they could decide if they want to enter the BAA. During a review of the facility's policy and procedure titled, Binding Arbitration Agreements, dated 12/19/2022, indicated the facility shall explain to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands, and ensure the resident or his or her representative acknowledges that he or she understands the agreement .This Agreement may be rescinded by written notice within thirty (30) days of signature. 555081 Page 10 of 13 555081 11/12/2023 Del Mar Convalescent Hospital 3136 North Del Mar Avenue Rosemead, CA 91770

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to label the nasal cannula (NC-a device used to deliver supplemental oxygen to people) tubing with the date when it was first used for one of three sampled residents (Resident 204). Residents Affected - Few This failure had the potential for Resident 204 to use contaminated or soiled NC tubing and result in the infection (a process when a microorganism, such as bacteria, fungi, or a virus, enters a person's body and causes harm) and a widespread infection in the facility. Findings: During a review of Resident 204's admission Record indicated the facility admitted Resident 204 on 11/6/2023 with diagnoses that include dementia (a term for a range of conditions that affect the brain's ability to think, remember, and function normally) and spinal stenosis (narrowing in the spine which puts pressure on the nerves and spinal cord, causing pain, numbness, and muscle weakness). During a review of Resident 204's History and Physical (H&P), dated 11/7/2023, indicated Resident 204 had the capacity to understand and make decisions. During A review of Resident 204's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/13/2023, indicated Resident 204 had intact cognition (ability to think and reason) for daily decision making. The MDS indicated Resident 204 was on oxygen therapy in the facility. During an observation on 11/10/2023 at 10:45 AM, in Resident 204's room, Resident 204 had the nasal cannula (NC) inserted into the nares (nose opening). The NC tubing was connected to the humidifier bottle (bottle with water use to provide moisture when the oxygen is delivered to the nares), which was attached to the operating oxygen machine at her bedside. The humidifier bottle was labeled and dated 11/6/2023. The NC tubing was not labeled with the date when it was first used. In a concurrent interview, Resident 204 stated she does not remember for how many days she had been using the NC tubing. During a concurrent observation and interview on 11/10/2023 at 10:52 AM with Licensed Vocational Nurse (LVN) 1, Resident 204's NC tubing was not labeled with the date and time of when it was first used. LVN 1 explained the staffs only need to date the humidifier and not the NC tubing. During an interview on 11/11/2023 at 5:15 PM with the Acting Director of Nursing (ADON), the ADON stated they changed NC tubing weekly and as needed when they were soiled. The ADON stated NC tubing and humidifier bottle were not one-piece equipment and should be labeled and dated individually. The ADON stated it was important to label and date the NC tubing because the staff could know when to change the NC tubing and to prevent infection for the residents. During a review of the facility's policy and procedure titled, Oxygen Administration, dated 12/19/2022, indicated infection control measures included to change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. 555081 Page 11 of 13 555081 11/12/2023 Del Mar Convalescent Hospital 3136 North Del Mar Avenue Rosemead, CA 91770

F 0911 Level of Harm - Potential for minimal harm Residents Affected - Some Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident bedrooms accommodate no more than four residents for five of 18 rooms (Rooms 16, 19, 22, 25 and 26) did not have more than four residents in one shared room. This deficient practice had the potential to limit care and services, and the ability to move easily in the room for residents and facility staff. Findings: On 11/10/23 at 9:00 AM, during the facility's Recertification Survey Entrance Conference, in the presence of the Social Service Supervisor (SSS) stated the facility had rooms with variances and will continue to apply for the Room Waiver. A review of the Client Accommodation Analysis form submitted by the facility on 11/10/23 indicated the following rooms had more than four beds: room [ROOM NUMBER] with 5 beds, room [ROOM NUMBER] with 5 beds, room [ROOM NUMBER] with 5 beds, room [ROOM NUMBER] with 5 beds, room [ROOM NUMBER] with 5 beds. On 11/10/23 to 11/12/23, during the recertification survey, the following were observed: 1. room [ROOM NUMBER] has 5 beds with 3 residents (2 unoccupied bed) 2. room [ROOM NUMBER] has 5 beds with 5 residents (0 unoccupied beds) 3. room [ROOM NUMBER] has 5 beds with 4 residents (1 unoccupied bed) 4. room [ROOM NUMBER] has 5 beds with 5 resident (5 unoccupied beds) 5. room [ROOM NUMBER] has 5 beds with 5 residents unoccupied beds) During an interview on 11/10/2023 at 10:47 AM, CNA 2 stated room [ROOM NUMBER] had 5 residents and there was enough room to provide care and to get the residents out of bed and into their wheelchair. During an interview on 11/10/2023 at 11:36 AM, Family Member (FM) stated that room [ROOM NUMBER] had 5 residents and her brother had enough space for her to take care of him and the nursing 555081 Page 12 of 13 555081 11/12/2023 Del Mar Convalescent Hospital 3136 North Del Mar Avenue Rosemead, CA 91770

F 0911 assistants are able to get him out of bed into the wheelchair with no problem. Level of Harm - Potential for minimal harm During an interview on 11/10/2023 at 3:10 PM, CNA 1 stated that room [ROOM NUMBER] had 5 residents and there was enough room to provide care to the residents. CNA 1 stated there are no issue for transferring the residents from bed to wheelchair or using the Hoyer lift (a patient lift used by caregivers to safely transfer patients) in the room. Residents Affected - Some During an interview on 11/10/2023 at 3:12 PM, LVN 1 stated the 5 resident rooms have enough space to safely care for the residents, for intravenous and feeding equipment, oxygen machine and transferring the residents from bed to wheelchair. During an observation on 11/10/2023 at 12:40 PM in room [ROOM NUMBER], Resident 33 was transferred from the wheelchair to the bed with the use of a Hoyer lift by two CNA's with no issues. A review of the room waiver letter submitted by the Administrator (ADM) on 11/11/23, indicated rooms 6,19, 22, 25, and 26 , had adequate space for nursing care and multiple beds per room would not adversely affect the health and safety of the residents. The room waiver filed by the facility will be submitted to CMS. 555081 Page 13 of 13